1
|
Zulfiqar M, Sugi M, Venkatesh SK, Loh JT, Ludwig DR, Ballard DH, Jayasekera C, Pannala R, Aqel B, Yano M. Imaging of Ischemic Cholangiopathy Following Donation after Circulatory Death Liver Transplant. Radiographics 2024; 44:e240031. [PMID: 39361529 DOI: 10.1148/rg.240031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Ischemic cholangiopathy (IC) is the leading cause of inferior long-term outcomes following donation after circulatory death (DCD) liver transplant. Biliary strictures related to IC are nonanastomotic strictures (NASs) by definition and involve the donor hepatic ducts proximal to the anastomosis, compared with postsurgical anastomotic strictures that form due to fibrotic healing. IC-related NASs can be microangiopathic with patent hepatic artery or macroangiopathic with occluded or stenotic hepatic artery. Recently, IC with NASs have been described to have four distinct patterns at imaging: diffuse necrosis, multifocal progressive, confluence dominant, and minor form, which correlate clinically with graft prognosis. Severe IC can lead to ductal wall breakdown with subsequent bile leaks that can cause significant patient morbidity, with imaging playing a vital role in diagnosis and guiding intervention. IC also predisposes the transplanted liver to biliary stasis and subsequent formation of stones, casts, and sludge. Some cases of posttransplant biliary stricturing are not IC but are a sequela of reflux cholangitis seen with choledochojejunal anastomosis. Other biliary findings in the posttransplant liver can be explained by sphincter of Oddi dysfunction that results from denervation. The authors describe and comprehensively categorize the various IC types and their imaging patterns at MRI and MR cholangiopancreatography, review the prognostic significance of these imaging patterns, and discuss imaging features of additional biliary complications associated with IC after DCD liver transplant. ©RSNA, 2024 Supplemental material is available for this article.
Collapse
Affiliation(s)
- Maria Zulfiqar
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Mark Sugi
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Sudhakar K Venkatesh
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Jiezhen Tracy Loh
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Daniel R Ludwig
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - David H Ballard
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Channa Jayasekera
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Rahul Pannala
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Bashar Aqel
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| | - Motoyo Yano
- From the Departments of Radiology (M.Z., M.S., M.Y.) and Gastroenterology and Hepatology (C.J., R.P., B.A.), Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259; Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (S.K.V.); Department of Anatomical Pathology, Singapore General Hospital, Singapore (J.T.L.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo (D.R.L., D.H.B.)
| |
Collapse
|
2
|
Sakamoto A, Sakamoto K, Hikida T, Ito C, Iwata M, Shine M, Uraoka M, Nishi Y, Nagaoka T, Honjo M, Tamura K, Funamizu N, Ogawa K, Takada Y. Prolonged warm ischemia time in the recipient is associated with post-transplant biliary stricture following living-donor liver transplantation. Surg Today 2024; 54:1193-1200. [PMID: 38478124 DOI: 10.1007/s00595-024-02823-z] [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: 02/19/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE Post-transplant biliary stricture (PBS) is a common and important complication following orthotopic liver transplantation (LT). This study clarified the incidence of PBS and identified its risk factors. METHODS We retrospectively reviewed the medical records of 67 patients who underwent living-donor LT (LDLT) at our institute between June 2010 and July 2022 and analyzed their clinical characteristics, prognosis, and risk factors for PBS. RESULTS Of the 67 patients, 26 (38.8%) developed PBS during the observation period. Multivariate analyses revealed the following independent risk factors for PBS formation: increased red cell transfusion volume per body weight (> 0.2 U/kg; hazard ratio [HR], 3.8; P = 0.002), increased portal vein pressure (PVP) at the end of LT (> 16 mmHg; HR, 2.88; P = 0.032), postoperative biliary leakage (HR, 4.58; P = 0.014), and prolonged warm ischemia time (WIT) (> 48 min; HR, 4.53; P = 0.008). In patients with PBS, the cumulative incidence of becoming stent free was significantly higher in patients with a WIT ≤ 48 min than in those with a WIT > 48 min (P = 0.038). CONCLUSION Prolonged WIT is associated with intractable PBS following LDLT.
Collapse
Affiliation(s)
- Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Takahiro Hikida
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Miku Iwata
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| |
Collapse
|
3
|
Steggerda JA, Heeger PS. The Promise of Complement Therapeutics in Solid Organ Transplantation. Transplantation 2024; 108:1882-1894. [PMID: 38361233 DOI: 10.1097/tp.0000000000004927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Transplantation is the ideal therapy for end-stage organ failure, but outcomes for all transplant organs are suboptimal, underscoring the need to develop novel approaches to improve graft survival and function. The complement system, traditionally considered a component of innate immunity, is now known to broadly control inflammation and crucially contribute to induction and function of adaptive T-cell and B-cell immune responses, including those induced by alloantigens. Interest of pharmaceutical industries in complement therapeutics for nontransplant indications and the understanding that the complement system contributes to solid organ transplantation injury through multiple mechanisms raise the possibility that targeting specific complement components could improve transplant outcomes and patient health. Here, we provide an overview of complement biology and review the roles and mechanisms through which the complement system is pathogenically linked to solid organ transplant injury. We then discuss how this knowledge has been translated into novel therapeutic strategies to improve organ transplant outcomes and identify areas for future investigation. Although the clinical application of complement-targeted therapies in transplantation remains in its infancy, the increasing availability of new agents in this arena provides a rich environment for potentially transformative translational transplant research.
Collapse
Affiliation(s)
- Justin A Steggerda
- Division of Abdominal Transplant Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Peter S Heeger
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Nephrology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
4
|
Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | | |
Collapse
|
5
|
Chau SS, Beutler BD, Grant EG, Tchelepi H. Ultrasound innovations in abdominal radiology: multiparametic imaging in liver transplantation. Abdom Radiol (NY) 2024:10.1007/s00261-024-04518-y. [PMID: 39167237 DOI: 10.1007/s00261-024-04518-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/31/2024] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE Ultrasound plays a central role in liver transplant evaluation. Acute, subacute, and chronic complications can be readily identified using grayscale and color Doppler ultrasound. Contrast-enhanced ultrasound adds a new dimension to liver transplant evaluation, depicting vascular and parenchymal processes with exquisite detail. In addition, emerging evidence suggests that contrast-enhanced ultrasound may allow for localization of biliary leak in select patients. We aimed to assess the use of multiparametric ultrasound-including grayscale, color and spectral Doppler, and contrast-enhanced ultrasound-in the setting of liver transplantation. METHODS A literature review was performed using the MEDLINE bibliographic database through the National Library of Medicine. The following terms were searched and relevant citations assessed: "abdominal ultrasound," "contrast-enhanced ultrasound," "liver transplant," and "ultrasound." RESULTS Grayscale and color Doppler ultrasound represent the mainstay imaging modalities for postoperative liver transplant evaluation. The addition of contrast enhancement plays a complementary role and can provide valuable information related to the allograft vasculature, parenchyma, and biliary tree. The appropriate implementation of grayscale, color Doppler, and contrast-enhanced ultrasound can optimize sensitivity, specificity, and accuracy for the detection of liver transplantation complications, including hepatic artery stenosis, biliary leakage, and infection. CONCLUSION Multimodal sonographic evaluation is essential to identify postoperative complications in liver transplant recipients. Contrast-enhanced ultrasound may be of value in challenging cases, providing excellent anatomic delineation and reducing the risk of false-positive and false-negative diagnoses. A broad familiarity with appropriate applications of both nonenhanced and contrast-enhanced ultrasound may help radiologists optimize allograft assessment and improve patient outcomes.
Collapse
Affiliation(s)
- Samantha S Chau
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
| | - Edward G Grant
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Hisham Tchelepi
- Department of Radiology, Los Angeles General Medical Center, Los Angeles, CA, USA
| |
Collapse
|
6
|
Xiang Z, Li J, Zeng H, Xiang X, Gao F, Wang K, Wei X, Zheng S, Xu X. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis 2024:AD.2024.0214. [PMID: 38607739 DOI: 10.14336/ad.2024.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/14/2024] [Indexed: 04/14/2024] Open
Abstract
End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.
Collapse
Affiliation(s)
- Ze Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jiarui Li
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Huixuan Zeng
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xiaonan Xiang
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, Cambridgeshire, UK
| | - Fengqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Kai Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
| | - Shusen Zheng
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Xiao Xu
- Zhejiang University School of Medicine, Hangzhou 310058, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Colombo M, Forcignanò E, Da Rio L, Spadaccini M, Andreozzi M, Giacchetto CM, Carrara S, Maselli R, Galtieri PA, Pellegatta G, Capogreco A, Massimi D, Khalaf K, Hassan C, Anderloni A, Repici A, Fugazza A. Endoscopic management of benign biliary strictures: Looking for the best stent to place. World J Clin Cases 2023; 11:7521-7529. [DOI: 10.12998/wjcc.v11.i31.7521] [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: 06/15/2023] [Revised: 08/10/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023] Open
Abstract
Benign biliary strictures (BBS) might occur due to different pancreaticobiliary conditions. The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations. The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS, considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable. The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.
Collapse
Affiliation(s)
- Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Edoardo Forcignanò
- Department of Surgical Sciences, University of Turin, Torino 10124, Piemonte, Italy
| | - Leonardo Da Rio
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Marta Andreozzi
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Carmelo Marco Giacchetto
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Antonio Capogreco
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Davide Massimi
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto M5B1T8, Ontario, Canada
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Andrea Anderloni
- Endoscopy Unit, First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia 27100, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| |
Collapse
|
9
|
Suto A, Ishido K, Kimura N, Wakiya T, Kikuchi H, Iino C, Igarashi G, Sato S, Sakuraba H, Hakamada K. A case of hepaticojejunal anastomotic obstruction after a living-donor liver transplantation and recanalization using a high-frequency knife under the rendezvous technique. Clin J Gastroenterol 2023; 16:726-731. [PMID: 37170062 DOI: 10.1007/s12328-023-01812-y] [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: 02/28/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was diagnosed with obstructive cholangitis due to stricture during a hepaticojejunostomy following impaired liver function. Endoscopic balloon dilation of anastomosis and placement of a plastic stent resulted in improved liver function. However, at 72 years, the patient experienced a flare-up of liver damage. The plastic stent had fallen out, and although endoscopic stenotic dilation was attempted, the anastomotic site was obstructed completely. Therefore, recanalization of the hepaticojejunostomy was attempted using a rendezvous technique. A percutaneous transhepatic biliary drainage tube was inserted through the B3 bile duct, and the complete obstructed anastomosis was confirmed by percutaneous transhepatic and transjejunal approaches. The anastomosis was reopened by excising the scarred tissues from the jejunal side using a 1.5-mm high-frequency knife. A 14-Fr. catheter for the internal fistula tube was percutaneously placed at the opened anastomosis to achieve anastomotic site recanalization. The patient's liver damage improved after the re-internalization, and no symptom recurrence such as obstructive cholangitis developed for 1 year. There are few reports of recanalization of the hepaticojejunostomy with a high-frequency knife. Herein, we report the case with a literature review.
