Management of biliary complications following orthotopic liver transplantation

Endoscopic Bridge-and-Seal of Bile Leaks Using a Fully Covered Self-Expandable Metallic Stent above the Papilla

Background/Aims: Endoscopic management by endoscopic sphincterotomy with or without plastic stents or fully covered self-expandable metallic stents (FCSEMSs) is widely accepted as the current standard of care for postoperative bile leaks. Biliary stents are placed across the papilla, not above the papilla. We investigated the safety and effectiveness of the bridge-and-seal technique for bile leaks by the placement of FCSEMS above the papilla. Methods: This was a retrospective study of FCSEMS placement above the papilla for bile leaks between October 2016 and July 2021. FCSEMS was placed above the papilla to bridge and seal the leak. The main outcome measures were the resolution of bile leaks and adverse events. Results: Seven patients with postoperative bile leaks underwent FCSEMS above the papilla. The locations of bile leaks were 1 cystic duct remnant; 2 intrahepatic bile duct; 1 hepatic duct; 2 common bile duct and 1 anastomosis. The technical success rate of FCSEMS placement was 100%, and resolution of bile leaks was achieved in five patients (71.4%). All the adverse events were observed after FCSEMS removal; as follows: 1 moderate cholangitis; 2 mild post-ERCP pancreatitis; and 1 mild remnant cholecystitis. Conclusions: FCSEMS placement above the papilla can be a treatment option for postoperative bile leaks.

The Need to Update Endpoints and Outcome Analysis in the Rapidly Changing Field of Liver Transplantation

Liver transplantation (LT) survival rates have continued to improve over the last decades, mostly due to the reduction of mortality early after transplantation. The advancement is facilitating a liberalization of access to LT, with more patients with higher risk profiles being added to the waiting list. At the same time, the persisting organ shortage fosters strategies to rescue organs of high-risk donors. This is facilitated by novel technologies such as machine perfusion. Owing to these developments, reconsideration of the current and emerging endpoints for the assessment of the efficacy of existing and new therapies is warranted. While conventional early endpoints in LT have focused on the damage induced to the parenchyma, the fate of the bile duct and the recurrence of the underlying disease have a stronger impact on the long-term outcome. In light of this evolving landscape, we here attempt to reflect on the appropriateness of the currently used endpoints in the field of LT trials.

The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification

Background

Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria.

Methods

We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP.

Results

Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up.

Conclusions

PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.

CEUS detection of biliary ischaemia during the first 4 weeks after liver transplantation predicts non-anastomotic biliary stricture

BACKGROUND

Biliary ischaemia is an important factor in the pathogenesis of non-anastomotic biliary stricture (NAS) after liver transplantation (LT). Contrast-enhanced ultrasound (CEUS) can be used to detect biliary ischaemia, but no study has examined the utility of CEUS in predicting NAS.

OBJECTIVE

To evaluate whether repeated CEUS as a non-invasive method of biliary ischaemia can identify NAS.

METHODS

Consecutive LT patients who underwent CEUS examinations at 1-4 weeks after LT from September 2012 to December 2015 at our institution were included. The CEUS images and clinical data were analysed.

RESULTS

Among 116 eligible LT patients, 39 (33.6%) were diagnosed with NAS within 1 year after LT. The patients with NAS had a significantly higher CEUS score at weeks 2-4 (all P <  0.05) and a higher slope of CEUS score progression (0.480 vs -0.044, P <  0.001). The accuracy of CEUS in identifying NAS improved over time after LT, reaching its maximum at week 4, with a sensitivity of 66.7%, a specificity of 87.9%, a positive predictive value (PPV) of 75.9%, a negative predictive value (NPV) of 82.3%, and an accuracy of 80.2%in the full cohort when a CEUS score≥3 was used as the cut-off. Multivariate analysis identified gamma-glutamyl transpeptidase (GGT), alanine transaminase (ALT) and the CEUS score at week 4 as independent predictors of NAS. In the task of identifying NAS, an NAS score combining the above 3 variables at week 4 showed areas under the receiver operating characteristic curve of 0.88 (95%CI, 0.78-0.99) in the estimation group (n = 60) and 0.82 (95%CI, 0.69-0.96) in the validation group (n = 56). An NAS score cut-off of 0.396 identified 87.2%of NAS cases in the estimation group, with a PPV of 93.3%; and 75.0%of NAS cases in the validation group, with a PPV of 58.8%.

