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Chon HK, Kozarek RA. History of the Interventional Pancreaticobiliary Endoscopy. Gastrointest Endosc Clin N Am 2024; 34:383-403. [PMID: 38796288 DOI: 10.1016/j.giec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
With the introduction of endoscopic retrograde cholangiopancreatography and linear endoscopic ultrasound, interventional pancreaticobiliary (PB) endoscopy has had an enormous impact in the management of pancreatic and biliary diseases. Continuous efforts to improve various devices and techniques have revolutionized these treatment modalities as viable alternatives to surgery. In recent years, trends toward combining endoscopic techniques with other modalities, such as laparoscopic and radiological interventions, for complex PB diseases have emerged using a multidisciplinary approach. Ongoing research and clinical experience will lead to refinements in interventional PB endoscopic techniques and subsequently improve outcomes and reduce complication rates.
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Affiliation(s)
- Hyung Ku Chon
- Division of Biliopancreas, Department of Internal Medicine, Wonkwang University Medical School, and Hospital, Iksan, Republic of Korea; Institution of Wonkwang Medical Science, Iksan, Republic of Korea
| | - Richard A Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason Franciscan Health, 1100 Ninth Avenue, Seattle, WA 98101, USA; Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason Franciscan Health, 1201 Ninth Avenue, Seattle, WA 98101, USA.
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2
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Lim C, Ng J, Sarraf B, Vaughan R, Efthymiou M, Zorron Cheng Tao Pu L, Chandran S. Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures. World J Transplant 2024; 14:91081. [PMID: 38947975 PMCID: PMC11212593 DOI: 10.5500/wjt.v14.i2.91081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Endoscopic management is the first-line therapy for post-liver-transplant anastomotic strictures. Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months, data on safety and duration for metal stents in this setting is scarce. Due to limited access to endoscopic retrograde cholangiopancreatography (ERCP) during the coronavirus disease 2019 pandemic in our centre, there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy. This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents. AIM To compare the safety and efficacy profile of different stenting durations using Kaffes stents. METHODS Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query. Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records. The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months. Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for ≤ 120 d or > 120 d. RESULTS During the study period, a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course. In 33 ERCPs, the stent was removed or exchanged on a 3-month interval. No pancreatitis, perforations or deaths occurred. Minor post-ERCP complications were similar between the 3-month (abdominal pain and intraductal migration) and 6-month (abdominal pain, septic shower and embedded stent) groups - 6.1% vs 9.1% respectively, P = 0.40. All strictures resolved at the end of the stenting course, but the stenting course was variable from 3 to 22 months. The recurrence rate for stenting courses lasting for up to 120 d was 71.4% and 21.4% for stenting courses of 121 d or over (P = 0.03). There were 28 patients that were treated with a single ERCP with Kaffes, 21 with removal after 120 d and 7 within 120 d. There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course (71.0% vs 10.0%, P = 0.01). CONCLUSION Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.
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Affiliation(s)
- Chee Lim
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Jonathan Ng
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Babak Sarraf
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Leonardo Zorron Cheng Tao Pu
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
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Canakis A, Gilman AJ, Baron TH. Management of biliary complications in liver transplant recipients using a fully covered self-expandable metal stent with antimigration features. Minerva Gastroenterol (Torino) 2024; 70:181-186. [PMID: 37162469 DOI: 10.23736/s2724-5985.23.03343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple side-by-side plastic stents are typically used for management of anastomotic strictures, fully covered self-expandable metal stents (FCSEMS) can be used to decrease the number of ERCPs with longer periods of stent patency. The risk of migration can limit their use. FCSEMS with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events (AEs). METHODS Single center retrospective study of LT patients who required FCSEMS from 1/2014 to 4/2022. Primary outcomes included stricture resolution and recurrence. Secondary outcomes were stent migration, occlusion, removability, and number of ERCPs. RESULTS Forty-three patients (mean age 55.5 years) with anastomotic strictures (N.=37), bile leaks (N.=4) or both (N.=2) were included. The median time from LT to FCSEMS placement was 125 days. Within one year of LT, 31 patients required intervention; early intervention at less than 30 and 90 days was needed in 7 and 19 patients, respectively. The median length of follow-up was 816.5 days. Stricture resolution was seen in 35 patients (81%) after a median stent dwell time of 130.5 days; recurrence occurred in 8 patients. There were three instances of partial stent migration that did not require reintervention or interfere with removability. The mean number of ERCPs required was 2.5. CONCLUSIONS The use of a FCSEMS with antimigration features yields effective stricture resolution with longer stent dwell times and fewer ERCPs.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew J Gilman
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA -
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Cho SH, Lee HS, Huh G, Oh D, Song TJ, Seo DW, Lee SK. Long-term outcomes of fully covered self-expandable metal stents for refractory biliary strictures after living donor liver transplantation: a retrospective study at a tertiary center. Surg Endosc 2024; 38:3223-3230. [PMID: 38649493 DOI: 10.1007/s00464-024-10837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Endoscopic multiple plastic stents are an established first-line treatment for anastomotic biliary stricture (ABS) management after liver transplantation (LT). Fully covered self-expandable metallic stents (FCSEMSs) have recently been used with favorable outcomes, but long-term treatment outcomes remain an issue for ABS. We evaluated the long-term outcomes of FCSEMS for the management of refractory ABS after LT. METHODS We reviewed the prospectively collected and maintained endoscopic retrograde cholangiography database at Asan Medical Center to retrieve consecutive post-LT ABS cases that underwent an endoscopic FCSEMS placement between August 2009 and August 2019 after MPS placement failure. RESULTS A total of 34 patients were enrolled in this study. Technical success had been achieved in all subjects (100%). The median stent placement duration was 3.1 months (IQR 2.7-6.1). Stricture resolution was achieved in 26 patients (clinical success 76.5%, 95% confidence interval 62-91). Early adverse events developed in 3 patients (8.8%), including distal stent migration. Late adverse events occurred in 9 patients (26.5%), including cholangitis (n = 7, 20.6%) and asymptomatic distal stent migration (n = 2, 5.9%). The median follow-up period was 57.9 months (IQR 51.9-64.3). Stricture recurrence occurred in 3 of 26 patients who achieved clinical success (11.5%). CONCLUSIONS FCSEMS placement appears to be an effective and advisable intervention for refractory ABS as it can provide persistent stricture improvement over the long-term.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho Seung Lee
- Department of Internal Medicine, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Gunn Huh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Mishra S, Taneja S. Algorithmic Approach to Deranged Liver Functions After Transplantation. J Clin Exp Hepatol 2024; 14:101317. [PMID: 38264576 PMCID: PMC10801315 DOI: 10.1016/j.jceh.2023.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector 22, Panchkula, Haryana 134109, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Hur J, Choi W, Choi SL, Suh SW. Percutaneous placement of a retrievable fully covered metal stent with anchoring flaps for the treatment of biliary anastomotic stricture following LDLT. J Int Med Res 2024; 52:3000605241239215. [PMID: 38513144 PMCID: PMC10958814 DOI: 10.1177/03000605241239215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024] Open
Abstract
To investigate the outcomes following percutaneous placement of a retrievable fully covered self-expanding metal stent (fcSEMS) with anchoring flaps at proximal and distal ends for the treatment of biliary anastomotic strictures following living-donor liver transplantation (LDLT). We retrospectively reviewed the medical records of nine patients who underwent this procedure at our centre between April 2020 and March 2021. Percutaneous stent placement was technically successful in 100% patients, and all stents were successfully retrieved. No proximal or distal stent migration or occlusion was observed during the mean (±SD) stent indwelling period of 191(± 77) days. Clinical success was 89%. There was one major bleeding complication related to the biliary approach and one minor stent-related complication of calculus/sludge. During the mean (±SD) follow-up period of 595 ± 207 days after stent retrieval, only one patient developed recurrent clinical biliary stricture and symptoms. Percutaneous placement of a retrievable fcSEMS with anchoring flaps is safe and feasible for the treatment of biliary anastomotic strictures following LDLT.