Collapse
Affiliation(s)
- Akiko Suto
- Department of Surgery, Odate Municipal General Hospital, 3-1 Yutaka-cho, Odate, Akita, 017-8550, Japan
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hidezumi Kikuchi
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Chikara Iino
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Go Igarashi
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Satoshi Sato
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hirotake Sakuraba
- Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| |
Collapse
|
10
|
Tingle SJ, Dobbins JJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson C. Machine perfusion in liver transplantation. Cochrane Database Syst Rev 2023; 9:CD014685. [PMID: 37698189 PMCID: PMC10496129 DOI: 10.1002/14651858.cd014685.pub2] [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] [Indexed: 09/13/2023]
Abstract
BACKGROUND Liver transplantation is the only chance of cure for people with end-stage liver disease and some people with advanced liver cancers or acute liver failure. The increasing prevalence of these conditions drives demand and necessitates the increasing use of donated livers which have traditionally been considered suboptimal. Several novel machine perfusion preservation technologies have been developed, which attempt to ameliorate some of the deleterious effects of ischaemia reperfusion injury. Machine perfusion technology aims to improve organ quality, thereby improving outcomes in recipients of suboptimal livers when compared to traditional static cold storage (SCS; ice box). OBJECTIVES To evaluate the effects of different methods of machine perfusion (including hypothermic oxygenated machine perfusion (HOPE), normothermic machine perfusion (NMP), controlled oxygenated rewarming, and normothermic regional perfusion) versus each other or versus static cold storage (SCS) in people undergoing liver transplantation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 10 January 2023. SELECTION CRITERIA We included randomised clinical trials which compared different methods of machine perfusion, either with each other or with SCS. Studies comparing HOPE via both hepatic artery and portal vein, or via portal vein only, were grouped. The protocol detailed that we also planned to include quasi-randomised studies to assess treatment harms. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. overall participant survival, 2. quality of life, and 3. serious adverse events. Secondary outcomes were 4. graft survival, 5. ischaemic biliary complications, 6. primary non-function of the graft, 7. early allograft function, 8. non-serious adverse events, 9. transplant utilisation, and 10. transaminase release during the first week post-transplant. We assessed bias using Cochrane's RoB 2 tool and used GRADE to assess certainty of evidence. MAIN RESULTS We included seven randomised trials (1024 transplant recipients from 1301 randomised/included livers). All trials were parallel two-group trials; four compared HOPE versus SCS, and three compared NMP versus SCS. No trials used normothermic regional perfusion. When compared with SCS, it was uncertain whether overall participant survival was improved with either HOPE (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.42 to 1.98; P = 0.81, I2 = 0%; 4 trials, 482 recipients; low-certainty evidence due to imprecision because of low number of events) or NMP (HR 1.08, 95% CI 0.31 to 3.80; P = 0.90; 1 trial, 222 recipients; very low-certainty evidence due to imprecision and risk of bias). No trials reported quality of life. When compared with SCS alone, HOPE was associated with improvement in the following clinically relevant outcomes: graft survival (HR 0.45, 95% CI 0.23 to 0.87; P = 0.02, I2 = 0%; 4 trials, 482 recipients; high-certainty evidence), serious adverse events in extended criteria DBD liver transplants (OR 0.45, 95% CI 0.22 to 0.91; P = 0.03, I2 = 0%; 2 trials, 156 participants; moderate-certainty evidence) and clinically significant ischaemic cholangiopathy in recipients of DCD livers (OR 0.31, 95% CI 0.11 to 0.92; P = 0.03; 1 trial, 156 recipients; high-certainty evidence). In contrast, NMP was not associated with improvement in any of these clinically relevant outcomes. NMP was associated with improved utilisation compared with SCS (one trial found a 50% lower rate of organ discard; P = 0.008), but the reasons underlying this effect are unknown. We identified 11 ongoing studies investigating machine perfusion technologies. AUTHORS' CONCLUSIONS In situations where the decision has been made to transplant a liver donated after circulatory death or donated following brain death, end-ischaemic HOPE will provide superior clinically relevant outcomes compared with SCS alone. Specifically, graft survival is improved (high-certainty evidence), serious adverse events are reduced (moderate-certainty evidence), and in donors after circulatory death, clinically relevant ischaemic biliary complications are reduced (high-certainty evidence). There is no good evidence that NMP has the same benefits over SCS in terms of these clinically relevant outcomes. NMP does appear to improve utilisation of grafts that would otherwise be discarded with SCS; however, the reasons for this, and whether this effect is specific to NMP, is not clear. Further studies into NMP viability criteria and utilisation, as well as head-to-head trials with other perfusion technologies are needed. In the setting of donation following circulatory death transplantation, further trials are needed to assess the effect of these ex situ machine perfusion methods against, or in combination with, normothermic regional perfusion.
Collapse
Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | | | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| |
Collapse
|
11
|
Hong SY, Yi NJ, Hong K, Han ES, Suh S, Lee JM, Hong SK, Choi Y, Jin US, Chang H, Lee KW, Suh KS, Minn KW. Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations. Liver Transpl 2023; 29:961-969. [PMID: 37254603 DOI: 10.1097/lvt.0000000000000185] [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: 08/30/2022] [Accepted: 04/19/2023] [Indexed: 06/01/2023]
Abstract
Hepatic artery thrombosis (HAT) after liver transplantation is associated with a marked increase in morbidity, leading to graft and patient loss. We evaluated the outcomes of adult living donor liver transplantation patients with HAT under an aggressive surgical intervention. A total of 1355 recipients underwent adult living donor liver transplantation at the Seoul National University Hospital. Surgical redo reconstruction for HAT was performed in all cases except in those with graft hepatic artery injury and late detection of HAT. Postoperative HAT developed in 33 cases (2.4%) at a median time of 3.5 days. Thirty patients (90.9%) underwent redo-arterial reconstruction. The survival rates in patients with HAT were similar to the rates in those without HAT (72.7% vs. 83.8%, p = 0.115). Although graft survival rates were lower in patients with HAT (84.8%) than in those without HAT (98.0%) ( p < 0.001), the graft survival rate was comparable (92.0% vs. 98.0%, p = 0.124) in the 25 patients with successful revascularization. Biliary complication rates were higher in patients with HAT (54.5%) than in those without HAT (32.0%) ( p = 0.008). In conclusion, the successful redo reconstruction under careful selection criteria saved the graft without retransplantation in 96.0% of the cases. Surgical revascularization should be preferentially considered for the management of HAT in adult living donor liver transplantation.
Collapse
Affiliation(s)
- Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwangpyo Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sanggyun Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Won Minn
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Jimenez-Romero C, Justo-Alonso I, del Pozo-Elso P, Marcacuzco-Quinto A, Martín-Arriscado-Arroba C, Manrique-Municio A, Calvo-Pulido J, García-Sesma A, San Román R, Caso-Maestro O. Post-transplant biliary complications using liver grafts from deceased donors older than 70 years: Retrospective case-control study. World J Gastrointest Surg 2023; 15:1615-1628. [PMID: 37701699 PMCID: PMC10494601 DOI: 10.4240/wjgs.v15.i8.1615] [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: 01/19/2023] [Revised: 03/27/2023] [Accepted: 06/25/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors. AIM To determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years. METHODS Between January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups. RESULTS Choledocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor. CONCLUSION The incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.
Collapse
Affiliation(s)
- Carlos Jimenez-Romero
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Iago Justo-Alonso
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Pilar del Pozo-Elso
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Alberto Marcacuzco-Quinto
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | | | - Alejandro Manrique-Municio
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Jorge Calvo-Pulido
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Alvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Ricardo San Román
- Department of Radiology, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| | - Oscar Caso-Maestro
- Unit of HPB Surgery and Abdominal Organs Transplantation, `12 de Octubre´ University Hospital, Madrid 28041, Spain
| |
Collapse
|
13
|
Mammadov RA, Selten JW, Roest HP, Verhoeven CJ, Maroni L, Bril SI, Tolenaars D, Gadjradj PS, van de Graaf SFJ, Oude Elferink RPJ, Kwekkeboom J, Metselaar HJ, Peppelenbosch MP, Beuers U, IJzermans JNM, van der Laan LJW. Intestinal Bacteremia After Liver Transplantation Is a Risk Factor for Recurrence of Primary Sclerosing Cholangitis. Transplantation 2023; 107:1764-1775. [PMID: 36978227 DOI: 10.1097/tp.0000000000004563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic progressive pathological process, related to inflammatory bowel disease and subsequent bacterial translocation. Liver transplantation (LT) is the only curative therapy, but outcomes are compromised by recurrence of PSC (rPSC). The aim of the study was to investigate a potential link between intestinal bacteremia, fucosyltransferase-2 (FUT2), and rPSC after LT. METHODS LT recipients with PSC (n = 81) or without PSC (n = 271) were analyzed for clinical outcomes and positive bacterial blood cultures. A link between bacteremia and the genetic variant of the FUT2 gene was investigated. RESULTS The incidence of inflammatory bowel disease was significantly higher in PSC recipients but not associated with rPSC. Bacteremia occurred in 31% of PSC recipients. The incidence of rPSC was 37% and was significantly more common in patients with intestinal bacteremia versus no bacteremia (82% versus 30%; P = 0.003). The nonsecretor polymorphism of the FUT2 gene was identified as a genetic risk factor for both intestinal bacteremia and rPSC. Combined FUT2 genotype and intestinal bacteremia in recipients resulted in the highest risk for rPSC (hazard ratio, 15.3; P < 0.001). CONCLUSIONS Thus, in this article, we showed that bacterial translocation is associated with rPSC after LT and related to the FUT2 nonsecretor status.