CONCLUSIONS

CEUS examination during the first 4 weeks is useful in assessing the risk of NAS within 1 year after LT. In particular, an NAS score combining the CEUS score, GGT level, and ALT level at week 4 can be used to accurately predict the risk of NAS in LT patients.

Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era

BACKGROUND

Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT.

METHODS

All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak).

RESULTS

A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted.

CONCLUSIONS

Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.

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.

Cystic Duct Bile Leak in Graft: An Unexpected Origin for Choleperitoneum After Liver Transplant

From the beginning of liver transplant implementation, biliary anastomosis has been considered its weakness. An anastomotic bile leak is the most frequent cause of bile in the peritoneum (choleperitoneum) after liver transplant but not the only one. Here, we report a 58-year-old man with hepatitis C virus-related cirrhosis who had orthotopic liver transplant due to presence of hepatocellular carcinoma.During the immediate postoperative period, bile leakwas diagnosed on trans-Kehr cholangiography. Contrast extravasation was observed on the graft's cystic duct, and no contrast flow into the native biliary tract was demonstrated. Surgical intervention was required after endoscopic management failure. Bile leak through the cystic duct was repaired, and a Rouxen-Y bilioenteric diversion was performed. Biliary complications can significantly increase morbidity and mortality after liver transplant. Anastomotic bile leaks are the most frequent; however, other locations must not be dismissed as possible origins of leak. It is mandatory to consider underlying hepatic artery complications as thrombosis or stenosis. Treatment will depend on the leak origin, which are most times accessible to endoscopic retrograde cholangiopancreatography. However, other locations and the different treatment options must also be considered. It is also necessary not to forget the influence of bile leaks on biliary stenosis development in the long term and its contribution to increased patient morbidity and mortality.

Endoscopic management of biliary strictures post-liver transplantation

Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.

A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation

Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.

Patient and Graft Survival: Biliary Complications after Liver Transplantation

BACKGROUND

Biliary complications (BCs) affect up to to 34% of liver transplant recipients and are a major source of morbidity and cost. This is a 13-year review of BCs after liver transplantation (LT) at a tertiary care center.

STUDY DESIGN

We conducted a single-center retrospective review of our prospective database to assess BCs in adult (aged 18 years or older) liver transplant recipients during a 13-year period (2002 to 2014). Biliary complications were divided into 3 subgroups: leak alone (L), stricture alone (S), and both leak and strictures (LS). Controls (no BCs) were used for comparison.

RESULTS

There were 1,041 adult LTs performed during the study period; BCs developed in 239 (23%) of these patients: 55 (23%) L, 148 (62%) S, and 36 (15%) LS. One hundred and two (43%) were early (less than 30 d). Surgical revision was required in 42 cases (17%) (30 L, 10 LS, and 2 S), while the remaining 197 (83%) were managed nonsurgically (25 L, 26 LS, and 146 S), with a mean of 4.2 interventions/patient. One-, 3-, and 5-year overall patient and graft survival was significantly reduced in patients with bile leaks (84%, 71%, and 68% and 76%, 67%, and 64%, respectively) compared with controls (90%, 84%, and 78% and 88%, 81%, and 76%, respectively [p < 0.05]). Patients with BCs had higher incidence of cholestatic liver disease, higher pre-LT bilirubin, higher use of T-tubes, higher use of donor after cardiac death grafts, and higher rates of acute rejection (p < 0.05). Patients with BCs had longer ICU and hospital stays and higher rates of 30- and 90-day readmissions (p < 0.01). Multivariate analysis identified cholestatic liver disease, Roux-en-Y anastomosis, donor risk index >2, and T-tubes as independent BC predictors.

CONCLUSIONS

Biliary complications after LT can significantly decrease patient and graft survival rates. Careful donor and recipient selection and attention to anastomotic technique can reduce BCs and improve outcomes.