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Affiliation(s)
- Joonho Hur
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
- Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Woosun Choi
- Chung-Ang University College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Sang Lim Choi
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
- Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Suk-Won Suh
- Chung-Ang University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
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Bofill A, Cárdenas A. A practical approach to the endoscopic management of biliary strictures after liver transplantation. Ann Hepatol 2024; 29:101186. [PMID: 38035999 DOI: 10.1016/j.aohep.2023.101186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
Biliary tract complications are an important cause of morbidity and mortality after liver transplantation (LT) occurring in 5% to 25% of patients. The most common biliary complication in LT recipients are strictures representing approximately half of these biliary adverse events. Bile duct strictures can be divided into anastomotic biliary strictures (ABS) and non-anastomotic biliary strictures (NABS) depending on their location in the biliary tree, being ABS the most encountered type. Several risk factors identified in previous studies can predispose to the development of ABS and NABS, especially those related to surgical techniques and donor characteristics. Magnetic resonance cholangiopancreatography (MRCP) is the recommended noninvasive imaging test for detecting post-LT biliary strictures, given its high sensitivity and specificity. Once the diagnosis of a biliary stricture after LT has been made, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy with good short and long-term results. Biliary sphincterotomy plus balloon dilation (BD) with placement of multiple plastic stents (MPS) has been the classic endoscopic approach for treating ABS, although fully-covered metallic stents (FCSEMS) have emerged as an alternative thanks to shorter total duration of stenting and fewer endoscopic procedures compared to MPS. In this review, we provide a practical update on the management of biliary strictures after LT, focusing our attention on the available evidence in the endoscopic therapy.
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Affiliation(s)
- Alex Bofill
- GI Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain
| | - Andrés Cárdenas
- GI and Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
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Aujla UI, Syed IA, Malik AK, Ramzan M, Saeed A. Percutaneous Transhepatic Sphincterotome-Guided Management of Post-Living Donor Liver Transplant Biliary Anastomotic Stricture: An Innovative Approach. ACG Case Rep J 2024; 11:e01288. [PMID: 38524260 PMCID: PMC10957006 DOI: 10.14309/crj.0000000000001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/22/2024] [Indexed: 03/26/2024] Open
Abstract
Post-liver transplantation biliary complications remain a serious concern and are associated with reduced patient and graft survival. Among various biliary complications, anastomotic stricture (AS) is the most frequent and challenging one. The frequency of AS after living donor liver transplantation (LDLT) is higher as compared to deceased donor liver transplantation. The management involves endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage, but refractory cases necessitate surgical revision. We present a case of complex biliary AS in a 63-year-old man after LDLT. The conventional approaches including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and cholangioscope-guided interventions remained unsuccessful. An innovative approach using a wire-guided sphincterotome through percutaneous transhepatic route successfully managed the complex post-LDLT AS. This is perhaps the first reported case of novel utilization of sphincterotome through transhepatic route for the management of AS in LDLT, averting major surgical interventions with related morbidity and mortality.
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Affiliation(s)
- Usman Iqbal Aujla
- Gastroenterology and Hepatology Department, Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Imran Ali Syed
- Gastroenterology and Hepatology Department, Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Ahmad Karim Malik
- Gastroenterology and Hepatology Department, Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Muhammad Ramzan
- Department of Radiology, Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Abdullah Saeed
- Department of Radiology, Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
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Fuentes-Valenzuela E, de Benito Sanz M, García-Pajares F, Estradas J, Peñas-Herrero I, Durá-Gil M, Carbajo AY, de la Serna-Higuera C, Sanchez-Ocana R, Alonso-Martín C, Almohalla C, Sánchez-Antolín G, Perez-Miranda M. Antimigration versus conventional fully covered metal stents in the endoscopic treatment of anastomotic biliary strictures after deceased-donor liver transplantation. Surg Endosc 2023; 37:6975-6982. [PMID: 37344754 DOI: 10.1007/s00464-023-10199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Migration of fully covered metal stents (FCMS) remains a limitation of the endoscopic treatment of anastomotic biliary strictures (ABS) following orthotopic liver transplantation (OLT). The use of antimigration FCMS (A-FCMS) might enhance endoscopic treatment outcomes for ABS. METHODS Single center retrospective study. Consecutive patients with ABS following OLT who underwent ERCP with FCMS placement between January 2005 and December 2020 were eligible. Subjects were grouped into conventional-FCMS (C-FCMS) and A-FCMS. The primary outcome was stent migration rates. Secondary outcomes were stricture resolution, adverse event, and recurrence rates. RESULTS A total of 102 (40 C-FCMS; 62 A-FCMS) patients were included. Stent migration was identified at the first revision in 24 C-FCMS patients (63.2%) and in 21 A-FCMS patients (36.2%) (p = 0.01). The overall migration rate, including the first and subsequent endoscopic revisions, was 65.8% in C-FCMS and 37.3% in A-FCMS (p = 0.006). The stricture resolution rate at the first endoscopic revision was similar in both groups (60.0 vs 61.3%, p = 0.87). Final stricture resolution was achieved in 95 patients (93.1%), with no difference across groups (92.5 vs 93.5%; p = 0.84). Adverse events were identified in 13 patients (12.1%) with no difference across groups. At a median follow-up of 52 (IQR: 19-85.5) months after stricture resolution, 25 patients (24.5%) developed recurrences, with no difference across groups (C-FCMS 30% vs A-FCMS 21%; p = 0.28). CONCLUSIONS The use of A-FCMS during ERCP for ABS following OLT results in significantly lower stent migration rates compared to C-FCMS. However, the clinical benefit of reduced stent migration is unclear. Larger studies focusing on stricture resolution and recurrence rates are needed.
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Affiliation(s)
- Esteban Fuentes-Valenzuela
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Marina de Benito Sanz
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Félix García-Pajares
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - José Estradas
- Gastroenterology Department, The American British Cowdray Medical Hospital, Mexico City, Mexico
| | - Irene Peñas-Herrero
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Miguel Durá-Gil
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Ana Yaiza Carbajo
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Carlos de la Serna-Higuera
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Ramon Sanchez-Ocana
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Carmen Alonso-Martín
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Carolina Almohalla
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Gloria Sánchez-Antolín
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain
| | - Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Calle Dulzaina 2, 47012, Valladolid, Spain.
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage. J Clin Gastroenterol 2023; 57:553-568. [PMID: 36040964 DOI: 10.1097/mcg.0000000000001760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, WA
| | | | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA CA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João
- Faculty of Medicine of the University of Porto, Porto, Portugal
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12
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Zhang CC, Sauer P. Response. Gastrointest Endosc 2023; 97:1172. [PMID: 37208047 DOI: 10.1016/j.gie.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 05/21/2023]
Affiliation(s)
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
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13
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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14
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Amateau SK, Kohli DR, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, Coelho-Prabhu N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence. Gastrointest Endosc 2023; 97:615-637.e11. [PMID: 36792483 DOI: 10.1016/j.gie.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 02/17/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.
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Affiliation(s)
- Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Medical Center, Spokane, Washington, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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15
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Yasen A, Feng J, Liang RB, Zhu CH, Li J, Liu AZ, Liu YM, Wang GY. Efficiency of percutaneous transhepatic cholangioscopy in the treatment of biliary complications after liver transplantation. HPB (Oxford) 2023; 25:463-471. [PMID: 36746707 DOI: 10.1016/j.hpb.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/20/2022] [Accepted: 01/20/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Percutaneous transhepatic cholangioscopy (PTCS) has provided an alternative therapeutic option for handling refractory biliary complications in liver transplanted recipients. This study aimed to evaluate short-term PTCS efficiency in the management of biliary complications following liver transplantation. METHODS Clinical data of 25 patients who received therapeutic PTCS due to biliary complications after liver transplantation were retrospectively analyzed. RESULTS Therapeutic PTCS was successfully performed in 25 patients. Biliary complications were anastomotic strictures in seven cases, intrahepatic cholangiolithiasis in four cases, extra-and intrahepatic cholangiolithiasis in three cases, choledocholithiasis complicated with anastomotic strictures in four cases, intrahepatic cholangiolithiasis complicated with non-anastomotic strictures in one case, intrahepatic cholangiolithiasis complicated with anastomotic strictures in five cases, intrahepatic cholangiolithiasis complicated with anastomotic strictures and ischemic cholangitis in one case. The median time between liver transplantation and first PTCS was 24 months, and median times of PTCS was 2.6. Clinical manifestations were significantly improved in most patients after PTCS, and biliary complications were successfully managed through PTCS in 15 cases, which were partially effective in eight cases and ineffective in two cases. PTCS was more effective in tackling anastomotic strictures and cholangiolithiasis. CONCLUSION PTCS was an effective therapeutic modality for treating refractory biliary complications following liver transplantation.