Collapse
Affiliation(s)
- Ruslan A Mammadov
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Jasmijn W Selten
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| | - Henk P Roest
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| | - Cornelia J Verhoeven
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
- Department of Otorhinolaryngology, University Medical Center Groningen, The Netherlands
| | - Luca Maroni
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
- Department of Gastroenterology, Marche Polytechnic University, Ancona, Italy
| | - Sandra I Bril
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| | - Dagmar Tolenaars
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Pravesh S Gadjradj
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| | - Stan F J van de Graaf
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Ronald P J Oude Elferink
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Jaap Kwekkeboom
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Ulrich Beuers
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| | - Luc J W van der Laan
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, The Netherlands
| |
Collapse
|
14
|
Michael FA, Friedrich-Rust M, Erasmus HP, Graf C, Ballo O, Knabe M, Walter D, Steup CD, Mücke MM, Mücke VT, Peiffer KH, Görgülü E, Mondorf A, Bechstein WO, Filmann N, Zeuzem S, Bojunga J, Finkelmeier F. Treatment of Non-Anastomotic Biliary Strictures after Liver Transplantation: How Effective Is Our Current Treatment Strategy? J Clin Med 2023; 12:jcm12103491. [PMID: 37240598 DOI: 10.3390/jcm12103491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/30/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Non-anastomotic biliary strictures (NAS) are a common cause of morbidity and mortality after liver transplantation. METHODS All patients with NAS from 2008 to 2016 were retrospectively analyzed. The success rate and overall mortality of an ERCP-based stent program (EBSP) were the primary outcomes. RESULTS A total of 40 (13.9%) patients with NAS were identified, of which 35 patients were further treated in an EBSP. Furthermore, 16 (46%) patients terminated EBSP successfully, and nine (26%) patients died during the program. All deaths were caused by cholangitis. Of those, one (11%) patient had an extrahepatic stricture, while the other eight patients had either intrahepatic (3, 33%) or combined extra- and intrahepatic strictures (5, 56%). Risk factors of overall mortality were age (p = 0.03), bilirubin (p < 0.0001), alanine transaminase (p = 0.006), and aspartate transaminase (p = 0.0003). The median duration of the stent program was 34 months (ITBL: 36 months; IBL: 10 months), and procedural complications were rare. CONCLUSIONS EBSP is safe, but lengthy and successful in only about half the patients. Intrahepatic strictures were associated with an increased risk of cholangitis.
Collapse
Affiliation(s)
- Florian A Michael
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Hans-Peter Erasmus
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Christiana Graf
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Olivier Ballo
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Mate Knabe
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Dirk Walter
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Christoph D Steup
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Marcus M Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Victoria T Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Kai H Peiffer
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Esra Görgülü
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Antonia Mondorf
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Wolf O Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| |
Collapse
|
15
|
Gheorghe G, Diaconu CC, Bungau S, Bacalbasa N, Motas N, Ionescu VA. Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:850. [PMID: 37241082 PMCID: PMC10221850 DOI: 10.3390/medicina59050850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.
Collapse
Affiliation(s)
- Gina Gheorghe
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Internal Medicine Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | - Nicolae Bacalbasa
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Natalia Motas
- Institute of Oncology “Profesor Doctor Alexandru Trestioreanu” Bucharest, 022328 Bucharest, Romania;
- Department of Thoracic Surgery, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
| | - Vlad-Alexandru Ionescu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| |
Collapse
|
16
|
Chouik Y, Francoz C, De Martin E, Guillaud O, Abergel A, Altieri M, Barbier L, Besch C, Chazouillères O, Conti F, Corpechot C, Dharancy S, Durand F, Duvoux C, Gugenheim J, Hardwigsen J, Hilleret MN, Houssel-Debry P, Kamar N, Minello A, Neau-Cransac M, Pageaux GP, Radenne S, Roux O, Saliba F, Samuel D, Vanlemmens C, Woehl-Jaegle ML, Leroy V, Duclos-Vallée JC, Dumortier J. Liver transplantation for autoimmune hepatitis: Pre-transplant does not predict the early post-transplant outcome. Liver Int 2023; 43:906-916. [PMID: 36577700 DOI: 10.1111/liv.15500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/06/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Autoimmune hepatitis (AIH) is a rare indication (<5%) for liver transplantation (LT). The aim of this study was to describe the early outcome after LT for AIH. METHODS A multicenter retrospective nationwide study including all patients aged ≥16 transplanted for AIH in France was conducted. Occurrences of biliary and vascular complications, rejection, sepsis, retransplantation and death were collected during the first year after LT. RESULTS A total of 344 patients (78.8% of women, 17.0% of (sub)fulminant hepatitis and 19.2% of chronic liver diseases transplanted in the context of acute-on-chronic liver failure [ACLF]) were included, with a median age at LT of 43.6 years. Acute rejection, sepsis, biliary and vascular complications occurred in respectively 23.5%, 44.2%, 25.3% and 17.4% of patients during the first year after LT. One-year graft and patient survivals were 84.3% and 88.0% respectively. The main cause of early death was sepsis. Pre-LT immunosuppression was not associated with an increased risk for early infections or surgical complications. Significant risk factors for septic events were LT in the context of (sub)fulminant hepatitis or ACLF, acute kidney injury at the time of LT (AKI) and occurrence of biliary complications after LT. AKI was the only independent factor associated with graft (HR = 2.5; 95% CI: 1.1-5.4; p = .02) and patient survivals (HR = 2.6; 95% CI: 1.0-6.5; p = .04). CONCLUSION Early prognosis is good after LT for AIH and is not impacted by pre-LT immunosuppression but by the presence of AKI at the time of LT.
Collapse
Affiliation(s)
- Yasmina Chouik
- Hospices civils de Lyon, Hôpital Edouard Herriot, et Université Claude Bernard Lyon 1, Lyon, France
- Service d'Hépato-Gastroentérologie, Hospices civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | - Claire Francoz
- Service d'Hépatologie et Transplantation Hépatique, APHP, Hôpital Beaujon, Université Paris Diderot, INSERM U1149, Clichy, France
| | - Eleonora De Martin
- Centre Hépato-Biliaire, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Inserm Unité 1193, AP-HP Hôpital Paul-Brousse, Université Paris-Saclay, FHU Hépatinov, Villejuif, France
| | - Olivier Guillaud
- Hospices civils de Lyon, Hôpital Edouard Herriot, et Université Claude Bernard Lyon 1, Lyon, France
| | - Armand Abergel
- CHU Estaing, Médecine digestive, Institut Pascal., UMR 6602 UCA CNRS SIGMA, Clermont-Ferrand, France
| | - Mario Altieri
- Service d'Hépato-Gastroentérologie, Nutrition et Oncologie Digestive, Hôpital Côte de Nacre, Caen, France
| | - Louise Barbier
- Service de chirurgie digestive, oncologique et endocrinienne, Transplantation hépatique, Hôpital Trousseau, CHU Tours, Tours, France
| | - Camille Besch
- Service de chirurgie hépato-bilio-pancréatique et transplantation hépatique, CHRU Hautepierre, Strasbourg, France
| | - Olivier Chazouillères
- Centre de Recherche Saint-Antoine, Centre de référence des maladies inflammatoires des voies biliaires et des hépatites auto-immunes, Filière de santé FILFOIE, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), INSERM UMRS 938, Sorbonne Université, Paris, France
| | - Filomena Conti
- Service de Chirurgie Digestive et Hépato-Biliaire, Transplantation Hépatique, AP-HP Hôpital Pitié Salpêtrière, Paris, France
| | - Christophe Corpechot
- Centre de Recherche Saint-Antoine, Centre de référence des maladies inflammatoires des voies biliaires et des hépatites auto-immunes, Filière de santé FILFOIE, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), INSERM UMRS 938, Sorbonne Université, Paris, France
| | | | - François Durand
- Service d'Hépatologie et Transplantation Hépatique, APHP, Hôpital Beaujon, Université Paris Diderot, INSERM U1149, Clichy, France
| | | | - Jean Gugenheim
- Service de Chirurgie Digestive et de Transplantation Hépatique, Hôpital universitaire de Nice, Université de Nice-Sophia-Antipolis, Nice, France
| | - Jean Hardwigsen
- Service chirurgie générale et transplantation hépatique, APHM, Hôpital La Timone, Marseille, France
| | - Marie-Noëlle Hilleret
- Service d'hépato-gastroentérologie, CHU Grenoble-Alpes, INSERM U1209-Université Grenoble-Alpes, La Tronche, France
| | - Pauline Houssel-Debry
- Service d'Hépatologie et Transplantation hépatique, Hôpital Universitaire de Pontchaillou, Rennes, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, CHU Rangueil, Toulouse, France
| | - Anne Minello
- Service d'Hépato-gastroentérologie et oncologie digestive, CHU Dijon, Inserm EPICAD LNC-UMR1231, Université de Bourgogne-Franche Comté, Dijon, France
| | - Martine Neau-Cransac
- Service de Chirurgie hépatobiliaire et de transplantation hépatique, CHU de Bordeaux, Hôpital Haut Lévêque, Bordeaux, France
| | | | - Sylvie Radenne
- Service d'Hépato-Gastroentérologie, Hospices civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | - Olivier Roux
- Service d'Hépatologie et Transplantation Hépatique, APHP, Hôpital Beaujon, Université Paris Diderot, INSERM U1149, Clichy, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Inserm Unité 1193, AP-HP Hôpital Paul-Brousse, Université Paris-Saclay, FHU Hépatinov, Villejuif, France
| | - Didier Samuel
- Centre Hépato-Biliaire, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Inserm Unité 1193, AP-HP Hôpital Paul-Brousse, Université Paris-Saclay, FHU Hépatinov, Villejuif, France
| | - Claire Vanlemmens
- Service d'Hépatologie et Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| | - Marie-Lorraine Woehl-Jaegle
- Service de chirurgie hépato-bilio-pancréatique et transplantation hépatique, CHRU Hautepierre, Strasbourg, France
| | - Vincent Leroy
- Service d'hépato-gastroentérologie, CHU Grenoble-Alpes, INSERM U1209-Université Grenoble-Alpes, La Tronche, France
| | - Jean-Charles Duclos-Vallée
- Centre Hépato-Biliaire, Centre de Référence Maladies Inflammatoires des Voies Biliaires et Hépatites Auto-immunes, Inserm Unité 1193, AP-HP Hôpital Paul-Brousse, Université Paris-Saclay, FHU Hépatinov, Villejuif, France
| | - Jérôme Dumortier
- Hospices civils de Lyon, Hôpital Edouard Herriot, et Université Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
17
|
Park H, Han ES, Park SJ, Hong SY, Suh S, Lee S, Lee JM, Hong SK, Choi Y, Lee KW, Suh KS, Yi NJ, Han JK. Anatomical classification and clinical outcomes of biliary strictures in living donor liver transplantation using right liver grafts. Liver Transpl 2023; 29:307-317. [PMID: 37160060 DOI: 10.1002/lt.26580] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 01/12/2023]
Abstract
This study aimed to classify the anatomical types of biliary strictures, including intrahepatic biliary stricture (IHBS), after living donor liver transplantations (LDLTs) using right liver grafts and evaluate their prognosis. Among 692 adult patients who underwent right liver LDLT, 198 recipients with biliary strictures (28.6%) were retrospectively reviewed. Based on data obtained during the first cholangiography, the patients' biliary strictures were classified into the following three types according to the levels and number of branches involved: Types 1 (anastomosis), 2 (second-order branch [a, one; b, two or more; c, extended to the third-order branch]), and 3 (whole graft [a, multifocal strictures; b, diffuse necrosis]). IHBS was defined as a nonanastomotic stricture. Among the 198 recipients with biliary strictures, the IHBS incidence rates were 38.4% ( n = 76). The most common type of IHBS was 2c ( n = 43, 56.6%), whereas Type 3 ( n = 10, 13.2%) was uncommon. The intervention frequency per year significantly differed among the types (Type 1, 2.3; Type 2a, 2.3; Type 2b, 2.8; Type 2c, 4.3; and Type 3, 7.2; p < 0.001). The intervention-free period for more than 1 year, which was as follows, also differed among the types: Type 1, 84.4%; Type 2a, 87.5%; Type 2b, 86.7%; Type 2c, 72.1%; and Type 3, 50.0% ( p = 0.048). The graft survival rates of Type 3 (80.0%) were significantly lower than those of the other types ( p = 0.001). IHBSs are relatively common in right liver LDLTs. Although Type 3 IHBSs are rare, they require more intensive care and are associated with poorer graft survival rates than anastomosis strictures and Type 2 IHBS.