An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

Effect of HSP27 and Cofilin in the injury of hypoxia/reoxygenation on hepatocyte membrane F-actin microfilaments

Hypoxia-reoxygenation (H/R) injury hepatocyte models were established to simulate the ischemia/reperfusion injury of transplanted organ. Through the study of the molecular mechanism of H/R on the F-actin damage of the liver cytomembrane, the mechanism of F-actin damage induced by ischemia and reperfusion was studied from the level of cell and molecule.The hypoxic environment of cells in vitro was simulated by chemical hypoxia agent CoCl2. Liver cells were detected by MTT, H/R group was subdivided into 3 subgroups: H/R 2, 4, and 6 h. Changes of cell shape and the growth state, apoptosis, ultrastructural changes, and the changes in F-actin microfilament content were observed. Heat shock protein 27 (HSP27), Cofilin, and F-actin gene and protein levels were determined by real-time polymerase chain reaction and western blot assay, respectively.Cells showed circular adherence growth under normal circumstances, while the spindle cells and shedding cells were significantly increased in H/R groups. Apoptosis cells in H/R group were increased significantly with the extension of hypoxia time. The number of endoplasmic reticulum was decreased significantly in the H/R group, the mitochondrion hydropic was degenerated and the glycogen was disappeared. The F-actin fibers in the H/R group were disordered, the morphology of the fibers was obviously decreased, and the fluorescence staining decreased obviously (P < .05). The transcription and expression levels of HSP27, Cofilin, and F-actin were significantly lower than those in the control group (P < .05).These results demonstrate that H/R can affect the correct assembly of F-actin microfilaments and weakens the normal cycle of F-actin microfilaments through inhibiting the protein expression and gene transcription of HSP27 and Cofilin in hepatocytes, thereby changing the skeleton of F-actin microfilaments.

Ischemia reperfusion of the hepatic artery induces the functional damage of large bile ducts by changes in the expression of angiogenic factors

Liver transplantation and cholangiocarcinoma induce biliary dysfunction following ischemia reperfusion (IR). The function of the intrahepatic biliary tree is regulated by both autocrine and paracrine factors. The aim of the study was to demonstrate that IR-induced damage of cholangiocytes is associated with altered expression of biliary angiogenic factors. Normal and bile duct ligation rats underwent 24-h sham or hepatic reperfusion after 30 min of transient occlusion of the hepatic artery (HAIR) or portal vein (PVIR) before collecting liver blocks and cholangiocyte RNA or protein. We evaluated liver histology, biliary apoptosis, proliferation and expression of VEGF-A/C, VEGFR-2/3, Ang-1/2, and Tie-1/2 in liver sections and isolated small and large cholangiocytes. Normal rat intrahepatic cholangiocyte cultures (NRICC) were maintained under standard conditions in normoxic or under a hypoxic atmosphere for 4 h and then transferred to normal conditions for selected times. Subsequently, we measured changes in biliary proliferation and apoptosis and the expression of VEGF-A/C and VEGFR-2/3. In vivo, HAIR (but not PVIR) induced damage of large bile ducts and decreased proliferation and secretin-stimulated cAMP levels. HAIR-induced damage of large bile ducts was associated with increased expression of VEGF-A/C, VEGFR-2/3, Ang-1/2, and Tie-1/2. In vitro, under hypoxic conditions, there was increased apoptosis and reduced proliferation of NRICC concomitant with enhanced expression of VEGF-A/C and VEGFR-2/3. The functional damage of large bile ducts by HAIR and hypoxia is associated with increased expression of angiogenic factors in small cholangiocytes, presumably due to a compensatory mechanism in response to biliary damage.

Endoscopic management of post-liver transplant biliary complications

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

Bile duct damage after cold storage of deceased donor livers predicts biliary complications after liver transplantation

BACKGROUND & AIMS

The aim of this study was to examine the development of biliary epithelial damage between organ retrieval and transplantation and its clinical relevance for patients.

METHODS

Common bile duct samples during donor hepatectomy, after cold storage, and after reperfusion were compared to healthy controls by hematoxylin and eosin (H&E) staining and immunofluorescence for tight junction protein 1 and Claudin-1. A bile duct damage score to quantify biliary epithelial injury was developed and correlated with recipient and donor data and patient outcome.