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Affiliation(s)
- Aimaiti Yasen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Jun Feng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Run-Bin Liang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Can-Hua Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Jun Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - An-Zhong Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Yan-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China
| | - Guo-Ying Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong Province, China.
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16
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Zhang CC, Rupp C, Exarchos X, Mehrabi A, Koschny R, Schaible A, Sauer P. Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation. Gastrointest Endosc 2023; 97:42-49. [PMID: 36041507 DOI: 10.1016/j.gie.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/13/2022] [Accepted: 08/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biliary strictures after liver transplantation are associated with significant morbidity and mortality. Although various endoscopic treatment strategies are available, consensus on a particular strategy is lacking. Moreover, the influence of endoscopic therapy on overall survival has not been studied. This retrospective study aimed to evaluate the impact of scheduled endoscopic dilatation of biliary strictures after orthotopic liver transplantation on therapeutic success, adverse events, and survival. METHODS Between 2000 and 2016, patients with post-transplant anastomotic and nonanastomotic strictures were treated with balloon dilatation at defined intervals until morphologic resolution and clinical improvement. The primary clinical endpoint was overall survival, whereas secondary outcomes were technical and sustained clinical success, adverse events, treatment failure, and recurrence. RESULTS Overall, 165 patients with a mean follow-up of 8 years were included; anastomotic and nonanastomotic strictures were diagnosed in 110 and 55 patients, respectively. Overall survival was significantly higher in patients with anastomotic strictures than in those with nonanastomotic strictures (median, 17.6 vs 13.9 years; log-rank: P < .05). Sustained clinical success could be achieved significantly more frequently in patients with anastomotic strictures (79.1% vs 54.5%, P < .001), and such patients showed significantly superior overall survival (19.7 vs 7.7 years; log-rank: P < .001). Sustained clinical success and the presence of nonanastomotic strictures were independently associated with better and worse outcomes (P < .05), respectively. CONCLUSIONS Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after liver transplantation is effective and safe, with high success rates. The implementation of this strategy controls symptoms and significantly improves survival.
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Affiliation(s)
| | - Christian Rupp
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Xenophon Exarchos
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ronald Koschny
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
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17
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Yang H, Yang Z, Hong J. Post-ERCP pancreatitis occurs more frequently in self-expandable metallic stents than multiple plastic stents on benign biliary strictures: a meta-analysis. Ann Med 2022; 54:2439-2449. [PMID: 36799364 PMCID: PMC9467625 DOI: 10.1080/07853890.2022.2105395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes. CONCLUSIONS Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement. METHODS A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity. RESULTS Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, p = .64; and OR = 2.3, 95%CI: 0.68-7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, p = .07). SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.
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Affiliation(s)
- Hui Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenzhen Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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18
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Ahmed W, Kyle D, Khanna A, Devlin J, Reffitt D, Zeino Z, Webster G, Phillpotts S, Gordon R, Corbett G, Gelson W, Nayar M, Khan H, Cramp M, Potts J, Fateen W, Miller H, Paranandi B, Huggett M, Everett SM, Hegade VS, O’Kane R, Scott R, McDougall N, Harrison P, Joshi D. Intraductal fully covered self-expanding metal stents in the management of post-liver transplant anastomotic strictures: a UK wide experience. Therap Adv Gastroenterol 2022; 15:17562848221122473. [PMID: 36187366 PMCID: PMC9516418 DOI: 10.1177/17562848221122473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/24/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis. OBJECTIVES We conducted a multicentre study to analyse their use and efficacy in the management of AS. DESIGN This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom. METHODS Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data. RESULTS In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma (n = 35, 22%), followed by alcohol-related liver disease (n = 29, 18%), non-alcoholic steatohepatitis (n = 20, 12%), primary biliary cholangitis (n = 15, 9%), acute liver failure (n = 13, 8%), viral hepatitis (n = 13, 8%) and autoimmune hepatitis (n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12-74), and stent duration was 15 weeks (range, 3 days-78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4-88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically. CONCLUSION IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.
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Affiliation(s)
| | - Dave Kyle
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
| | - Amardeep Khanna
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
| | - John Devlin
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
| | - David Reffitt
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
| | - Zeino Zeino
- Southmead Hospital/North Bristol NHS Trust,
Bristol, UK
| | - George Webster
- Hepatopancreatobiliary Unit, University College
Hospital, London, UK
| | - Simon Phillpotts
- Hepatopancreatobiliary Unit, University College
Hospital, London, UK
| | - Robert Gordon
- Cambridge Liver Unit, Addenbrooke’s Hospital,
Cambridge, UK
| | - Gareth Corbett
- Cambridge Liver Unit, Addenbrooke’s Hospital,
Cambridge, UK
| | - William Gelson
- Cambridge Liver Unit, Addenbrooke’s Hospital,
Cambridge, UK
| | - Manu Nayar
- Freeman Hospital, Newcastle upon Tyne,
UK
| | - Haider Khan
- Southwest Liver Unit and Plymouth University
Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Matthew Cramp
- Southwest Liver Unit and Plymouth University
Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Potts
- Royal Free Sheila Sherlock Liver Centre, Royal
Free Hospital and UCL Institute of Liver and Digestive Health, London,
UK
| | - Waleed Fateen
- Royal Free Sheila Sherlock Liver Centre, Royal
Free Hospital and UCL Institute of Liver and Digestive Health, London,
UK
| | - Hamish Miller
- Royal Free Sheila Sherlock Liver Centre, Royal
Free Hospital and UCL Institute of Liver and Digestive Health, London,
UK
| | | | | | | | | | | | - Ryan Scott
- Belfast Health and Social Care Trust, Belfast,
UK
| | | | - Phillip Harrison
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
| | - Deepak Joshi
- Institute of Liver Studies, King’s College
Hospital NHS Foundation Trust, London, UK
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19
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Feasibility and Safety of ERCP in the Treatment of Biliary Strictures after Liver Transplantation: With a Report of 37 Cases. Gastroenterol Res Pract 2022; 2022:4498443. [PMID: 36052377 PMCID: PMC9427298 DOI: 10.1155/2022/4498443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Liver transplantation (LT) is an effective treatment option for patients with end-stage liver disease; biliary complications are important cause of death in posttransplant patients. Endoscopic retrograde cholangiopancreatography (ERCP) has an irreplaceable role in the diagnosis and treatment of patients with biliary tract disease. Methods. The clinical data of patients with biliary strictures (BS) after LT treated with ERCP admitted to the Third Xiangya Hospital of Central South University from September 2016 to October 2021 were reviewed; the changes in temperature, bilirubin, and albumin before and after treatment and postoperative complications were analyzed. Results. A total of 41 patients were included in the study, and biliary stents were successfully placed in 37 cases (90.2%), while 4 cases (9.8%) were unsuccessful due to complete BS. Patients with ERCP guided biliary stenting had a significant improvement in bilirubin index compared to the preoperative period (
). 27 patients (73.0%) had complete relief of symptoms after 1 ERCP-guided treatment, and 10 patients (27.0%) developed BS again at different times after the first ERCP treatment, among which 8 patients developed BS again within 1 year after the first treatment and 2 patients developed BS again after 1 year after the first treatment. The incidence of endoscopy-related adverse events was 35.14%, with no serious adverse events. Conclusion. ERCP-guided biliary stenting was an effective and safety treatment for BS after LT.
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20
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Conigliaro R, Pigò F, Bertani H, Greco S, Burti C, Indriolo A, Di Sario A, Ortolani A, Maroni L, Tringali A, Barbaro F, Costamagna G, Magarotto A, Masci E, Mutignani M, Forti E, Tringali A, Parodi MC, Assandri L, Marrone C, Fantin A, Penagini R, Cantù P, Di Benedetto F, Ravelli P, Vivarelli M, Agnes S, Mazzaferro V, De Carlis L, Andorno E, Cillo U, Rossi G. Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group. Liver Int 2022; 42:1861-1871. [PMID: 35302273 DOI: 10.1111/liv.15246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/05/2022] [Accepted: 03/08/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND STUDY AIM The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.