Collapse
Affiliation(s)
- Hansang Park
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Eui Soo Han
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sae-Jin Park
- Department of Radiology , Seoul National University College of Medicine , Seoul , South Korea
| | - Su Young Hong
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sanggyun Suh
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Sola Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Jeong-Moo Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Suk Kyun Hong
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - YoungRok Choi
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Kwang-Woong Lee
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Kyung-Suk Suh
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Nam-Joon Yi
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
| | - Joon Koo Han
- Department of Radiology , Seoul National University College of Medicine , Seoul , South Korea
| |
Collapse
|
18
|
Prognostic Factors for Non-anastomotic Biliary Strictures Following Adult Liver Transplantation: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:2683-2694. [PMID: 36757492 DOI: 10.1007/s10620-023-07861-0] [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: 09/11/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION The development of non-anastomotic biliary strictures (NAS) following orthotopic adult liver transplantation (OLT) is associated with significant morbidity. We performed a systematic review and meta-analysis to identify all prognostic factors for the development of NAS. METHODS A systematic review was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. We used the Newcastle-Ottawa scale to assess the quality of the included studies. Using the random-effects model, we calculated the weighted pooled odds ratios (OR), mean differences (MD), hazard ratios (HR), and 95% confidence intervals (CI) of the risk factors. RESULTS Based on 19 international studies that included a total of 8269 adult LT patients, we calculated an 8% overall incidence of NAS. In this study, 7 potential prognostic factors were associated with a statistically significant hazard ratio for NAS in pooled analyses including (1) DCD donors compared to DBD donors (2) PSC as an indication for a liver transplant (3) Roux-en-Y bile duct reconstruction compared to duct-to-duct reconstruction (4) hepatic artery thrombosis (5) longer cold ischemia time (6) longer warm ischemia time (7) and total operative times. CONCLUSION In this systematic review and meta-analysis, we identified 7 prognostic factors for the development of NAS following OLT. These findings might lay the groundwork for development of diagnostic algorithms to better risk stratify patients at risk for development of NAS.
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Fuentes-Valenzuela E, Sánchez-Delgado L, Maroto-Martín C, Juan-Casamayor L, Fernández-Prada S, Rodríguez MM, Tejedor-Tejada J, Rubiales BM, Alonso-Martín C, Peñas-Herrero I, Álvarez CA, García-Pajares F. Postreperfusion Biopsy as a Predictor of Biliary Complication After Deceased Donor Liver Transplantation. A Retrospective Cohort Study. Transplant Proc 2022; 54:2541-2544. [DOI: 10.1016/j.transproceed.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 11/07/2022]
|
21
|
Bowen H, Wenzhi G, Peihao W, Jihua S, Shuijun Z. The reasonable therapeutic modality for biliary duct-to-duct anastomotic stricture after liver transplantation: ERCP or PTC? Front Oncol 2022; 12:1035722. [PMID: 36249014 PMCID: PMC9554635 DOI: 10.3389/fonc.2022.1035722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To compare the initial success rate, feasibility, and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTC) for anastomotic biliary stricture after liver transplantation (LT). Methods We retrospectively analyzed the data collected during January 2015 to December 2021 from liver transplantation recipients who developed anastomotic biliary stricture after liver transplantation and treated by ERCP and/or PTC. The success rate, complications and patients’ survival rate of ERCP and PTC procedures was evaluated. Results Forty-eight patients who underwent LT and were confirmed to have the anastomotic biliary stricture were enrolled. Overall, 48/48 patients underwent single or multiple ERCP procedures as the first line therapy; 121 therapeutic ERCPs (3.36 ± 2.53 ERCPs per patient) were performed in 36/48 patients successfully. All the 12 patients who failed ERCP tend to have special bile duct conditions such as overlong, angle shaped, and/or extremely narrowed bile duct and underwent PTC as an alternative treatment. The initial success rate of ERCP was 75% (36/48) while the success rate of ERCP for the 12 patients with special bile duct was 0% (0/12). PTC was an effective second-line treatment for those 12 patients who failed ERCP, and 58.33% (7 of 12 cases) were treated successfully. The average procedure time in PTC group was significantly lower than ERCP group (t=2.292, P=0.027). The feasibility of ERCP was associated with the anatomical shape of bile duct and the severity of the stricture site. Finally, the cumulative survival rate was 100% (12/12) in PTC group compared to 86.11% (31/36) in ERCP group (χ2 =0.670, P=0.413). Conclusion ERCP is the gold standard method for the diagnosis and effective intervention for the management of biliary complications after LT. However, its use in certain types of biliary complications (e.g., patients with severe anastomotic biliary stricture and those with overlong and angle shaped bile ducts) is not promising and associated with significant risk of complications. PTC and other interventions should be studied along with ERCP for patients for whom ERCP may not work. The feasibility and efficacy of primary management can be predicted by the noninvasive imaging examinations like Magnetic Resonance Cholangiopancreatography (MRCP) before the procedure, which may help with the choice of the most reasonable therapeutic modality and avoiding unnecessary financial burden and complications.
Collapse
Affiliation(s)
- Hu Bowen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Digestive Organ Transplantation, Zhengzhou, China
- Henan Research Centre for Organ Transplantation, Zhengzhou, China
| | - Guo Wenzhi
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Digestive Organ Transplantation, Zhengzhou, China
- Henan Research Centre for Organ Transplantation, Zhengzhou, China
| | - Wen Peihao
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Digestive Organ Transplantation, Zhengzhou, China
- Henan Research Centre for Organ Transplantation, Zhengzhou, China
| | - Shi Jihua
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Digestive Organ Transplantation, Zhengzhou, China
- Henan Research Centre for Organ Transplantation, Zhengzhou, China
| | - Zhang Shuijun
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Digestive Organ Transplantation, Zhengzhou, China
- Henan Research Centre for Organ Transplantation, Zhengzhou, China
- *Correspondence: Zhang Shuijun,
| |
Collapse
|
22
|
Owen A, Patten D, Vigneswara V, Frampton J, Newsome PN. PDGFRα/Sca-1 Sorted Mesenchymal Stromal Cells Reduce Liver Injury in Murine Models of Hepatic Ischemia-Reperfusion Injury. Stem Cells 2022; 40:1056-1070. [PMID: 35999023 PMCID: PMC9707286 DOI: 10.1093/stmcls/sxac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 07/06/2022] [Indexed: 11/12/2022]
Abstract
Liver transplantation is an effective therapy, but increasing demand for donor organs has led to the use of marginal donor organs with increased complication rates. Mesenchymal stromal cells (MSC) pleiotropically modulate aberrant immune-mediated responses and represent a potential therapy to target the inflammation seen post-transplant with marginal donor livers. To avoid the confounding effects of xenotransplantation seen in studies with human MSC, a PDGFRα/Sca-1 (PaS) sorted MSC population was used which was analogous to human MSC populations (LNGFR+Thy-1+VCAM-1Hi). PaS MSC are a well-described population that demonstrate MSC properties without evidence of clonal mutation during expansion. We demonstrate their anti-inflammatory properties herein through their suppression of T-lymphocyte proliferation in vitro and secretion of anti-inflammatory cytokines (IL-10 and OPG) after stimulation (P = .004 and P = .003). The MDR2-/- model of biliary injury and hepatic ischemia-reperfusion (HIR) injury models were used to replicate the non-anastomotic biliary complications seen following liver transplantation. Systemic MSC therapy in MDR2-/- mice led to reduced liver injury with an increase in restorative macrophages (5913 ± 333.9 vs 12 597 ± 665.8, P = .002, n = 7) and a change in lymphocyte ratios (3.55 ± 0.37 vs 2.59 ± 0.139, P = .023, n = 17), whereas subcutaneous administration of MSC showed no beneficial effect. MSC also reduced cell death in the HIR model assessed by Periodic acid-Schiff (PAS) staining (91.7% ± 2.8 vs 80.1% ± 4.6, P = .03). Systemically administered quantum dot-labeled MSC were tracked using single-cell resolution CryoViz imaging which demonstrated their sequestration in the lungs alongside retention/redistribution to injured liver tissue. MSC represent a potential novel therapy in marginal organ transplantation which warrants further study.
