Potential effect of cyclosporin A in formation of cholesterol gallstones in pediatric liver transplant recipients

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Small bowel obstruction due to Roux-en-Y enterolith 13 years following deceased donor liver transplantation: a case report

Primary sclerosing cholangitis (PSC) is a progressive, cholestatic liver disease, and liver transplantation (LT) is considered the only therapeutic option for patients with end-stage liver disease secondary to PSC. Intestinal obstruction in adults after LT surgery is a rare complication with diverse clinical presentations. The most common etiology is intestinal adhesions, but this can also result from other rare causes such as enterolith. We describe the first case report of small bowel obstruction secondary to biliary stone formation in the common limb of Roux-en-Y hepaticojejunostomy 13 years after the deceased donor LT. The patient failed initial conservative management and developed peritonitis, requiring urgent surgical exploration to remove the enterolith and resect the involved small bowel. In conclusion, small bowel obstructions due to enteroliths are unusual clinical complications following LT, which require a high degree of suspicion in patients who develop a bowel obstruction in the setting of a previous hepaticojejunostomy.

Management of Biliary Complications in Liver Transplant Recipients

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population

Cholelithiasis is one of the most prevalent diseases in the general population. Among kidney transplant (KT) recipients, atypical clinical presentation may delay the diagnosis and proper treatment. This single-center retrospective cohort study compared cholelithiasis clinical presentation and cholecystectomy-associated complications in 230 KT recipients and in 172 members of the general population. KT recipients had a higher proportion of men, comorbidities, biliary pancreatitis, choledocholithiasis, and acute cholecystitis clinical presentations than the general population. KT recipients presented higher American Society of Anesthesiologists scores and higher rates of emergency surgeries (15.7% vs 9.9%, P = .091), conversion (5.7% vs 1.2%, P = .019), drainage (7.8% vs 2.3%, P = .016), postoperative complications (10% vs 4.7%, P = .047), and longer hospital length of stay (1 vs 1 days, interquartile range, 2 vs 0 days; P < .001). There were 5 deaths, all of which occurred in KT recipients. History of diabetes mellitus, renal function, and surgical conversion were independent risk factors associated with postoperative complications. Male sex and level of renal function were independent risk factors associated with postoperative acute cholecystitis. KT was an independent risk factor associated with postoperative choledocholithiasis (adjusted odds ratio, 5.89; 95% confidence interval, 3.03-15.66) and pancreatitis (adjusted odds ratio, 6.89; 95% confidence interval, 2.99-11.61). In conclusion, KT recipients with cholelithiasis have an increased risk for clinical and surgical complications compared with the general population.

Incidence and Treatment of Bile Stones After Liver Transplant

OBJECTIVES

Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality.

MATERIALS AND METHODS

We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens.

RESULTS

Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures.

CONCLUSIONS

Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.

Small bowel obstruction due to an unconjugated ursodeoxycholic acid enterolith following living donor liver transplantation: Report of a case

We report an unusual case of small bowel obstruction due to an ursodeoxycholic acid (UDCA) enterolith that occurred 7 years after liver transplantation. A 70-year-old man had undergone multiple operations, including a living donor liver transplantation (LDLT) and hepaticojejunostomy. Four years after the LDLT, cholestasis developed, for which oral UDCA was administrated. Seven years after the LDLT, he was admitted to our hospital because of pneumonia; intestinal obstruction occurred following its resolution. A radiographic contrast study and computed tomographic scan indicated a movable mass as the cause of the ileus, suggesting a giant stone. We were unable to observe or remove the stone by double balloon enteroscopy owing to the presence of severe adhesion; thus, we surgically removed the mass. The patient's postoperative course was uneventful. He was discharged 20 days after the operation. An infrared spectrophotometric analysis revealed that the stone was a true enterolith, primarily composed of unconjugated UDCA. An ileus caused by a true enterolith is a rare clinical complication of LDLT. Nevertheless, it must be considered in the differential diagnosis of intestinal obstructions in liver transplant recipients with Roux-en-Y hepaticojejunostomies and/or bowel stasis.