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Affiliation(s)
- Rita Conigliaro
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Flavia Pigò
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Helga Bertani
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
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21
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Kuo CY, Wu JW, Yeh JH, Wang WL, Tu CH, Chiu HM, Liao WC. Implementing precision medicine in endoscopy practice. J Gastroenterol Hepatol 2022; 37:1455-1468. [PMID: 35778863 DOI: 10.1111/jgh.15933] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/17/2022] [Accepted: 06/28/2022] [Indexed: 12/12/2022]
Abstract
In contrast to the "one-size-fits-all" approach, precision medicine focuses on providing health care tailored to individual variabilities. Implementing precision medicine in endoscopy practice involves selecting the appropriate procedures among the endoscopic armamentarium in the diagnosis and management of patients in a logical sequence, jointly considering the pretest probabilities of possible diagnoses, patients' comorbidities and preference, and risk-benefit ratio of the individual procedures given the clinical scenario. The aim of this review is to summarize evidence-supported strategies and measures that may enhance precision medicine in general endoscopy practice.
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Affiliation(s)
- Chen-Ya Kuo
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Jer-Wei Wu
- Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
| | - Jen-Hao Yeh
- Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung, Taiwan
| | - Wen-Lun Wang
- Department of Internal Medicine, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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22
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Fasullo M, Patel M, Khanna L, Shah T. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000778. [PMID: 35552193 PMCID: PMC9109012 DOI: 10.1136/bmjgast-2021-000778] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
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Affiliation(s)
- Matthew Fasullo
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Milan Patel
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lauren Khanna
- Gastroenterology, New York University Medical Center, New York, New York, USA
| | - Tilak Shah
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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23
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Sandru V, Stan-Ilie M, Plotogea OM, Vladut C, Ungureanu BS, Balan GG, Gheonea DI, Constantinescu G. Endoscopic Management of Biliary Strictures after Orthotopic Liver Transplantation: A Single Center Experience Study. Diagnostics (Basel) 2022; 12:diagnostics12051221. [PMID: 35626376 PMCID: PMC9140460 DOI: 10.3390/diagnostics12051221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/17/2022] [Accepted: 05/12/2022] [Indexed: 12/04/2022] Open
Abstract
Background and Aim. Endoscopic therapy is the method of choice in the management of biliary strictures after orthotopic liver transplantation (OLT). Even though the mainstay approach for OLT stricture complications is represented by consecutive procedures of multiple plastic stents (MPS) insertion, a valuable alternative is the use of fully covered self-expandable metal stents (FCSEMS). The aim of the study was to compare MPS with FCSEMS used in the management of OLT biliary strictures, in terms of clinical outcomes and complications. Material and Methods. This is a retrospective, single-center study conducted between February 2014 and November 2019 in the Clinical Emergency Hospital of Bucharest, Romania. We enrolled all consecutive patients who developed biliary strictures after OLT and were treated by endoscopic retrograde cholangiopancreatography (ERCP) either with MPS or FCSEMS. Results. Thirty-six patients were included in the study, 27 patients had MPS and nine patients had FCSEMS. 106 ERCP procedures were performed and 159 stents were inserted. The mean number of ERCP procedures required per patient was significantly higher for MPS than for FCSEMS (3.34 ± 1.46 vs. 2.11 ± 0.33, p < 0.001). In the FCSEMS group only one patient had three procedures, due to stent migration. Difficult cannulation was encountered in 22 patients, 18 patients from MPS group and four patients from FCSEMS group. Dilation was performed in 20 (77%) MPS patients and in four FCSEMS patients (44%). Overall, we used 159 stents for stricture resolution, 149 plastic stents and 10 FCSEMS. Mean number of stents inserted was significantly lower in the FCSEMS group compared to MPS group (1.16 ± 0.40 vs. 5.73 ± 2.64, p < 0.001). Conclusions. Stricture resolution using FCSEMS is comparable to MPS and even has some advantages. In line with prior studies, FCSEMS are effective, with fewer complications and similar outcome compared to plastic stents. Other particular aspects should be further assessed, especially long-term follow up of FCSEMS and their cost efficiency.
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Affiliation(s)
- Vasile Sandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Madalina Stan-Ilie
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Oana-Mihaela Plotogea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalina Vladut
- Department of Gastroenterology, Prof. Dr. Agrippa Ionescu Clinical Emergency Hospital, 011356 Bucharest, Romania;
| | - Bogdan Silviu Ungureanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Correspondence:
| | - Gheorghe G. Balan
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania;
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, 700111 Iasi, Romania
| | - Dan Ionut Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Gabriel Constantinescu
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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24
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Fasullo M, Shah T, Zhou H, Siddiqui MS. Post-Transplant Biliary Strictures: An Updated Review. Semin Liver Dis 2022; 42:225-232. [PMID: 35263796 DOI: 10.1055/s-0042-1744144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Huiping Zhou
- Department of Microbiology and Immunology, VCU and McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mohammad S Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia
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25
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Ding S, Wu W, Lu J, Zhu H, Zheng S, Li Q. Migration of fully covered self-expandable metallic stents used to treat anastomotic strictures after orthotopic liver transplantation: A single-center, retrospective analysis. Medicine (Baltimore) 2022; 101:e28685. [PMID: 35089220 PMCID: PMC8797473 DOI: 10.1097/md.0000000000028685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 01/04/2022] [Indexed: 01/05/2023] Open
Abstract
Insertion of a fully covered self-expandable metallic stent (FCEM) through endoscopic retrograde cholangiopancreatography is an effective solution for biliary anastomotic stricture following orthotopic liver transplantation (OLT). However, FCEM migration continues to plague patients. This study aimed to evaluate the FCEM migration rate in our center, and to investigate the factors increasing the migration risk for FCEM.The study enrolled 43 post-OLT patients with confirmed duct-to-duct AS. The effects of age, gender, albumin, alanine aminotransferase, aspartate aminotransferase (AST), γ-glutamyl transpeptidase, alkaline phosphatase, total bilirubin, direct bilirubin, ABO (blood group system consists of four antigens) incompatibility, stricture length, FCEM brand, FCEM length, donor liver and recipient bile duct diameters, size mismatches between the donor and recipient bile ducts >2 mm, diabetes and/or hypertension status, endoscopic sphincterotomy status, the use of plastic stents or nasobiliary drainage prior to FCEM implantation, duration from OLT to FCEM placement, and OLT etiology on FCEM migration were retrospectively analyzed.The FCEM migration rate was 48.8% (21/43) at 6 months. The serum AST level was significantly higher in the migration group than that in the nonmigration group (52.48 vs 29.50 U/L, P < .05). A lower serum AST level was associated with a decreased risk of FCEM migration in post-OLT patients with duct-to-duct anastomotic stricture (hazard ratio = 0.968, 95% confidence interval: 0.940-0.996, P = .028).In this single-center, retrospective cohort study, we showed that an elevated serum AST level was a potential risk factor for FCEM migration.
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26
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Farida JP, Schulman AR. Time to Come Inside? A Novel Approach to Anastomotic Biliary Strictures. Liver Transpl 2022; 28:13-14. [PMID: 34596942 DOI: 10.1002/lt.26322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Jeremy P Farida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
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27
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Nishikawa Y, Uza N, Hata K, Marui S, Kuwada T, Matsumori T, Maruno T, Shiokawa M, Kuriyama K, Kurita A, Yazumi S, Kodama Y, Yoshizawa A, Anazawa T, Ito T, Uemoto S, Seno H. Long-term Outcomes of Stent Placement Inside the Bile Duct for Biliary Strictures After Living Donor Liver Transplantation. Liver Transpl 2022; 28:88-97. [PMID: 34327805 DOI: 10.1002/lt.26247] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
In living donor liver transplantation (LDLT), anastomotic biliary stricture is a serious and refractory complication. In this study, we reviewed the transition of post-LDLT anastomotic biliary strictures and evaluated long-term outcomes of stent placement inside the bile duct, which is referred to as an "inside-stent." Of 805 consecutive adult LDLT recipients in our institution (2000-2018), we reviewed 639 patients with duct-to-duct biliary reconstruction and analyzed chronological changes of post-LDLT biliary strictures. Moreover, we focused on the year 2006 when various surgical modifications were introduced and compared the details of post-LDLT biliary strictures before and after 2006, especially focusing on the long-term outcome of inside-stent placement. The proportion of left lobe grafts had increased from 1.8% before 2005 to 39.3% after 2006 (P < 0.001) to maximize the living donor safety. Overall, post-LDLT anastomotic biliary strictures occurred in 21.3% of the patients with a median follow-up period of 106.1 months, which was decreased from 32.6% before 2005 to 12.8% after 2006 (P < 0.001). Anastomotic biliary strictures were less frequent in patients with left lobe grafts than with right lobe grafts (9.4% versus 25.4%; P < 0.001). The overall technical success rate of inside-stent placement was 82.4%, with an improvement from 75.3% before 2005 up to 95.7% after 2006 (P < 0.01). Furthermore, the stricture resolution rate remained high at approximately 90% throughout the observation period. Increased use of left lobe grafts with several surgical modifications significantly reduced post-LDLT anastomotic biliary strictures, leading to favorable long-term outcomes of inside-stent placements for this condition.