Collapse
Affiliation(s)
| | | | | | | | - Philip N Newsome
- Corresponding author: Philip N. Newsome, Centre for Liver and Gastrointestinal Research, Institute of Biomedical Research, University of Birmingham, Vincent Drive, Birmingham B15 2TT, UK.
| |
Collapse
|
23
|
Incidence of Ischemia Reperfusion Injury Related Biliary Complications in Liver Transplantation: Effect of Different Types of Donors. Transplant Proc 2022; 54:1865-1873. [DOI: 10.1016/j.transproceed.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/07/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022]
|
24
|
Del Turco S, Cappello V, Tapeinos C, Moscardini A, Sabatino L, Battaglini M, Melandro F, Torri F, Martinelli C, Babboni S, Silvestrini B, Morganti R, Gemmi M, De Simone P, Martins PN, Crocetti L, Peris A, Campani D, Basta G, Ciofani G, Ghinolfi D. Cerium oxide nanoparticles administration during machine perfusion of discarded human livers: A pilot study. Liver Transpl 2022; 28:1173-1185. [PMID: 35100468 DOI: 10.1002/lt.26421] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 01/13/2023]
Abstract
The combined approach of ex situ normothermic machine perfusion (NMP) and nanotechnology represents a strategy to mitigate ischemia/reperfusion injury in liver transplantation (LT). We evaluated the uptake, distribution, and efficacy of antioxidant cerium oxide nanoparticles (nanoceria) during normothermic perfusion of discarded human livers. A total of 9 discarded human liver grafts were randomized in 2 groups and underwent 4 h of NMP: 5 grafts were treated with nanoceria conjugated with albumin (Alb-NC; 50 µg/ml) and compared with 4 untreated grafts. The intracellular uptake of nanoceria was analyzed by electron microscopy (EM) and inductively coupled plasma-mass spectrometry (ICP-MS). The antioxidant activity of Alb-NC was assayed in liver biopsies by glutathione (GSH), superoxide dismutase (SOD) and catalase (CAT) assay, telomere length, and 4977-bp common mitochondrial DNA deletion (mtDNA4977 deletion). The cytokine profile was evaluated in perfusate samples. EM and ICP-MS confirmed Alb-NC internalization, rescue of mitochondrial phenotype, decrease of lipid droplet peroxidation, and lipofuscin granules in the treated grafts. Alb-NC exerted an antioxidant activity by increasing GSH levels (percentage change: +94% ± 25%; p = 0.01), SOD (+17% ± 4%; p = 0.02), and CAT activity (51% ± 23%; p = 0.03), reducing the occurrence of mtDNA4977 deletion (-67.2% ± 11%; p = 0.03), but did not affect cytokine release. Alb-NC during ex situ perfusion decreased oxidative stress, upregulating graft antioxidant defense. They could be a tool to improve quality grafts during NMP and represent an antioxidant strategy aimed at protecting the graft against reperfusion injury during LT.
Collapse
Affiliation(s)
- Serena Del Turco
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Valentina Cappello
- Center for Materials Interfaces, Electron Crystallography, Istituto Italiano di Tecnologia, Pontedera, Italy
| | - Christos Tapeinos
- Smart Bio-Interfaces, Istituto Italiano di Tecnologia, Pontedera, Italy
| | - Aldo Moscardini
- National Enterprise for nanoScience and nanoTechnology, Scuola Normale Superiore, Pisa, Italy
| | - Laura Sabatino
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Matteo Battaglini
- Smart Bio-Interfaces, Istituto Italiano di Tecnologia, Pontedera, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Caterina Martinelli
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Serena Babboni
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Beatrice Silvestrini
- Division of Interventional Radiology, University of Pisa Medical School Hospital, Pisa, Italy
| | | | - Mauro Gemmi
- Center for Materials Interfaces, Electron Crystallography, Istituto Italiano di Tecnologia, Pontedera, Italy
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paulo N Martins
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, Massachusetts, USA
| | - Laura Crocetti
- Division of Interventional Radiology, University of Pisa Medical School Hospital, Pisa, Italy
| | - Adriano Peris
- Regional Transplant Authority of Tuscany, Florence, Italy
| | - Daniela Campani
- Division of Pathology, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Gianni Ciofani
- Smart Bio-Interfaces, Istituto Italiano di Tecnologia, Pontedera, Italy
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Klein F, Wellhöner F, Plumeier I, Kahl S, Chhatwal P, Vital M, Voigtländer T, Pieper DH, Manns MP, Lenzen H, Solbach P, Heidrich B. The biliary microbiome in ischaemic-type biliary lesions can be shaped by stenting but is resilient to antibiotic treatment. Liver Int 2022; 42:1070-1083. [PMID: 35152539 DOI: 10.1111/liv.15194] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 02/13/2023]
Abstract
This study aims to characterize the biliary microbiome as neglected factor in patients with ischaemic-type biliary lesions (ITBL) after liver transplantation. Therefore, the V1-V2 region of the 16S rRNA gene was sequenced in 175 bile samples. Samples from patients with anastomotic strictures (AS) served as controls. Multivariate analysis and in silico metagenomics were applied cross-sectionally and longitudinally. The microbial community differed significantly between ITBL and AS in terms of alpha and beta diversity. Both, antibiotic treatment and stenting were associated independently with differences in the microbial community structure. In contrast to AS, in ITBL stenting was associated with pronounced differences in the biliary microbiome, whereas no differences associated with antibiotic treatment could be observed in ITBL contrasting the pronounced differences found in AS. Bacterial pathways involved in the production of antibacterial metabolites were increased in ITBL with antibiotic treatment. After liver transplantation, the biliary tract harbours a complex microbial community with significant differences between ITBL and AS. Fundamental changes in the microbial community in ITBL can be achieved with biliary stenting. However, the effect of antibiotic treatment in ITBL was minimal. Therefore, antibiotics should be administered wisely in order to reduce emerging resistance of the biliary microbiome towards external antibiotics.
Collapse
Affiliation(s)
- Friederike Klein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany.,Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Freya Wellhöner
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Iris Plumeier
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Silke Kahl
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Patrick Chhatwal
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Marius Vital
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Torsten Voigtländer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Dietmar H Pieper
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Henrike Lenzen
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hanover, Germany
| | - Philipp Solbach
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany.,Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hanover, Germany
| | - Benjamin Heidrich
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany.,Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, Hannover, Germany
| |
Collapse
|
28
|
de Jong IEM, Overi D, Carpino G, Gouw ASH, van den Heuvel MC, van Kempen LC, Mancone C, Onori P, Cardinale V, Casadei L, Alvaro D, Porte RJ, Gaudio E. Persistent biliary hypoxia and lack of regeneration are key mechanisms in the pathogenesis of posttransplant nonanastomotic strictures. Hepatology 2022; 75:814-830. [PMID: 34543480 PMCID: PMC9300015 DOI: 10.1002/hep.32166] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Nonanastomotic biliary strictures (NAS) are a major cause of morbidity after orthotopic liver transplantation (OLT). Although ischemic injury of peribiliary glands (PBGs) and peribiliary vascular plexus during OLT has been associated with the later development of NAS, the exact underlying mechanisms remain unclear. We hypothesized that bile ducts of patients with NAS suffer from ongoing biliary hypoxia and lack of regeneration from PBG stem/progenitor cells. APPROACH AND RESULTS Forty-two patients, requiring retransplantation for either NAS (n = 18), hepatic artery thrombosis (HAT; n = 13), or nonbiliary graft failure (controls; n = 11), were included in this study. Histomorphological analysis of perihilar bile ducts was performed to assess differences in markers of cell proliferation and differentiation in PBGs, microvascular density (MVD), and hypoxia. In addition, isolated human biliary tree stem cells (hBTSCs) were used to examine exo-metabolomics during in vitro differentiation toward mature cholangiocytes. Bile ducts of patients with NAS or HAT had significantly reduced indices of PBG mass, cellular proliferation and differentiation (mucus production, secretin receptor expression, and primary cilia), reduced MVD, and increased PBG apoptosis and hypoxia marker expression, compared to controls. Metabolomics of hBTSCs during in vitro differentiation toward cholangiocytes revealed a switch from a glycolytic to oxidative metabolism, indicating the need for oxygen. CONCLUSIONS NAS are characterized by a microscopic phenotype of chronic biliary hypoxia attributed to loss of microvasculature, resulting in reduced proliferation and differentiation of PBG stem/progenitor cells into mature cholangiocytes. These findings suggest that persistent biliary hypoxia is a key mechanism underlying the development of NAS after OLT.
Collapse
Affiliation(s)
- Iris E M de Jong
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands.,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| | - Guido Carpino
- Division of Health SciencesDepartment of Movement, Human and Health SciencesUniversity of Rome "Foro Italico"RomeItaly
| | - Annette S H Gouw
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Marius C van den Heuvel
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Léon C van Kempen
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Carmine Mancone
- Department of Molecular MedicineSapienza University of RomeRomeItaly
| | - Paolo Onori
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and BiotechnologiesPolo Pontino, Sapienza University of RomeRomeItaly
| | - Luca Casadei
- Department of ChemistrySapienza University of RomeRomeItaly
| | - Domenico Alvaro
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| |
Collapse
|
29
|
Forde JJ, Bhamidimarri KR. Management of Biliary Complications in Liver Transplant Recipients. Clin Liver Dis 2022; 26:81-99. [PMID: 34802665 DOI: 10.1016/j.cld.2021.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
Collapse
Affiliation(s)
- Justin J Forde
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA.
| |
Collapse
|
30
|
Karakoyun R, Ericzon BG, Kar I, Nowak G. Risk Factors for Development of Biliary Stricture After Liver Transplant in Adult Patients: A Single-Center Retrospective Study. Transplant Proc 2021; 53:3007-3015. [PMID: 34763882 DOI: 10.1016/j.transproceed.2021.09.023] [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: 05/17/2021] [Revised: 08/31/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
Identification of risk factors for biliary stricture after liver transplant and its potential prevention is crucial to improve the outcomes and reduce the complications. We retrospectively analyzed donor and recipient characteristics with intraoperative and postoperative parameters to identify the risk factors for development of post-transplant anastomotic and nonanastomotic biliary strictures with additional analysis of the time onset of those strictures. A total of 412 patients were included in this study. Mean (SD) follow-up time was 79 (35) months (range, 1-152 months). Biliary stricture was diagnosed in 84 patients (20.4%). Multivariate analysis indicated that postoperative biliary leakage (odd ratio [OR], 3.94; P = .001), acute cellular rejection (OR, 3.05; P < .001), donor age older than 47.5 years (OR, 2.05; P = .032), preoperative recipient platelet value < 77.5 × 103/mL (OR, 1.91; P = .023), University of Wisconsin solution (OR, 1.73; P = .041)), recipient male sex (OR, 1.78; P = .072), portal/arterial flow ratio > 4 (OR, 1.76; P = .083), and intraoperative bleeding > 2850 mL (OR, 1.70; P = .053) were independent risk factors for biliary stricture regardless of the time of their appearance. Multiple risk factors for biliary stricture were determined in this study. Some of these risk factors are preventable, and implementation of strategies to eliminate some of those factors should reduce the development of post-transplant biliary stricture.