[Laparoscopic cholecystectomy in transplant patients]

OBJECTIVE

This study reviews our experience with laparoscopic cholecystectomy in the treatment of cholelithiasis in transplant patients.

METHODS

Demographic data, medications used, and operative and postoperative data of all transplant recipients who were subjected to laparoscopic cholecystectomy for cholelithiasis at our hospital were obtained.

RESULTS

A total of 15 transplant patients (13 renal transplantation and 2 bone marrow transplantation) underwent laparoscopic cholecystectomy. All patients were admitted to the hospital on the day of the operation. The immunosuppressive regimen was not modified during hospitalization. Clinical presentation of cholelithiasis was biliary colicky (n=12), acute cholecystitis (n=2), and jaundice (n=1). The operation was uneventful in all patients. Postoperative complications were nausea and vomiting in 2 patients, prolonged tracheal intubation in 1, wound infection in 1 and large superficial hematoma in 1 patient.

CONCLUSION

Laparoscopic cholecystectomy is associated to a low morbidity and mortality and good postoperative outcome in transplant patients with uncomplicated cholecystitis.

Biliary diseases in heart transplanted patients: a comparison between cyclosporine A versus tacrolimus-based immunosuppression

A cyclosporine (CsA)-based immunosuppression is associated with an increased incidence of cholelithiasis after heart transplantation. It is not known if tacrolimus (Tac) has comparable biliary side effects in humans.

We evaluated the incidence of gallbladder sludge and cholelithiasis under Tac-based immunosuppression by ultrasound examinations in 31 cardiac transplants (25 male, 6 female, mean age: 59 ± 11 years). Data were compared to 57 patients (47 male, 10 female, mean age: 58 ± 11 years) who received CsA-based immunosuppression.

6 patients receiving Tac and 6 patients receiving CsA had already gallstones prior to transplantation so that finally 25 patients of the Tac group and 51 patients of the CsA group could be evaluated.

In the Tac group the incidence of biliary sludge was 4% (1 of 25), of gallstones 28% (7 of 25). In comparison, patients receiving CsA developed biliary sludge in also 4% (2 of 51) and gallstones in 25% (13 of 51). Nine of 42 males in the CsA group (21%) and eight of 20 males in the Tac group (40%) developed either gallstones or sludge (n.s). Six of nine females in the CsA group (67%), but none of five females in the Tac group (0%) developed either gallstones or sludge (p = 0.01).

In summary, the incidence of biliary disease in patients with Tac is comparable with CsA-based immunosuppression. We recommend regular sonographical examinations to detect biliary diseases as early as possible. In cases of clinically, laboratory and sonographical signs of cholecystitis cholecystectomy is indicated. It seems that towards lithogenicity female patients benefit more from a Tac-based treatment because the occurrence of gallstones is rare.

Risk factors and outcomes in post-liver transplantation bile duct stones and casts: A case-control study

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post-liver transplant. A case-control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t-tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre- and post-OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18-year-period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow-up of 1530 days. Use of ursodeoxycholic acid was protective (P = 0.005), whereas bile duct pathology (P = 0.003), total cholesterol >/= 200 mg/dL (P = 0.008), and triglyceride >/= 150 mg/dL (P = 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients.

Perioperative concerns for transplant recipients undergoing nontransplant surgery

At some time in a general surgeon's career it is likely that they will be asked to care for a surgical problem in a transplant recipient. In many instances, the treating surgeon may opt for transferring the patient to a transplant center more familiar with organ transplant recipients, but at other times transfer may not be the optimal option for the patient. This article is intended to touch on some of the more common situations that a general surgeon in community practice might encounter in dealing with organ transplant recipients, and highlight perioperative and in a few cases, intraoperative, concerns.