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Affiliation(s)
- Yoshihiro Nishikawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kuwada
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoaki Matsumori
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takahisa Maruno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Shiokawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsutoshi Kuriyama
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Shiga, Japan
| | - Akira Kurita
- Digestive Disease Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Shujiro Yazumi
- Digestive Disease Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Atsushi Yoshizawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Anazawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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28
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Matar AJ, Ross-Driscoll K, Kenney L, Wichmann HK, Magliocca JF, Kitchens WH. Biliary Complications Following Adult Deceased Donor Liver Transplantation: Risk Factors and Implications at a High-volume US Center. Transplant Direct 2021; 7:e754. [PMID: 34514109 PMCID: PMC8425824 DOI: 10.1097/txd.0000000000001207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/11/2021] [Accepted: 07/02/2021] [Indexed: 01/20/2023] Open
Abstract
Biliary leaks and anastomotic strictures comprise the majority of biliary complications (BCs) following liver transplantation (LT). Currently, there are few large contemporary case series of BCs in adult deceased donor liver transplant (DDLT) recipients in the literature. The purpose of this study was to examine the pretransplant and intraoperative risk factors associated with BCs at a high-volume tertiary care center and determine the impact of these BCs on their posttransplant course and long-term transplant outcomes. METHODS We retrospectively reviewed all adult patients undergoing a DDLT from a donor after brain death (DBD) at Emory University between January 2015 and December 2019. RESULTS A total of 647 adult patients underwent DDLT from a DBD during the study period and were included in analyses. The median length of follow-up posttransplant was 2.5 y. There were a total of 27 bile leaks (4.2%) and 69 biliary strictures (10.7%). Recipient age and cold ischemic time were identified as risk factors for biliary leak, whereas alcoholic cirrhosis as transplant indication was a risk factor for biliary stricture. Placement of a biliary stent was associated with the development of both biliary leaks and anastomotic strictures. Posttransplant, biliary leaks were a significant risk factor for future episodes of acute rejection but did not impact overall survival. In contrast, biliary strictures were associated with a significantly reduced overall survival at 1- and 4-y post DDLT. CONCLUSIONS BCs are a major source of morbidity and mortality following DDLT, with strictures and leaks associated with distinct posttransplant complications.
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Affiliation(s)
- Abraham J. Matar
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Katie Ross-Driscoll
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Lisa Kenney
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Hannah K. Wichmann
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Joseph F. Magliocca
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - William H. Kitchens
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
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29
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Barbaro F, Tringali A, Larghi A, Baldan A, Onder G, Familiari P, Boškoski I, Perri V, Costamagna G. Endoscopic management of non-anastomotic biliary strictures following liver transplantation: Long-term results from a single-center experience. Dig Endosc 2021; 33:849-857. [PMID: 33080081 DOI: 10.1111/den.13879] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Studies on endoscopic treatment of non-anastomotic biliary strictures (NABS) following orthotopic liver transplantation (OLT) are scanty and with a short follow-up. The long-term results of endoscopic treatment with plastic stents of NABS following OLT were analyzed. METHODS Retrospective analysis of consecutive enrolled patients who underwent endoscopic treatment for NABS after OLT between 1997 and 2015. Endoscopic treatment success was defined as stricture resolution, without recurrence. RESULTS During the study period, 33 patients with NABS underwent endoscopic retrograde cholangiopancreatography (ERCP) in our center. A total of 68 ERCP were performed with a 4.4% of procedure-related adverse events. Mortality related to cholangitis secondary to endoscopic procedures was 12%. After median follow-up of 70.3 months from stents removal, NABS resolution was obtained in 12 out of 24 (50%) patients. Only one case of late NABS recurrence was observed which was successfully retreated endoscopically. According to our data analysis NABS occurring <12 months from OLT showed a worse prognosis (P < 0.04). CONCLUSIONS The follow-up of this study confirms that endoscopic treatment of NABS is unsatisfactory. However, patients who respond to endoscopic treatment maintain the response over time. Prompt treatment of acute cholangitis due to stents occlusion is advised in these patients to avoid high mortality rates.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Baldan
- Gastroenterology and Transplant Hepatology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Graziano Onder
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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30
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Jang SI, Chung TR, Cho JH, Lee KH, Joo SM, Choi JH, Kim SI, Lee DK. Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation. Dig Endosc 2021; 33:840-848. [PMID: 33043522 DOI: 10.1111/den.13871] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/08/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs. METHODS Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. RESULTS A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%). CONCLUSIONS The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.
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Affiliation(s)
- Sung Ill Jang
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Ryong Chung
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Moon Joo
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hye Choi
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sae In Kim
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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31
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Tao H, Wang P, Sun B, Zhou X, Xie J. One-step Percutaneous Transhepatic Cholangioscopy Combined With High-frequency Needle-knife Electrotomy in Biliary Strictures After Liver Transplantation. Surg Laparosc Endosc Percutan Tech 2021; 31:787-793. [PMID: 33935263 DOI: 10.1097/sle.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endoscopic management is the mainstay for biliary strictures after liver transplantation. However, this method is often failed in cases associated with hepatolithiasis or refractory strictures. The aim of this study is to investigate whether 1-step percutaneous transhepatic biliary cholangiography (PTC) combined with high-frequency needle-knife electrotomy can be an alternative method in biliary strictures after liver transplantation that could not be treated by endoscopic management. METHODS Clinical data of 14 patients suffering from biliary strictures after liver transplantation from June 2014 to January 2018 were retrospectively analyzed. One-step PTC combined with high-frequency needle-knife electrotomy was used to resolve the strictures. RESULTS One-step PTC was successfully performed in all 14 patients. In 10 of 12 (83.3%) patients with hepatolithiasis, the stones were removed completely. Stricture resolution was detected in 13 of 14 (92.9%) patients at first postoperative choledochoscopy. Three mild adverse events occurred (cholangitis, 2 patients; delayed hemobilia, 1 patient), but were resolved with conservative treatment. The follow-up after supporting catheter removal was 15.7±4.5 months. Only 1 patient (8.3%) had stone recurrence and no stenosis occurred during supporting-catheter-free follow-up. CONCLUSIONS One-step PTC combined with high-frequency needle-knife electrotomy seems to be a useful for treating biliary strictures after liver transplantation.