Collapse
Affiliation(s)
- Rojbin Karakoyun
- Division of Transplantation Surgery, CLINTEC, Karolinska Institute and Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, CLINTEC, Karolinska Institute and Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Irem Kar
- Department of Biostatistics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Greg Nowak
- Division of Transplantation Surgery, CLINTEC, Karolinska Institute and Karolinska University Hospital, Huddinge, Stockholm, Sweden
| |
Collapse
|
31
|
Machine Perfusion of Donation After Circulatory Death Liver and Lungs Before Combined Liver-lung Transplantation. Transplant Direct 2021; 7:e718. [PMID: 34476297 PMCID: PMC8384395 DOI: 10.1097/txd.0000000000001165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/14/2022] Open
Abstract
Shortage of deceased donor organs for transplantation has led to the increased use of organs from donation after circulatory death (DCD) donors. There are currently no reports describing outcomes after multiorgan transplantation with DCD livers. The use of DCD organs for multiorgan transplantation can be enhanced if the detrimental effects of prolonged cold ischemia and subsequent ischemia-reperfusion injury are overcome. We present a case in which the liver and lungs of a DCD donor were preserved using ex situ machine perfusion for combined liver-lung transplantation. The recipient was a 19-year-old male patient requiring bilateral lung transplantation for severe progressive pleural parenchymal fibroelastosis and portal hypertension with portal vein thrombosis. The donor liver was preserved with dual hypothermic oxygenated machine perfusion, whereas the lungs were perfused using ex vivo lung perfusion. With ex vivo lung perfusion, total preservation time of right and left lung reached 17 and 21 h, respectively. Now, 2 y after transplantation, liver function is normal and lung function is improving. To conclude, we suggest that combined transplantation of DCD liver and lungs is feasible when cold ischemia is reduced with ex situ machine perfusion preservation.
Collapse
|
32
|
Channaoui A, Tambucci R, Pire A, de Magnée C, Sokal E, Smets F, Stephenne X, Scheers I, Reding R. Management and outcome of hepatic artery thrombosis after pediatric liver transplantation. Pediatr Transplant 2021; 25:e13938. [PMID: 33314551 DOI: 10.1111/petr.13938] [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: 08/25/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pediatric LT are at particular risk of HAT, and its management still constitutes a matter of debate. Our purpose was to study predisposing factors and outcome of HAT post-LT, including the impact of surgical revisions on survival and biliary complications. METHODS Among 882 primary pediatric LT performed between 1993 and 2015, 36 HAT were encountered (4.1%, 35 fully documented). Each HAT case was retrospectively paired with a LT recipient without HAT, according to diagnosis, age at LT, type of graft, and era. RESULTS Five-year patient survivals were 77.0% versus 83.9% in HAT and non-HAT paired groups, respectively (P = .321). Corresponding graft survivals were 20.0% versus 80.5% (P < .001), and retransplantation rates 77.7% versus 10.7%, respectively (P < .001). One-year biliary complication-free survivals were 16.6% versus 83.8% in the HAT and non-HAT groups, respectively (P < .001). Regarding chronology of surgical re-exploration, only HAT cases that occurred within 14 days post-LT were re-operated, fourteen of them being explored within 7 days post-LT (revascularization rate: 6/14), versus two beyond 7 days (no revascularization). When revascularization was achieved, graft and biliary complication-free survival rates at 1 year were 33.3% and 22.2%, respectively, both rates being 0.0% in case of failure. CONCLUSIONS The pejorative prognosis associated with HAT in terms of graft survival is confirmed, whereas patient survival could be preserved through retransplantation. Results suggest that HAT should be re-operated if occurring within 7 days post-LT, but not beyond.
Collapse
Affiliation(s)
- Aniss Channaoui
- Pediatric Surgery and Transplant Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Roberto Tambucci
- Pediatric Surgery and Transplant Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Aurore Pire
- Pediatric Surgery and Transplant Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Catherine de Magnée
- Pediatric Surgery and Transplant Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Etienne Sokal
- Pediatric Gastroenterology and Hepatology Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Françoise Smets
- Pediatric Gastroenterology and Hepatology Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Xavier Stephenne
- Pediatric Gastroenterology and Hepatology Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Isabelle Scheers
- Pediatric Gastroenterology and Hepatology Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Raymond Reding
- Pediatric Surgery and Transplant Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| |
Collapse
|
33
|
Vo HD, Radio SJ, Reyes-Santiago EM, Mauch TJ. Post-transplant hepatic fibrosis in pediatric liver-small bowel transplant recipients: A single-center, retrospective, observational study. Pediatr Transplant 2021; 25:e13965. [PMID: 33378567 DOI: 10.1111/petr.13965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/02/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about the prevalence of hepatic graft fibrosis in combined LSBT children. We aimed to determine the prevalence of and identify potential predictors for hepatic graft fibrosis in LSBT children and to compare them with those in LT children. METHODS We retrospectively included children younger than 19 years who had received a primary LT/LSBT between 2000 and 2018 and had a liver biopsy performed at least 6 months post-transplant. A Cox proportional hazards regression model was used to determine predictors associated with significant hepatic graft fibrosis (≥F2) in LSBT vs LT children. RESULTS Ninety-six children (47 LSBT, 54 females) were included. The median post-transplant follow-up (years) was 12.8 in LT vs 10.5 in LSBT patients (P = .06). Hepatic graft fibrosis was found in 81.6% of LT vs 70.2% of LSBT children (P = .19), after a median time of 2.5 years and 2.6 years, respectively. On multivariate analyses, having post-transplant biliary complications was found to be associated with significant graft fibrosis in LT children, whereas AST/ALT ratio was found to predict significant hepatic graft fibrosis in LSBT children. The use of parenteral nutrition after transplant was not associated with significant hepatic graft fibrosis. CONCLUSIONS The prevalence of hepatic graft fibrosis in LSBT children did not significantly differ from that in LT children, but the predictors may differ. Future studies should investigate the role of post-transplant autoimmune antibodies and donor-specific antibodies in the development and progression of hepatic graft fibrosis in LSBT children.
Collapse
Affiliation(s)
- Hanh D Vo
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stanley J Radio
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Emille M Reyes-Santiago
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Teri J Mauch
- Pediatric Nephrology, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
34
|
Kulkarni CB, Prabhu NK, Kader NP, Rajeshkannan R, Pullara SK, Moorthy S. Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients. Indian J Radiol Imaging 2021; 27:92-99. [PMID: 28515595 PMCID: PMC5385786 DOI: 10.4103/0971-3026.202950] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients. MATERIALS AND METHODS We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed. RESULTS Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2-3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis). CONCLUSIONS Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.
Collapse
Affiliation(s)
- Chinmay B Kulkarni
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| | - Nirmal K Prabhu
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| | - Nazar P Kader
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| | - Ramiah Rajeshkannan
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| | - Sreekumar K Pullara
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| | - Srikanth Moorthy
- Department of Radiology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala, India
| |
Collapse
|
35
|
Ghinolfi D, Melandro F, Torri F, Martinelli C, Cappello V, Babboni S, Silvestrini B, De Simone P, Basta G, Del Turco S. Extended criteria grafts and emerging therapeutics strategy in liver transplantation. The unstable balance between damage and repair. Transplant Rev (Orlando) 2021; 35:100639. [PMID: 34303259 DOI: 10.1016/j.trre.2021.100639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
Due to increasing demand for donor organs, "extended criteria" donors are increasingly considered for liver transplantation, including elderly donors and donors after cardiac death. The grafts of this subgroup of donors share a major risk to develop significant features of ischemia reperfusion injury, that may eventually lead to graft failure. Ex-situ machine perfusion technology has gained much interest in liver transplantation, because represents both a useful tool for improving graft quality before transplantation and a platform for the delivery of therapeutics directly to the organ. In this review, we survey ongoing clinical evidences supporting the use of elderly and DCD donors in liver transplantation, and the underlying mechanistic aspects of liver aging and ischemia reperfusion injury that influence graft quality and transplant outcome. Finally, we highlight evidences in the field of new therapeutics to test in MP in the context of recent findings of basic and translational research.
Collapse
Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124 Pisa, Italy.
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Caterina Martinelli
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Valentina Cappello
- Center for Nanotechnology Innovation@NEST, Istituto Italiano di Tecnologia, Piazza S. Silvestro 12, 56127 Pisa, Italy
| | - Serena Babboni
- Institute of Clinical Physiology, CNR San Cataldo Research Area, via Moruzzi 1, 56124 Pisa, Italy
| | - Beatrice Silvestrini
- Department of Surgical, Medical, Molecular Pathology, and Critical Area, University of Pisa, 56122 Pisa, Italy.
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, CNR San Cataldo Research Area, via Moruzzi 1, 56124 Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, CNR San Cataldo Research Area, via Moruzzi 1, 56124 Pisa, Italy.
| |
Collapse
|
36
|
Larivière J, Giard JM, Zuo RM, Massicotte L, Chassé M, Carrier FM. Association between intraoperative fluid balance, vasopressors and graft complications in liver transplantation: A cohort study. PLoS One 2021; 16:e0254455. [PMID: 34242370 PMCID: PMC8270449 DOI: 10.1371/journal.pone.0254455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Biliary complications following liver transplantation are common. The effect of intraoperative fluid balance and vasopressors on these complications is unknown. Materials and methods We conducted a cohort study between July 2008 and December 2017. Our exposure variables were the total intraoperative fluid balance and the use of vasopressors on ICU admission. Our primary outcome was any biliary complication (anastomotic and non-anastomotic strictures) up to one year after transplantation. Our secondary outcomes were vascular complications, primary graft non-function and survival. Results We included 562 consecutive liver transplantations. 192 (34%) transplants had a biliary complication, 167 (30%) had an anastomotic stricture and 56 had a non-anastomotic stricture (10%). We did not observe any effect of intraoperative fluid balance or vasopressor on biliary complications (HR = 0.97; 95% CI, 0.93 to 1.02). A higher intraoperative fluid balance was associated with an increased risk of primary graft non-function (non-linear) and a lower survival (HR = 1.40, 95% CI, 1.14 to 1.71) in multivariable analyses. Conclusion Intraoperative fluid balance and vasopressors upon ICU admission were not associated with biliary complications after liver transplantation but may be associated with other adverse events. Intraoperative hemodynamic management must be prospectively studied to further assess their impact on liver recipients’ outcomes.