Obstructive jaundice caused by biliary stone formation around the stent after liver transplantation

We report an unusual case of obstructive jaundice caused by a biliary stone, which developed in the stump of a Roux-en-Y hepaticojejunostomy after undergoing LT. The patient was a 13-yr-old male. At 74 days after birth, a hepaticojejunostomy (Kasai's procedure) was performed for the treatment of biliary atresia. He underwent a reduced size deceased donor LT in the left subphrenic space twice at the age of one and three years in Australia. Eleven years after his second LT, he developed liver dysfunction and jaundice with a low grade fever. Computed tomography showed a marked jejunal loop enlargement by a rugby ball-shaped stone and the bile duct in the graft was thus dilated. A surgical exploration revealed the jejunal loop to be bent sharply while its stump side was dilated by stagnated bile including a biliary stone. The stone included a stent that had been previously used for the hepaticojejunostomy. This case suggests that a retained stent used for hepaticojejunostomy had thus caused biliary stone formation because of a combination of various conditions in the jejunal loop.

Management of asymptomatic cholelithiasis for patients awaiting renal transplantation

BACKGROUND

There is no consensus regarding the most appropriate management of asymptomatic cholelithiasis in patients awaiting renal transplantation. Cholecystectomy is considered before renal transplantation because of potential worsened complications from cholelithiasis with posttransplantation immunosuppression. This study reviewed the outcomes for operative and nonoperative management of asymptomatic cholelithiasis in patients awaiting renal transplantation.

METHODS

A retrospective chart review of all patients who received renal transplant at the authors' institution during the period 1994 to 2000 was completed. All patients underwent pretransplantation abdominal ultrasound.

RESULTS

Of the 411 patients receiving renal transplants (242 men and 169 women with a mean age of 45.7 years), 32 had cholelithiasis at the pretransplantation workup (7.8%), and 35 had gallbladder abnormalities (8.5%): polyps, thickened wall, sludge, bile duct dilation. Before transplantation, 12 of the 32 patients (38%) with cholelithiasis underwent uncomplicated cholecystectomy. None of the remaining 19 patients with cholelithiasis required cholecystectomy after renal transplantation (mean follow-up period 6.2 years). Of the 35 patients with gallbladder abnormalities, 2 required post transplantation elective cholecystectomy.

CONCLUSIONS

No evidence was found for increased morbidity related to cholelithiasis or gallbladder abnormalities after renal transplantation. As in the general population, the risks associated with asymptomatic cholelithiasis do not appear to warrant prophylactic cholecystectomy for patients awaiting renal transplantation.

Biliary casts after orthotopic liver transplantation: clinical factors, treatment, biochemical analysis

OBJECTIVES

Biliary casts develop in up to 18% of liver transplant recipients. Casts are associated with morbidity, graft failure, need for retransplantation, and mortality. Proposed etiological mechanisms include acute cellular rejection, ischemia, infection, and biliary obstruction. We aimed to identify clinical features associated with biliary cast formation, review treatments, and analyze the biochemical composition of casts at a single, large, liver transplant center.

METHODS

Patient records were reviewed retrospectively to identify patients who developed casts. Data were collected with attention to ischemia, rejection, obstruction, infection, immunosuppression, postoperative biliary drain use, and cast-directed management, and were compared with data from controls. Cast specimens, retrieved at cholangiography, were analyzed with chromatography techniques.

RESULTS

Ischemic factors were noted in 70% (7/10) of cast patients versus 15% (6/40) of controls (OR = 13.2; 95% CI = 2.7-66.0; p = 0.001). Biliary strictures were present in 50% of cast patients versus 10% of controls (OR = 9.0; 95% CI = 1.8-45.2; p = 0.01). Differences in cold ischemia time, acute cellular rejection, cyclosporin use, infection, and postoperative biliary drain use were not significant. Casts were successfully treated by endoscopic and percutaneous methods in 60% of patients. One patient died of cast-related complications (mortality 10%). Four casts were in satisfactory condition for biochemical analysis. Bilirubin was the main component ( approximately 10-50%). Bile acid synthesis products and cholesterol comprised smaller percentages, and protein comprised only 5-10%.