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Affiliation(s)
- Haisu Tao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Ping Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Beiwang Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xinghua Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiafen Xie
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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32
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Cantù P, Santi G, Rosa R, Parzanese I, Macchini F, Tenca A, Fanetti I, Invernizzi F, Donato MF, Lampertico P, Reggiani P, Rossi G, Vecchi M, Penagini R. Cost analysis of a long-term randomized controlled study in biliary duct-to-duct anastomotic stricture after liver transplantation. Transpl Int 2021; 34:825-834. [PMID: 33730421 DOI: 10.1111/tri.13867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Multiple plastic stent (MPS) for biliary anastomotic stricture (AS) after liver transplantation requires multiple procedures with consequent costs. To compare the success, adverse events and treatment-related costs of fully covered self-expandable metal stents (FCSEMS) versus MPS. Thirty liver transplant (LT) patients with clinically relevant naïve AS were prospectively randomized to FCSEMS or MPS, with stent numbers increased at 3-month intervals. Treatment costs per patient were calculated for endoscopic retrograde cholangiopancreatography (including all devices and stents) and overall hospital stay. Radiological success was achieved in 73% of FCSEMS (median indwelling period of 6 mos) and 93% of MPS patients (P = NS) (median period of 11 mos). AS recurrence occurred in 36% of FCSEMS and 7% of MPS patients (P = NS), and AS re-treatment was needed in 53% and 13% (P < 0.01), respectively, during follow-up of 60 (34-80) months. Stents migrated after 29% and 2.6% of FCSEMS and MPS procedures, respectively (P < 0.01). Including re-treatments, long-term clinical success was achieved in 28/30 (93%) patients. Overall treatment-related costs were similar between groups. In the subgroup of LT patients in clinical remission after first-line treatment, treatment costs were 41% lower per FCSEMS patient compared with MPS patients. FCSEMS did not perform better than MPS. FCSEMS migration increased the rate of re-treatment and costs.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulio Santi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Rosa
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Macchini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Tenca
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Clinic of Gastroenterology, Department of Medicine, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Ilaria Fanetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Invernizzi
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Francesca Donato
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Lampertico
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
| | - Paolo Reggiani
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Rossi
- Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy.,General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
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Sung MJ, Jo JH, Lee HS, Park JY, Bang S, Park SW, Song SY, Joo DJ, Chung MJ. Optimal drainage of anastomosis stricture after living donor liver transplantation. Surg Endosc 2021; 35:6307-6317. [PMID: 33796905 DOI: 10.1007/s00464-021-08456-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/17/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). METHODS Patients with biliary ASs after an LDLT (mean age: 57.3 years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4 months. Patients were followed-up for at least 1-year post-stent removal. RESULTS Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2 months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4 months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59). CONCLUSIONS EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.
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Affiliation(s)
- Min Je Sung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Gastroenterology, Department of Internal Medicine CHA Bundang Medical Center, CHA University, Gyeonggi-do, Republic of Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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35
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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36
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Poley JW, Ponchon T, Puespoek A, Bruno M, Roy A, Peetermans J, Rousseau M, Lépilliez V, Dolak W, Tringali A, Blero D, Carr-Locke D, Costamagna G, Devière J. Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes. Gastrointest Endosc 2020; 92:1216-1224. [PMID: 32417298 DOI: 10.1016/j.gie.2020.04.078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Minimally invasive treatments of anastomotic benign biliary stricture (BBS) after orthotopic liver transplantation (OLT) include endoscopic placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMSs). No multiyear efficacy data are available on FCSEMS treatment after OLT. METHODS We prospectively studied long-term efficacy and safety of FCSEMS treatment in adults aged ≥18 years with past OLT, cholangiographically confirmed BBS, and an indication for ERCP with stent placement. Stent removal was planned after 4 to 6 months, with subsequent follow-up until 5 years or stricture recurrence. Long-term outcomes were freedom from stricture recurrence, freedom from recurrent stent placement, and stent-related serious adverse events (SAEs). RESULTS In 41 patients, long-term follow-up began after FCSEMS removal (n = 33) or observation of complete distal migration (CDM) (n = 8). On an intention-to-treat basis, the 5-year probability of remaining stent-free after FCSEMS removal or observation of CDM was 48.9% (95% confidence interval [CI], 33.2%-64.7%) among all patients and 60.9% (95% CI, 43.6%-78.2%) among 31 patients with over 4 months of FCSEMS indwell time. In 28 patients with stricture resolution at FCSEMS removal or observed CDM (median, 5.0 months indwell time), the 5-year probability of no stricture recurrence was 72.6% (95% CI, 55.3%-90%). Sixteen patients (39%) had at least 1 related SAE, most commonly cholangitis (n = 10). CONCLUSIONS By 5 years after temporary FCSEMS treatment of post-OLT BBS, approximately half of all patients remained stent-free on an intention-to-treat basis. Stent-related SAEs (especially cholangitis) were common. FCSEMS placement is a viable long-term treatment option for patients with post-OLT BBS. (Clinical trial registration number: NCT01014390.).
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Affiliation(s)
- Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Thierry Ponchon
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Lyon, France
| | - Andreas Puespoek
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - André Roy
- Département de Chirurgie, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | | | | | - Vincent Lépilliez
- Service d'Hépato-Gastroentérologie, Hôpital Edouard Herriot, Lyon, France
| | - Werner Dolak
- Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Vienna, Austria
| | - Andrea Tringali
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Daniel Blero
- Department of Gastroenterology and Hepato-pancreatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - David Carr-Locke
- The Center for Advanced Digestive Care, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Guido Costamagna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Centre for Endoscopic Research Therapeutics and Training (CERTT), Rome, Italy
| | - Jacques Devière
- Department of Gastroenterology and Hepato-pancreatology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dumortier J, Chambon-Augoyard C, Guillaud O, Pioche M, Rivory J, Valette PJ, Adham M, Ponchon T, Scoazec JY, Boillot O. Anastomotic bilio-biliary stricture after adult liver transplantation: A retrospective study over 20 years in a single center. Clin Res Hepatol Gastroenterol 2020; 44:564-571. [PMID: 31547998 DOI: 10.1016/j.clinre.2019.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary complications are the main surgical complication after liver transplantation (LT). The aims of the present retrospective single center study were to describe anastomotic bilio-biliary strictures (ABS) in a large cohort of liver transplant recipients with long follow-up. METHODS All adult LT recipients who underwent a LT, with bilio-biliary anastomosis, between 1990 and 2010 in Edouard Herriot hospital, Lyon, France were included in the study. RESULTS The study population consisted in 783 patients (70.0% males), median age 50.5 years; main indication was alcohol-related liver disease (46.8%). The median follow-up after LT was 11.9 years (range 0-27 years). The overall incidence of anastomotic biliary complications was 9.7%: 50 patients developed an ABS (6.6%), after a median delay of 4.4 months (range 0.1-245.2) after LT and 32 (4.1%) developed biliary leakage after a median delay of 25 days (range 1-179). The actuarial risk of developing an ABS was 1.6% at 1-month, 2.7% at 3-months, 4.1% at 6-months, and 5.1%, 6.0%, 6.4%, 6.6%, 7.3% at 1-, 2-, 5-, 10- and 15-years, respectively. Univariate analysis disclosed that post-reperfusion syndrome and liver graft steatosis (≥30%) were significant risk factors for ABS. Multivariate analysis disclosed that graft steatosis (OR=6.262, 95%CI 1.936-20.257, P=0.002) and MELD score (OR=1.071, 95%CI 1.018-1.128, P=0.008) were significant risk factors for ABS. The first-line treatment of ABS consisted in endoscopic stenting for 44 patients (88.0%) and immediate success rate was 75.0%. Delayed recurrence of ABS occurred in 8/33 patients (24.0%). CONCLUSION Our results suggest that steatotic grafts should be used for recipients without severe liver failure to avoid ABS, and that endoscopic stenting of post-LT ABS leads to a high success rate, but is associated with a significant risk of recurrence.
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Affiliation(s)
- Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France.
| | - Christine Chambon-Augoyard
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France
| | - Olivier Guillaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France
| | - Mathieu Pioche
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France
| | - Jérôme Rivory
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France
| | - Pierre-Jean Valette
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Radiologie digestive, Lyon, France
| | - Mustapha Adham
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Thierry Ponchon
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Yves Scoazec
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Anatomie et Cytologie Pathologiques, Lyon, France
| | - Olivier Boillot
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
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39
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Jang SI, Cho JH, Lee DK. Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture. Clin Endosc 2020; 53:266-275. [PMID: 32506893 PMCID: PMC7280848 DOI: 10.5946/ce.2020.095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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40
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Khoury T, Kumar M, Mizrahi M. Concise Commentary: Penny Wise and Pound Foolish-Why SEMS Makes More Sense When Treating Post-anastomotic Biliary Strictures. Dig Dis Sci 2020; 65:609-610. [PMID: 31555947 DOI: 10.1007/s10620-019-05810-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Manoj Kumar
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Meir Mizrahi
- Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, AL, USA.
