Endoscopic treatment of biliary stones in patients with liver transplantation

Procedure-related readmissions following endoscopic retrograde cholangiopancreatography in a liver transplant cohort

Background and Aim

Data on post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events and readmission rates in liver transplantation (LT) patients remain scarce. This study determined the 30-day procedure-related readmission rate following ERCP in an LT cohort at an Australian tertiary academic center.

Methods

All unplanned readmissions within 30 days following ERCP in orthotopic LT patients between December 2012 and August 2021 were retrospectively identified. Demographic data, procedure variables, and readmission characteristics were also collected.

Results

Forty-five procedure-related readmissions were identified (3.3%) from a total of 1369 ERCP procedures. This included 33 cases of cholangitis (2.4%), 7 cases of nonspecific abdominal pain (0.5%), 5 cases of mild post-ERCP pancreatitis (0.5%), and 3 cases of bleeding (0.2%). No procedure-related mortality was observed.

Conclusion

The procedure-related readmission rate following ERCP in this LT cohort was 3.3%, which is likely lower than comparable studies carried out on the overall population.

Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones

BACKGROUND

Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones.

METHODS

Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated.

RESULTS

The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 ( P =0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant.

CONCLUSION

FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.

Risk factors and management of biliary stones after living donor liver transplant and its effect on graft outcome

Background

Bile stones are associated with numerous complications in liver transplant recipients. Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be safe and highly effective in dealing with most post-transplant biliary complications.

Objective

The objective of this study was to identify the possible risk factors for bile stone formation on top of biliary stricture, the effects of stones on graft outcomes, and their management.

Methods

This case–control study included 83 patients who underwent living donor liver transplant (LDLT) and suffered from postoperative biliary stricture with or without stones. Patients were divided into two groups. Group 1 (n = 55) included patients with biliary strictures with no stones and group 2 (n = 28) included patients who developed stones on top of biliary strictures. Data about the recipient and donor characteristics, surgical technique, blood lipid profile, immunosuppressive drugs, post-transplant complications, and interventions were collected from the medical records.

Results

The frequency of hepatitis C virus (HCV) was significantly higher in group 2 compared to group 1 (71.4% vs. 47.3%, p = 0.036). The body mass index (BMI) of the donors was significantly higher in group 2 than in group 1 (25.17 ± 2.53 vs. 23.68 ± 2.63, p = 0.015). Episodes of acute rejection were significantly higher in group 2 than in group 1 (21.4% vs. 5.5%, p = 0.027). The ERCP was sufficient in most of the cases (89.2%) to ensure biliary drainage. The identified independent risk factors for biliary stones included HCV, biliary drain, donor's BMI, and serum cholesterol level.

Conclusion

Positive HCV, biliary drain insertion, donor's BMI, and serum cholesterol level were independent risk factors for developing bile stones on top of biliary strictures. Biliary stones were associated with high episodes of acute graft rejection, and they could be successfully managed by the ERCP modality.

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis

OBJECTIVE

To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors.

METHODS

This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25).

CONCLUSION

DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.

Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases

BACKGROUND Postoperative pancreatitis is one of the most serious complications in endoscopic retrograde cholangiopancreatography (ERCP). To detect potential risk factors for post-ERCP hyperamylasemia and pancreatitis. MATERIAL AND METHODS We reviewed 1786 ERCP procedures in Zhongnan Hospital of Wuhan University from January 2015 to April 2018. Clinical data were extracted, and the complications after ERCP procedures were re-evaluated. Single- and multiple-variable analyses were conducted to detect the potential risk factors. RESULTS We found that 1786 procedures were applied on 1707 patients; 64 patients (3.58%) developed pancreatitis, while asymptomatic hyperamylasemia occurred in 263 cases (14.73%). In multivariate analysis, pancreatic deep wire pass (odds ratio [OR]: 2.280, 95% CI [confidence interval]: 1.129-4.605, P=0.022), endoscopic metal biliary endoprosthesis (OR: 2.399, 95% CI: 1.120-5.138, P=0.024), operation after liver transplantation (OR: 3.057, 95% CI: 1.110-8.422, P=0.031), and fistulotomy (OR: 3.148, 95% CI: 1.036-9.561, P=0.043) were identified as independent risk factors for post-ERCP pancreatitis. Pancreatic deep wire pass (OR: 1.678, 95% CI: 1.136-2.478, P=0.009), fistulotomy (OR: 2.553, 95% CI: 1.096-5.948, P=0.030), and younger age (OR: 0.990, 95% CI: 0.980-0.999, P=0.037) were identified as independent risk factors for hyperamylasemia. CONCLUSIONS To prevent post-ERCP pancreatitis, it is important to avoid high-risk procedures such as fistulotomy and pancreatic deep wire pass, especially in high-risk patients with liver transplantation. For patients with endoscopic metal biliary endoprosthesis, clinicians should pay more attention to the occurrence of post-ERCP pancreatitis.