CONCLUSIONS

Biliary casts are more likely to develop in the setting of hepatic ischemia and biliary strictures. Endoscopic and percutaneous cast extraction might achieve favorable results and should be attempted before surgical therapy.

Cholangitis caused by Roux-en-Y hepaticojejunostomy obstruction by a biliary stone after liver transplantation

Biliary stones may occur after liver transplantation, mostly in relation with biliary strictures. We describe an unusual case of biliary stone developing 18 years after liver transplantation and biliary-enteric anastomosis for biliary atresia, responsible for an acute cholangitis caused by obstruction of the jejunal loop. Surgical exploration allowed the removal of the stone and did not reveal any enteric stricture. Both biliary and enteric anastomosis were patent. An hepatobiliary scintigraphy performed 2 weeks after surgery demonstrated a delayed bile excretion through the jejunal limb and a focal accumulation of the tracer at the level where the stone was found. In conclusion, biliary stone formation could develop after liver transplantation and biliary-enteric anastomosis, in the absence of mechanical stricture, secondarily to bile stasis caused by functional disorder of the efferent jejunal loop. Hepatobiliary scintigraphy plays a central role in the diagnosis and comprehension of such a disorder.

Gallstone disease in heart transplant recipients

OBJECTIVE

To review the outcome of cholecystectomy after heart transplant.

SUMMARY BACKGROUND DATA

The optimal timing for gallbladder surgery in heart transplant patients is controversial.

METHODS

Between April 1985 and October 2000, 518 cardiac transplants were performed at Ochsner Foundation Hospital. Data gathered included ultrasound reports, cholecystectomy operative reports, gallbladder pathologic reports, complications, and deaths.

RESULTS

Charts were available for 509 patients (98%), 68 (13%) of whom underwent cholecystectomy before transplantation. Of the 509, 53 (10%) had serial ultrasound examinations and 29 of the 53 (55%) developed gallstones. After transplant, 47 (9%) underwent cholecystectomy. Five cholecystectomies were performed during the immediate postoperative course. Two patients who underwent cholecystectomy had acalculous cholecystitis; one was incidental. Four patients died (one with rejection and three with sepsis). After discharge, 42 cholecystectomies were performed: 16 for biliary colic (no deaths, three patients with complications), 19 for acute cholecystitis (one death, nine patients with complications), 5 for biliary pancreatitis (1 death, 1 patient with complications), and 2 others.

CONCLUSIONS

The risk of morbidity and mortality from gallstone disease is high in cardiac transplant patients, particularly immediately posttransplant. Posttransplant patients require annual ultrasound examinations to detect the onset of gallstone disease, and this risk is higher than in the general population. Gallstones alone are an indication for cholecystectomy in the cardiac transplant patient. Pretransplant cholecystectomy should be considered in clinically stable patients with gallstones.

Weight gain and cardiovascular risk after organ transplantation

Organ transplantation has become a common and effective approach to the management of patients with organ failure. The improvement in long-term survival has resulted in the emergence of cardiovascular disease as the primary cause of death in renal transplant patients and a significant complication in other organ recipients. A number of factors explain this trend, including a high incidence of hypertension, posttransplant diabetes, hyperlipidemia, and obesity-risk factors that are mediated by direct effects of immunosuppressive medications. Weight gain posttransplant affects approximately 50% of patients and represents a significant problem because of the potential synergism between obesity and immunosuppressive medication-induced effects on cardiovascular disease risk factor development. This review discusses the incidence and implications of cardiovascular disease risk factors in organ transplant recipients, strategies for clinical management, and future research directions.

Cholelithiasis and cholecystitis in children

With advances in medical technology, including intensive care, new medications, alterations in the composition of parenteral nutrition, and the institution of minimally invasive surgery, our understanding of the spectrum of diseases of the gallbladder resulting in stone formation or inflammation, and the management of these disorders has changed over the past few decades. The discussion herein focuses on our thinking about the current diagnosis and treatment for these disorders.