Collapse
Affiliation(s)
- Jordan Larivière
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jeanne-Marie Giard
- Department of Medicine—Liver Diseases Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Rui Min Zuo
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Michaël Chassé
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - François Martin Carrier
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Carrefour de l’innovation, Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- * E-mail:
| |
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
Fodor M, Cardini B, Peter W, Weissenbacher A, Oberhuber R, Hautz T, Otarashvili G, Margreiter C, Maglione M, Resch T, Krendl F, Meszaros AT, Bogensperger C, Gasteiger S, Messner F, Henninger B, Zoller H, Tilg H, Öfner D, Schneeberger S. Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study. Br J Surg 2021; 108:1082-1089. [PMID: 34027968 DOI: 10.1093/bjs/znab118] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Given the susceptibility of organs to ischaemic injury, alternative preservation methods to static cold storage (SCS), such as normothermic machine perfusion (NMP) are emerging. The aim of this study was to perform a comparison between NMP and SCS in liver transplantation with particular attention to bile duct lesions. METHODS The outcomes of 59 consecutive NMP-preserved donor livers were compared in a 1 : 1 propensity score-matched fashion to SCS control livers. Postoperative complications, patient survival, graft survival and bile duct lesions were analysed. RESULTS While patients were matched for cold ischaemia time, the total preservation time was significantly longer in the NMP group (21 h versus 7 h, P < 0.001). Patient and graft survival rates at 1 year were 81 versus 82 per cent (P = 0.347) and 81 versus 79 per cent (P = 0.784) in the NMP and SCS groups, respectively. The postoperative complication rate was comparable (P = 0.086); 37 per cent NMP versus 34 per cent SCS patients had a Clavien-Dindo grade IIIb or above complication. There was no difference in early (30 days or less) (NMP 22 versus SCS 19 per cent, P = 0.647) and late (more than 30 days) (NMP 27 versus SCS 36 per cent, P = 0.321) biliary complications. However, NMP-preserved livers developed significantly fewer ischaemic-type bile duct lesions (NMP 3 versus SCS 14 per cent, P = 0.047). CONCLUSION The use of NMP allowed for a significantly prolonged organ preservation with a lower rate of observed ischaemic-type bile duct lesions.
Collapse
Affiliation(s)
- M Fodor
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - B Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - W Peter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - A Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - R Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - T Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - G Otarashvili
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - C Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - M Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - T Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - F Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - A T Meszaros
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - C Bogensperger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - S Gasteiger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - F Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - B Henninger
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - H Zoller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - H Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - D Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - S Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
39
|
Liu JQ, Chen WJ, Zhou MJ, Li WF, Tang J. Ultrasound-Based Multimodal Imaging Predicting Ischemic-Type Biliary Lesions After Living-Donor Liver Transplantation. Int J Gen Med 2021; 14:1599-1609. [PMID: 33958890 PMCID: PMC8096442 DOI: 10.2147/ijgm.s305827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Ischemic-type biliary lesions (ITBL) are accepted as the most incomprehensible biliary complications after living-donor liver transplantation (LDLT). Early predicting the development of ITBL in pediatric patients permits more preventive strategies. However, few studies have focused on the early prediction of ITBL. OBJECTIVE This study aimed to establish a nomogram including ultrasound-based multimodal imaging to predict ITBL in children with biliary atresia (BA) within 2 years after receiving LDLT. METHODS The records of 94 BA children with at least one year of follow-up after LDLT were reviewed retrospectively. They were randomly divided into a training cohort for constructing a nomogram (n=64) and a validation cohort (n=30). In the training cohort, patients diagnosed as ITBL were included in the ITBL group and those without any vascular and biliary complication were included in the non-ITBL group. Multivariate Cox regression was used for the establishment of the nomogram in predicting the risk of ITBL within 2 years post-LDLT. The discrimination and calibration of the nomogram were internally and externally validated. The performances of the nomogram and the individual components were compared by the area under the curve (AUC) of receiver operating characteristic (ROC) curve. RESULTS In the training cohort, 18 BA children were included in the ITBL group and 46 were in the non-ITBL group. Last pediatric end-stage liver disease (PELD) score, gamma-glutamyl transpeptidase (GGT), resistive index (RI), and liver stiffness measurement (LSM) were the independent predictors for the development of ITBL within 2 years post-LDLT. The nomogram incorporating these independent predictors showed good discrimination and calibration by the internal and external validation. Its performance was better than any individual component in predicting the prognosis (P < 0.05). CONCLUSION The established nomogram may be used to predict the risk of ITBL within 2 years post-LDLT in BA children.
Collapse
Affiliation(s)
- Jin-qiao Liu
- Department of Ultrasound, Hunan Children’s Hospital, Changsha City, Hunan Province, People’s Republic of China
| | - Wen-juan Chen
- Department of Ultrasound, Hunan Children’s Hospital, Changsha City, Hunan Province, People’s Republic of China
| | - Meng-jie Zhou
- Department of Ultrasound, Hunan Children’s Hospital, Changsha City, Hunan Province, People’s Republic of China
| | - Wen-feng Li
- Department of Ultrasound, Hunan Children’s Hospital, Changsha City, Hunan Province, People’s Republic of China
| | - Ju Tang
- Department of Ultrasound, Hunan Children’s Hospital, Changsha City, Hunan Province, People’s Republic of China
| |
Collapse
|
40
|
Glowka TR, Karlstetter C, Weismüller TJ, Vilz TO, Strassburg CP, Kalff JC, Manekeller S. Intensified Endoscopic Evaluation for Biliary Complications After Orthotopic Liver Transplantation. Ann Transplant 2021; 26:e928907. [PMID: 33820906 PMCID: PMC8035812 DOI: 10.12659/aot.928907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Biliary complications are common causes of morbidity and mortality after liver transplantation. Material/Methods From 2013 to 2018, 102 whole-organ liver transplantations were conducted in our department. Patients were closely monitored for biliary complication development. In all suspected cases, patients underwent either endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangial drainage. Patients’ demographic characteristics, preexisting conditions, and perioperative characteristics, as well as morbidity and mortality, were analyzed. Risk factors for 1-year survival were calculated. Results Of the 102 patients, 43 (42%) experienced biliary complications. In comparison with patients without biliary complications, patients with biliary complications exhibited the following risk factors: underlying liver disease (viral hepatitis; P=0.009), blood group A (P=0.005), and previous abdominal surgery (P=0.037). Neither perioperative characteristics, especially duration of cold ischemia (P=0.86), nor postoperative course differed between patients with and without biliary complications. Risk factors for mortality within 1 year were cirrhosis caused by entities other than viral hepatitis (P=0.017), cardiac comorbidities (P=0.019), re-transplantation (P=0.032), and reduced organ weight (P=0.002). Biliary complications, postoperative hemorrhage, primary nonfunction, and repeated surgery worsened outcome; moreover, serum bilirubin trough in the first 30 days after transplantation might be prognostic for mortality (P=0.043). Conclusions Biliary complications adversely affect outcome after liver transplantation. Neither frequency nor outcome of biliary complications was improved by intensified endoscopic evaluation. Patients on the waiting list for liver transplants should also be closely monitored for cardiac comorbidities.
Collapse
Affiliation(s)
- Tim R Glowka
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | | | | | - Tim O Vilz
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | | | - Jörg C Kalff
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | | |
Collapse
|
41
|
Rashidi-Alavijeh J, Crämer JC, Sauter HL, Willuweit K, Straub K, Wedemeyer H, Herzer K. Primary sclerosing cholangitis as an independent risk factor for cytomegalovirus infection after liver transplant. Transpl Infect Dis 2021; 23:e13553. [PMID: 33368987 DOI: 10.1111/tid.13553] [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: 02/24/2020] [Revised: 11/07/2020] [Accepted: 12/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is one of the most common infectious complications after solid organ transplant; it is associated with morbidity and mortality and with many direct and indirect effects. However, monitoring and therapeutic procedures are very heterogeneous across treatment centers. Additionally, factors that place patients at risk of CMV infection are poorly defined. METHODS Clinical and demographic data from 833 LT recipients and their donors were retrospectively analyzed. Univariate and multivariate analysis were applied. CMV infection was detected by quantitative nucleic acid testing with a lower limit of detection of 40 IU/mL. RESULTS In total, 192 of 833 patients (23%) experienced at least one episode of CMV infection after LT; CMV infection occurred to a large extent during the first year after transplant (70%). Multivariate analysis demonstrated that CMV donor-recipient risk constellation (OR 2.05, 95% CI) and primary sclerosing cholangitis (PSC) before LT (OR 3.76, 95% CI) are independent risk factors for CMV infection after LT. CONCLUSION Patients with high-risk serostatus, PSC, or both should be monitored more thoroughly and should receive prolonged prophylaxis against CMV infection.
Collapse
Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Jens Christoph Crämer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Helena Louisa Sauter
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Katja Straub
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| | - Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg, Essen, Germany
| |
Collapse
|
42
|
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.
Collapse
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.
| |
Collapse
|
43
|
Fischer RT, Day JC, Wasserkrug H, Faseler M, Kats A, Daniel JF, Slowik V, Andrews W, Hendrickson RJ. Complications of Cryptosporidium infection after pediatric liver transplantation: Diarrhea, rejection, and biliary disease. Pediatr Transplant 2020; 24:e13807. [PMID: 32777150 DOI: 10.1111/petr.13807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/22/2020] [Accepted: 06/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cryptosporidium enteritis can be devastating in the immunocompromised host. In pediatric liver transplant recipients, infection may be complicated by prolonged carriage of the parasite, rejection, and biliary tree damage and fibrosis. Herein, we report on six patients and their long-term outcomes following cryptosporidiosis. METHODS We reviewed all cases of cryptosporidiosis in a pediatric liver transplant population over a 17-year period at a single center. Six patients with infection were identified, and their outcomes were analyzed. RESULTS Infection was associated with significant diarrhea and dehydration in all cases, and led to hospitalization in one-half of patients. Four of the six patients developed biopsy-proven rejection following infection, with three of those patients developing rejection that was recalcitrant to intravenous steroid treatment. Additionally, three patients developed biliary tree abnormalities with similarity to sclerosing cholangitis. In one patient, those biliary changes led to repeated need for biliary drain placement and advancing fibrotic liver allograft changes. CONCLUSIONS Cryptosporidiosis in pediatric liver transplant recipients may lead to significant complications, including recalcitrant episodes of rejection and detrimental biliary tree changes. We advocate for increased awareness of this cause of diarrheal disease and the allograft injuries that may accompany infection.
Collapse
Affiliation(s)
- Ryan T Fischer
- Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - J Christopher Day
- Division of Infectious Disease, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Heather Wasserkrug
- Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Megan Faseler
- Division of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Alexander Kats
- Division of Pathology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - James F Daniel
- Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Voytek Slowik
- Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Walter Andrews
- Division of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Richard J Hendrickson
- Division of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA
| |
Collapse
|
44
|
Can ultrasonography differentiate anastomotic and non-anastomotic biliary strictures after orthotopic liver transplantation- a single-center experience. Eur J Radiol 2020; 134:109416. [PMID: 33249391 DOI: 10.1016/j.ejrad.2020.109416] [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: 08/11/2020] [Revised: 11/04/2020] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the role of ultrasonography (US) in differentiating anastomotic biliary strictures (AS) and non-anastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT). METHOD This retrospective study included 1259 OLT recipients between 2005-2018. Seventy-six with anastomotic strictures (AS) and 103 with non-anastomotic strictures (NAS) were analyzed. The reference standard was cholangiography. The sensitivity, specificity, accuracy of US was evaluated. RESULTS There were significant differences between AS and NAS groups (p < 0.001) for skipped and irregular dilatation of intrahepatic bile duct and visualization of hilar biliary lumen. The better US imaging feature for NAS was poorly visualized and non- visible hilar bile duct luminal contour. The sensitivity, specificity and accuracy were 94.2 %, 84.2 % and 88.9 % respectively. Combined two predictors greatly increased the specificity to 93.4 % while diminished its sensitivity and accuracy. CONCLUSION US is useful and efficient to differentiate AS and NAS after OLT.