RESULTS

Control (N=16) and donor hepatectomy bile ducts (N=10) showed regular epithelial morphology and tight junction architecture. After cold storage (N=37; p=0.0119), and even more after reperfusion (N=62; p=0.0002), epithelial damage, as quantified by the bile duct damage score, was markedly increased, and both tight junction proteins were detected with inappropriate morphology. Patients with major bile duct damage after cold storage had a significantly increased risk of biliary complications (relative risk 18.75; p<0.0001) and graft loss (p=0.0004).

CONCLUSIONS

In many cases, the common bile duct epithelium shows considerable damage after cold ischemia with further damage occurring after reperfusion. The extent of epithelial damage can be quantified by our newly developed bile duct damage score and is a prognostic parameter for biliary complications and graft loss. Possibly, in an intraoperative histological examination, this bile duct damage score may influence decision-making in transplantation surgery.

Post-liver Transplant Biliary Complications

Biliary tract complications remain a common source of morbidity and mortality in liver transplant (LT) recipients with an estimated incidence of 5-30% after orthotopic LT and a mortality rate of up to 10%. Biliary complications after LT may be related to various factors including hepatic artery thrombosis or stenosis, ischemia reperfusion injury, immunologic injury, infections, donor pool, and technical issues which include imperfect anastomosis and T-tube-related complications. Management of the detected biliary complications includes nonsurgical and surgical methods. A majority of these post transplant biliary complications can be treated with endoscopic retrograde cholangiography. If unsuccessful, a percutaneous intervention or surgery may be required. In this article, we review the incidence, clinical presentation, and management of the main types of biliary complications.

Three-dimensional imaging for hepatobiliary and pancreatic diseases: Emphasis on clinical utility

Three-dimensional (3D) imaging allows disease processes and anatomy to be better understood, both by radiologists as well as physicians and surgeons. 3D imaging can be performed with USG, CT scan and MRI, using different modes or rendering that include surface-shaded display, volume-based rendering, multiplanar imaging, etc. All these techniques are used variably depending on the indications.

Biliary complications following liver transplantation

The aphorism that reconstruction of the biliary anastomosis is the "Achilles heel" of liver transplantation remains valid as biliary complications following liver transplantation remain a major source of morbidity with an incidence of 5-32%. Biliary complications include biliary strictures, biliary leaks, and stones. Biliary strictures can be divided into anastomotic and non-anastomotic. The management of biliary complications previously relied on surgical intervention. However, advances in endoscopic and radiological interventions have resulted in less-invasive options. The management of biliary complications post-liver transplantation requires a multidisciplinary approach and continues to evolve. Biliary complications also reflect the continued expansion of the donor pool with extended, live, and non-heart beating donors.

Endoscopic management of biliary complications after liver transplantation

Complications of the biliary tract are an important cause of morbidity and mortality after liver transplantation. The most frequent complications are anastomotic biliary tract strictures, bile leaks, and bile duct stones. The estimated incidence of these complications ranges between 5% and 25%, although rates have been decreasing in recent years. Most complications can be managed successfully with endoscopic retrograde cholangiography. This article reviews the various biliary complications after liver transplantation (both deceased donor and living-related donor) and their endoscopic management.

Biliary tract complications after liver transplantation

Biliary tract complications are an important source of morbidity after liver transplantation, and present a challenge to all involved in their care. With increasing options for transplantation, including living donor and split liver transplants, the complexity of these problems is increasing. However, diagnosis is greatly facilitated by modern noninvasive imaging techniques. A team approach, including transplant hepatology and surgery, interventional endoscopy and interventional radiology, results in effective solutions in most cases, such that operative reintervention or retransplantation is rarely required.

Management of biliary complications after orthotopic liver transplantation: The role of endoscopy

Biliary complications are significant causes of morbidity and mortality after orthotopic liver transplantation (OLT). The estimated incidence of biliary complications after OLT ranges between 10%-25%, however, these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures (both anastomotic and non-anastomotic) and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde cholangiography (ERC). Other complications such as bile duct stones, bile casts, sphincter of Oddi dysfunction, and hemobilia, are less frequent and also can be managed with ERC. This article will review the risk factors, diagnosis, and endoscopic management of the most common biliary complications after OLT.