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Jang S, Stevens T, Lopez R, Chahal P, Bhatt A, Sanaka M, Vargo JJ. Self-Expandable Metallic Stent Is More Cost Efficient Than Plastic Stent in Treating Anastomotic Biliary Stricture. Dig Dis Sci 2020; 65:600-608. [PMID: 31104197 DOI: 10.1007/s10620-019-05665-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 05/07/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Anastomotic bile duct stricture (ABS) is one of the most common complications after liver transplantation. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with multiple plastic stent (MPS) insertion often requires multiple sessions before achieving stricture resolution. We aimed to compare the efficacy of fully covered self-expandable metallic stent (FCSEMS) with MPS method while simultaneously analyzing the relative healthcare cost between the two methods in the management of ABS. METHODS Liver transplant patients with ABS who received ERCP with stent placement were identified by query of our endoscopic database. Comparative analyses between the group of patients treated with ERCP with MPS and the group treated with FCSEMS were performed. The costs to achieve stricture resolution, and the rates of stricture resolution, recurrence and complications were also compared. RESULTS A total of 158 patients underwent ERCP with stent insertion for the management of ABS. Of those, 49 patient received FCSEMS for their ABS while 109 patients were treated with MPS only. Our cost analysis showed early utilization of FCSEMS can deliver up to 25% savings in the total procedure cost while providing comparable rates of stricture resolution. The rates of technical success, stricture recurrence and adverse outcomes, and stricture free durations were also comparable between the two groups. CONCLUSION While providing efficacy and safety rates comparable to ERCP-MPS, the incorporation of FCSEMS at early stage of ABS management could provide a substantial savings by reducing the number of ERCP session to achieve stricture resolution. Optimization of the timing and duration of FCSEMS indwelling time needs further validation.
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Affiliation(s)
- Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA.
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA
| | - Rocio Lopez
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA
| | - Madhu Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Q3-1, Cleveland, OH, 44195, USA
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Han SJ, Jang SI, Yoo SH, Lee DK. A case with combined postoperative bile leakage and anastomotic stricture after liver transplantation treated with magnet compression anastomosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Sang Jo Han
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hwan Yoo
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Li Y, Sun H, Yan X, Wang S, Dong D, Liu X, Wang B, Su M, Lv Y. Magnetic compression anastomosis for the treatment of benign biliary strictures: a clinical study from China. Surg Endosc 2019; 34:2541-2550. [PMID: 31399950 DOI: 10.1007/s00464-019-07063-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/05/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Magnetic compression anastomosis (MCA) is a revolutionary minimally invasive method to perform choledochocholedochostomy in patients with benign biliary stricture (BBS). We conducted MCA for the treatment of severe BBS that could not be treated by conventional methods. PATIENTS AND METHODS Patients with BBSs that could not be treated using conventional treatments were included. All patients underwent percutaneous transhepatic biliary drainage (PTBD) before MCA, and underwent cholangiography via simultaneous PTBD and endoscopic retrograde cholangiopancreatography (ERCP). The MCA device consisted of a parent and a daughter magnet. The daughter magnet was delivered via the PTBD route to the proximal end of the obstruction, and the parent magnet was delivered via ERCP to the distal end of the obstruction. After recanalization, the MCA device was removed, and biliary stenting (or PTBD) was performed for at least 6 months. RESULTS Of the 9 patients (age 49 ± 12.9 years), 6 had undergone orthotopic liver transplantation. MCA was successful in all 9 patients. The stricture length was 3 ± 1.7 mm, and recanalization occurred after 16.3 ± 13.2 days. Multiple plastic stents (4 patients), fully covered self-expandable metallic stents (4 patients), or PTBD (1 patient) was used after recanalization. Two mild adverse events occurred (cholangitis, 1 patient; biliary bleeding, 1 patient), but were resolved with conservative treatment. Stents were retrieved after > 6 months, and no stenosis occurred during 2-66 months of stent-free follow-up. CONCLUSION The MCA technique is a revolutionary method for choledochocholedochostomy in patients with severe BBS unresponsive to conventional procedures.
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Affiliation(s)
- Yu Li
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Hao Sun
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Xiaopeng Yan
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Shanpei Wang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Xuemin Liu
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Bo Wang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Maosheng Su
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yi Lv
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
- Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
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Efficacy of Different Endoscopic Stents in the Management of Postoperative Biliary Strictures: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2019; 53:418-426. [PMID: 30807403 DOI: 10.1097/mcg.0000000000001193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endoscopic stents are the first-line treatment in the management of benign biliary stricture (BBS) which include multiple plastic stents (MPSs), fully covered self-expandable metal stents (FCSEMS) including the conventional and modified ones (FCSEMS-C and FCSEMS-M) and biodegradable stents. However, different stents have their distinct advantages and disadvantages. We aim to conduct this systematic review to compare the efficacy of different stents in the management of BBS. METHODS Several databases were searched from inception through March 2018. Studies including >10 patients with postoperative stricture treated with endoscopic stents were enrolled. Pooled odds ratio of outcomes were calculated to compare MPS with FCSEMS. Weighted pooled rates were calculated to show the efficacy of FCSEMS-M, FCSEMS-C, and MPS. RESULTS Twenty-two articles were reviewed including 4 randomized controlled studies, 4 cohort studies, and 14 case series studies. Comparing FCSEMS with MPS, the pooled odds ratio was 0.48 [95% confidence interval (CI): 0.22-1.05] (P=0.07) for stricture resolution, 0.3 (95% CI: 0.1-0.92) (P=0.03) for adverse event, 1.9 (95% CI: 0.3-12) (P=0.49) for stent migration, and 1.38 (95% CI: 0.36-5.3) (P=0.34) for stricture recurrence. The pooled rates for stricture recurrence of MPS, FCSEMS-C, and FCSEMS-M were 19%, 19%, and 7%, respectively. The pooled rates for stent migration were 4% of MPS, 25% of FCSEMS-C, and 3% of FCSEMS-M. CONCLUSIONS FCSEMS-M is more favorable in the management of BBS comparing with MPS or FCSEMS-C. The biodegradable stent may be a promising option but currently available data is insufficient to draw a firm conclusion.
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Cantù P, Tarantino I, Baldan A, Mutignani M, Tringali A, Lombardi G, Cerofolini A, Di Sario A, Catalano G, Bertani H, Ghinolfi D, Boarino V, Masci E, Bulajic M, Pisani A, Fantin A, Ligresti D, Barresi L, Traina M, Ravelli P, Forti E, Barbaro F, Costamagna G, Rodella L, Maroni L, Salizzoni M, Conigliaro R, Filipponi F, Merighi A, Staiano T, Monteleone M, Mazzaferro V, Zucchi E, Zilli M, Nadal E, Rosa R, Santi G, Parzanese I, De Carlis L, Donato MF, Lampertico P, Maggi U, Caccamo L, Rossi G, Vecchi M, Penagini R. Endo-therapies for biliary duct-to-duct anastomotic stricture after liver transplantation: Outcomes of a nationwide survey. Liver Int 2019; 39:1355-1362. [PMID: 30500104 DOI: 10.1111/liv.14010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/03/2018] [Accepted: 11/14/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. AIM To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy. METHODS Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). RESULTS Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self-expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self-expandable metal stenting). After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered self-expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self-expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self-expandable metal stenting) respectively. Procedure-related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow-up of 25 months. CONCLUSION Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered self-expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Anna Baldan
- Digestive Endoscopy Unit, Department of Gastroenterology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Massimiliano Mutignani
- Diagnostic and Interventional Digestive Endoscopy, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Gemelli University Hospital, Catholic University, Rome, Italy
| | | | | | - Antonio Di Sario
- Department of Gastroenterology and Transplantation, Gastroenterology Clinic, Polytechnic Marche University - United Hospitals of Ancona, Ancona, Italy
| | - Giorgia Catalano
- Liver Transplant Center and General Surgery, A.O.U. Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin, Turin, Italy
| | - Helga Bertani
- U.O.C. Gastroenterology and Digestive Endoscopy Unit, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Oncology, Transplants and Advances in Medicine, University of Pisa Medical School Hospital, Pisa, Italy
| | - Valentina Boarino
- Gastroenterology and Endoscopy Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Enzo Masci
- Diagnostic and Therapeutic Endoscopy Unit, Foundation IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Milutin Bulajic
- University Clinical Hospital "Santa Maria della Misericordia", Udine, Italy
| | - Antonio Pisani
- Gastroenterology Section, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alberto Fantin
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Azienda Ospedaliera - Università di Padova, Padova, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Paolo Ravelli
- Digestive Endoscopy Unit, Department of Gastroenterology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Edoardo Forti
- Diagnostic and Interventional Digestive Endoscopy, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Federico Barbaro
- Digestive Endoscopy Unit, Gemelli University Hospital, Catholic University, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Gemelli University Hospital, Catholic University, Rome, Italy
| | - Luca Rodella
- Emergency Endoscopy Unit, Borgo Trento Hospital, Verona, Italy
| | - Luca Maroni
- Department of Gastroenterology and Transplantation, Gastroenterology Clinic, Polytechnic Marche University - United Hospitals of Ancona, Ancona, Italy
| | - Mauro Salizzoni
- Liver Transplant Center and General Surgery, A.O.U. Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin, Turin, Italy
| | - Rita Conigliaro
- U.O.C. Gastroenterology and Digestive Endoscopy Unit, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Franco Filipponi
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Oncology, Transplants and Advances in Medicine, University of Pisa Medical School Hospital, Pisa, Italy
| | - Alberto Merighi
- Gastroenterology and Endoscopy Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Teresa Staiano
- Diagnostic and Therapeutic Endoscopy Unit, Foundation IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Michela Monteleone
- Liver Surgery, Transplantation and Gastroenterology, University of Milan and Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Vincenzo Mazzaferro
- Liver Surgery, Transplantation and Gastroenterology, University of Milan and Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Elena Zucchi
- University Clinical Hospital "Santa Maria della Misericordia", Udine, Italy
| | - Maurizio Zilli
- University Clinical Hospital "Santa Maria della Misericordia", Udine, Italy
| | - Elena Nadal
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Azienda Ospedaliera - Università di Padova, Padova, Italy
| | - Roberto Rosa
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi, Milan, Italy
| | - Giulio Santi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi, Milan, Italy
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Università degli Studi Milano-Bicocca, Milan, Italy
| | - Maria Francesca Donato
- Gastroenterology and Hepatology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Pietro Lampertico
- Università degli Studi, Milan, Italy.,Gastroenterology and Hepatology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Umberto Maggi
- General Surgery and Liver Transplantation Unit, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucio Caccamo
- General Surgery and Liver Transplantation Unit, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Rossi
- Università degli Studi, Milan, Italy.,General Surgery and Liver Transplantation Unit, Department of Pathophysiology and Transplantation, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi, Milan, Italy
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Bartel MJ, Higa JT, Tokar JL. The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures. Curr Gastroenterol Rep 2019; 21:29. [PMID: 31098767 DOI: 10.1007/s11894-019-0696-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage. RECENT FINDINGS Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.