Collapse
|
45
|
Neuberger M, Sommerer C, Böhnisch S, Metzendorf N, Mehrabi A, Stremmel W, Gotthardt D, Zeier M, Weiss KH, Rupp C. Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients. Clin Res Hepatol Gastroenterol 2020; 44:543-550. [PMID: 31924555 DOI: 10.1016/j.clinre.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients. AIM Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival. METHODS This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival. RESULTS The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival. CONCLUSION MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.
Collapse
Affiliation(s)
- M Neuberger
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Sommerer
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - S Böhnisch
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - N Metzendorf
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - A Mehrabi
- University of Heidelberg, Department of General, Visceral, and Transplantation Surgery, 69120 Heidelberg, Germany
| | - W Stremmel
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - D Gotthardt
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - M Zeier
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - K H Weiss
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Rupp
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany.
| |
Collapse
|
46
|
Kahn J, Pregartner G, Avian A, Kniepeiss D, Müller H, Schemmer P. The Graz Liver Allocation Strategy-Impact of Extended Criteria Grafts on Outcome Considering Immunological Aspects. Front Immunol 2020; 11:1584. [PMID: 32849538 PMCID: PMC7427688 DOI: 10.3389/fimmu.2020.01584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 06/15/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Transplant centers are forced to use livers of extended criteria donors for transplantation due to a dramatic organ shortage. The outcome effect of extended donor criteria (EDCs) remains unclear. Thus, this study was designed to assess the impact of EDCs on outcome including immunological aspects after liver transplantation (LT). Patients and Methods: Between November 2016 and March 2018, 49 patients (85.7% male) with a mean age of 57 ± 11 years underwent LT. The impact of EDCs on outcome after LT was assessed retrospectively using both MedOcs and ENIS (Eurotransplant Network Information System). Results: About 80% of grafts derived from extended criteria donors. Alanine aminotransferase/aspartate aminotransferase (AST/ALT) levels elevated more than three times above normal values in organ donors was the only significant risk factor for primary dysfunction (PDF) and primary non-function (PNF)/Re-LT and early non-anastomotic biliary strictures (NAS). Balance of risk (BAR) score did not differ between EDC and non-EDC recipients. PDF (14.3% of all patients) and PNF (6.1% of all patients) occurred in 23.1% of EDC-graft recipients and in 10.0% of non-EDC-graft recipients (RR 2.31, p = 0.663). The 90-day mortality was 3.6%. There was no difference of early non-anastomotic biliary tract complications and biopsy proven rejections (BPR). There was no correlation of PDF/PNF with BPR and NAS, respectively; however, 66.7% of the patients with BPR also developed early NAS (p < 0.001). Conclusion: With the Graz liver allocation strategy, excellent survival can be achieved selecting livers with no more than 2 not outcome-relevant EDCs for patients with MELD >20. Further, BPR is associated with biliary complications.
Collapse
Affiliation(s)
- Judith Kahn
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Daniela Kniepeiss
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Helmut Müller
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| |
Collapse
|
47
|
Cortez AR, Morris MC, Brown NG, Winer LK, Safdar K, Poreddy S, Shah SA, Quillin RC. Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era. J Gastrointest Surg 2020; 24:1639-1647. [PMID: 31228080 DOI: 10.1007/s11605-019-04292-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. METHODS All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). RESULTS A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. CONCLUSIONS Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.
Collapse
Affiliation(s)
- Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nicholas G Brown
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Leah K Winer
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kamran Safdar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Sampath Poreddy
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - R Cutler Quillin
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati, Cincinnati, OH, USA. .,Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA.
| |
Collapse
|
48
|
Kim JD, Kwak SG, Choi DL. Safety and Efficacy of Living Donor Hepatectomy Without Systemic Heparinization: Short- and Long-Term Outcomes. Transplant Proc 2020; 52:1778-1783. [PMID: 32571699 DOI: 10.1016/j.transproceed.2020.01.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/26/2022]
Abstract
There is no consensus regarding the use of systemic heparin, and long-term outcomes of living donor hepatectomy (LDH) without systemic heparinization have not yet been determined. This study was performed to determine whether systemic heparinization can be omitted during LDH, with a focus on donor safety and long-term outcomes. We retrospectively analyzed the outcomes of 175 cases of LDH performed in our institution between January 2011 and December 2014: group I (n = 79) received systemic heparinization, whereas group II (n = 96) did not, but liver graft was flushed with a heparinized perfusate. Postoperative bleeding requiring blood transfusion or intervention was more frequent in group I than in group II (P = .028). The decreases in donor hemoglobin and hematocrit levels, and platelet count during the early postoperative period, were greater in group I than in group II. In multivariate analysis, systemic heparin was the only independent risk factor for blood transfusion (odds ratio [OR] = 5.114; 95% confidence interval [CI]: 1.201-21.775; P = .027) and significant postoperative bleeding (OR = 7.731; 95% CI: 1.345-44.429; P = .022) after LDH. Most postoperative complications including graft vascular thrombosis were similar between the 2 groups, as was the survival rate, and neither graft loss due to vascular thrombosis nor non-anastomotic biliary stricture was evident. In conclusion, omission of systemic heparinization during LDH is a feasible and safe option without adverse effects.
Collapse
Affiliation(s)
- Joo Dong Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea.
| | - Sang-Gyu Kwak
- Department of Medical Statistics, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Lak Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
| |
Collapse
|
49
|
Rauber C, Awad M, Koschny R, Sauer P, Mehrabi A, Gath P, Weiss KH, Gotthardt DN, Rupp C. Biliary calprotectin, lactoferrin and dimeric pyruvate kinase after liver transplantation are associated with biliary damage and graft survival in a case-control study. Clin Res Hepatol Gastroenterol 2020; 44:38-48. [PMID: 31201006 DOI: 10.1016/j.clinre.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/05/2019] [Accepted: 05/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND After liver transplantation (LT), biliary complications are associated with reduced graft survival. We tested inflammation markers for their association with biliary damage and graft loss in bile. MATERIAL AND METHODS The study design was a retrospective case-control study. Calprotectin, lactoferrin and pyruvate kinase were measured in endoscopically retrieved bile with ELISA. RESULTS Calprotectin and lactoferrin were significantly higher in bile of ischemic-type biliary lesions and donor duct non-anastomotic strictures than in control, bile leakage, Cytomegalovirus infection, anastomotic stricture or acute cellular rejection patients (p<0.001) independent of serum liver values at endoscopy. Calprotectin (p=0.02) was independently associated with retransplantation free survival in multivariate analysis, as was γGT (p=0.03) but not ERC radiographic classification of the bile duct or cold ischemia time. CONCLUSION Calprotectin and lactoferrin are bile markers for biliary damage and are associated with re-transplantation free survival. They can differentiate progressive biliary damage from non-biliary liver value alterations after LT.
Collapse
Affiliation(s)
- Conrad Rauber
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany; Université Paris-Sud, Université Paris-Saclay, 91400 Paris, France; Gustave Roussy Cancer Campus (GRCC), 94800 Villejuif, France.
| | - Miriam Awad
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Philip Gath
- Department of Gastroenterology and Hepatology, Hospital Ludwigshafen, 67063 Ludwigshafen, Germany
| | - Karl-Heinz Weiss
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Daniel Nils Gotthardt
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, University Hospital Heidelberg, University of Heidelberg, 69120 Heidelberg, Germany
| |
Collapse
|
50
|
Jiménez-Romero C, Manrique A, García-Conde M, Nutu A, Calvo J, Caso Ó, Marcacuzco A, García-Sesma Á, Álvaro E, Villar R, Aguado JM, Conde M, Justo I. Biliary Complications After Liver Transplantation From Uncontrolled Donors After Circulatory Death: Incidence, Management, and Outcome. Liver Transpl 2020; 26:80-91. [PMID: 31562677 DOI: 10.1002/lt.25646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 12/26/2022]
Abstract
The utilization of livers from donation after uncontrolled circulatory death (uDCD) increases the availability of liver grafts, but it is associated with a higher incidence of biliary complications (BCs) and lower graft survival than those organs donated after brain death. From January 2006 to December 2016, we performed 75 orthotopic liver transplantations (OLTs) using uDCD livers. To investigate the relationship of BCs with the use of uDCD OLT, we compared patients who developed BCs (23 patients) with those who did not (non-BC group, 43 patients) after excluding cases of hepatic artery thrombosis (a known cause of BC) and primary nonfunction. The groups had similar uDCD donor maintenance, donor and recipient characteristics, and perioperative morbidity/mortality rates, but we observed a higher rate of hepatocellular carcinoma and hepatitis C virus in the non-BC group. Percutaneous transhepatic biliary dilation, endoscopic retrograde cholangiopancreatography dilation, Roux-en-Y hepaticojejunostomy (HJ), a T-tube, and retransplantation were used for BC management. In the BC group, 1-, 3-, and 5-year patient survival rates were 91.3%, 69.6%, and 65.2%, respectively, versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P = 0.89). However, 1-, 3-, and 5-year graft survival rates were 78.3%, 60.9%, and 56.5%, respectively, in the BC group versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P = 0.38). Multivariate analysis did not indicate independent risk factors for BC development. In conclusion, patient and graft survival rates were generally lower in patients who developed BCs but not significantly so. These complications were managed in the majority of patients through radiological dilation, endoscopic dilation, or Roux-en-Y HJ. Retransplantation is necessary in rare cases after the failure of biliary dilation or surgical procedures.
Collapse
Affiliation(s)
- Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Anisa Nutu
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Óscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Edurne Álvaro
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - Roberto Villar
- Department of Radiology, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| | - María Conde
- Service of General and Digestive Surgery, Lucus Augusti Hospital, Lugo, Spain
| | - Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of Surgery, Faculty of Medicine, Instituto de Investigación, Doce de Octubre University Hospital, Complutense University, Madrid, Spain
| |
Collapse
|