Treatment options for biliary complications after orthotopic liver transplantation

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

PURPOSE

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

MATERIALS AND METHODS

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

RESULTS

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%.

CONCLUSIONS

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Percutaneous transhepatic cholangiography and drainage is an effective rescue therapy for biliary complications in liver transplant recipients who fail endoscopic retrograde cholangiopancreatography

BACKGROUND

We attempted to evaluate both the factors that predispose a patient to biliary complications after liver transplantation and the results of percutaneous transhepatic cholangiography and drainage (PTCD) for the management of those complications.

METHODS

This study retrospectively reviewed the cases of 81 patients who received liver transplants at Taipei Veterans General Hospital between February 2003 and June 2008. Biliary complications were diagnosed on the basis of clinical findings, laboratory data, and the results of imaging studies.

RESULTS

A total of 18 patients (22.2%) developed biliary complications, and living donor liver transplantation (LDLT) was a significant risk factor (p = 0.035), compared to cadaveric liver transplantation. Eight patients with biliary complications received PTCD as the first treatment modality and 6 had successful results. An additional 10 patients received endoscopic retrograde cholangiopancreatography (ERCP) initially, but only 2 patients were effectively managed. One patient received conservative treatment after ERCP failure. One patient died from sepsis after ERCP. The remaining 6 patients with failed ERCP were successfully managed with PTCD. The overall mortality rate in these patients with biliary complications was 16.7%. No significant prognostic predictors were identified, including age, sex, biochemical data, and model for end-stage liver disease scores.

CONCLUSION

Biochemical markers cannot predict biliary complications preoperatively. LDLT increases the risk of biliary complications. PTCD is an effective rescue therapy when ERCP fails.