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Affiliation(s)
- M J Bartel
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA.
| | - J T Higa
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
| | - J L Tokar
- Section of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, PA, USA
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Akhter A, Pfau P, Benson M, Soni A, Gopal D. Endoscopic management of biliary strictures post-liver transplantation. World J Meta-Anal 2019; 7:120-128. [DOI: 10.13105/wjma.v7.i4.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ahmed Akhter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Patrick Pfau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Mark Benson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Anurag Soni
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Jang SI, Lee KH, Joo SM, Park H, Choi JH, Lee DK. Maintenance of the fistulous tract after recanalization via magnetic compression anastomosis in completely obstructed benign biliary stricture. Scand J Gastroenterol 2019; 53:1393-1398. [PMID: 30351979 DOI: 10.1080/00365521.2018.1526968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study compared the efficacy of a percutaneous transhepatic cholangioscopy (PTCS) catheter and a fully covered self-expandable metal stent (FCSEMS) for maintaining biliary tract patency after magnetic compression anastomosis (MCA). METHODS This study included patients with completely obstructed benign biliary stricture (BBS), which was resolved by MCA and subsequent insertion of a PTCS catheter or FCSEMS. We compared the restenosis-free time after removal of the PTCS catheter or FCSEMS, and the rate of complications. RESULTS A total of 49 patients were analyzed. The mean ages of the patients in these groups were 50.1 and 49.6 years, respectively. The predisposing conditions causing complete BBS were liver transplantation (n = 38), abdominal surgery (n = 10) and trauma (n = 1). The mean indwelling durations were 176 and 128 days in the PTCS catheter and FCSEMS groups, respectively. The mean follow-up duration after removal of the PTCS catheter and FCSEMS were 2259 and 680.5 days, respectively. Three patients in the PTCS group and three patients in the FCSEMS group experienced stricture relapse. The mean duration between recurrence and stent removal were 924 and 265 days, respectively, and the numbers of stricture-free days did not differ significantly between the two groups. The adverse event rate did not differ significantly between the PTCS and FCSEMS groups (50% vs. 24.2%, respectively). CONCLUSIONS FCSEMSs have an efficacy and safety similar to those of PTCS catheters for maintaining biliary tract patency after MCA, but are more convenient for patients.
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Affiliation(s)
- Sung Ill Jang
- a Department of Internal Medicine , Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
| | - Kwang-Hun Lee
- b Department of Radiology , Gangnam Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
| | - Seung-Moon Joo
- b Department of Radiology , Gangnam Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
| | - Hyunsung Park
- a Department of Internal Medicine , Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
| | - Jung Hye Choi
- a Department of Internal Medicine , Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
| | - Dong Ki Lee
- a Department of Internal Medicine , Severance Hospital, Yonsei University College of Medicine , Seoul , Korea
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Tringali A, Tarantino I, Barresi L, Traina M, Bonato G, Cintolo M, Hassan C, Mutignani M, Adler DG. Multiple plastic versus fully covered metal stents for managing post-liver transplantation anastomotic biliary strictures: a meta-analysis of randomized controlled trials. Ann Gastroenterol 2019; 32:407-415. [PMID: 31263364 PMCID: PMC6595920 DOI: 10.20524/aog.2019.0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/23/2019] [Indexed: 12/15/2022] Open
Abstract
Background Anastomotic biliary strictures (ABS) following liver transplantation (LT) are one of the most common complications, occurring in 4.5-32% of patients. Multiple plastic stenting (MPS) requires multiple sessions, with the associated risk, cost and patient discomfort. Fully covered self-expandable metal stents (FC-SEMS) have increasingly been used in this setting. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing the role of FC-SEMS and MPS in the treatment of ABS post-LT. Methods We conducted a bibliographic search using PubMed and EMBASE, aimed at identifying available RCTs that compared MPS to FC-SEMS in patients with ABS post LT from January 2000 to October 2017. Primary outcomes were ABS resolution and recurrence, while secondary outcomes were adverse events and number of procedures performed. Pooled estimates were calculated using random-effects models. Results Four RCTs (205 patients) were included. ABS resolution and recurrence did not differ significantly between the groups (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.43-2.56, P=0.92; and OR 2.37, 95%CI 0.54-10.38, P=0.25). The same was true for adverse events (OR 0.91, 95%CI 0.84-3.48, P=0.86) and migration rate (OR 1.31, 95%CI 0.46-3.71, P=0.61). The mean number of endoscopic retrograde cholangiopancreatography procedures was lower for FC-SEMS (mean difference [MD] -2.08). Conclusions FC-SEMS and MPS had equal ABS resolution and recurrence, although there was a trend towards a higher recurrence rate in FC-SEMS that disappeared when trials with a shorter stent indwelling time were excluding. No difference was found in overall adverse events or migration rate.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Ilaria Tarantino
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Luca Barresi
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Mario Traina
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Giulia Bonato
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Marcello Cintolo
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy (Cesare Hassan)
| | - Massimiliano Mutignani
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Douglas G Adler
- Division of Gastroenterology & Hepatology University of Utah, Salt Lake City, Utah, USA (Douglas G. Adler)
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Crismale JF, Ahmad J. Endoscopic Management of Biliary Issues in the Liver Transplant Patient. Gastrointest Endosc Clin N Am 2019; 29:237-256. [PMID: 30846151 DOI: 10.1016/j.giec.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Biliary complications remain a common problem after liver transplantation (LT). The therapeutic endoscopist encounters a variety of situations in LT including strictures at the duct-to-duct biliary anastomosis, strictures elsewhere in the biliary tree caused by an ischemic injury, and bile leaks at the anastomosis or from the cut surface and stone disease. Biliary complications lead to significant morbidity and occasionally reduced graft and patient survival. Several factors increase the risk of strictures and leaks. Endoscopic intervention in experienced hands is successful in the management of biliary complications following LT and percutaneous or surgical correction should seldom be required.
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Affiliation(s)
- James F Crismale
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jawad Ahmad
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
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