Biliary Anastomotic Stricture After Adult Living Donor Liver Transplantation With Duct-to-Duct Reconstruction: Outcome After Endoscopic Treatment Including Rendezvous Procedure

Endoscopic ultrasound-rendezvous versus percutaneous-endoscopic rendezvous endoscopic retrograde cholangiopancreatography for bile duct access: Systematic review and meta-analysis

OBJECTIVES

Endoscopic ultrasound (EUS) or percutaneous-assisted antegrade guidewire insertion can be used to achieve biliary access when standard endoscopic retrograde cholangiopancreatography (ERCP) fails. We conducted a systematic review and meta-analysis to evaluate and compare the effectiveness and safety of EUS-assisted rendezvous (EUS-RV) and percutaneous rendezvous (PERC-RV) ERCP.

METHODS

We searched multiple databases from inception to September 2022 to identify studies reporting on EUS-RV and PERC-RV in failed ERCP. A random-effects model was used to summarize the pooled rates of technical success and adverse events with 95% confidence interval (CI).

RESULTS

In total, 524 patients (19 studies) and 591 patients (12 studies) were managed by EUS-RV and PERC-RV, respectively. The pooled technical successes were 88.7% (95% CI 84.6-92.8%, I2  = 70.5%) for EUS-RV and 94.1% (95% CI 91.1-97.1%, I2  = 59.2%) for PERC-RV (P = 0.088). The technical success rates of EUS-RV and PERC-RV were comparable in subgroups of benign diseases (89.2% vs. 95.8%, P = 0.068), malignant diseases (90.3% vs. 95.5%, P = 0.193), and normal anatomy (90.7% vs. 95.9%, P = 0.240). However, patients with surgically altered anatomy had poorer technical success after EUS-RV than after PERC-RV (58.7% vs. 93.1%, P = 0.036). The pooled rates of overall adverse events were 9.8% for EUS-RV and 13.4% for PERC-RV (P = 0.686).

CONCLUSIONS

Both EUS-RV and PERC-RV have exhibited high technical success rates. When standard ERCP fails, EUS-RV and PERC-RV are comparably effective rescue techniques if adequate expertise and facilities are feasible. However, in patients with surgically altered anatomy, PERC-RV might be the preferred choice over EUS-RV because of its higher technical success rate.

Efficacy of intraductal placement of nonflared fully-covered metal stent for refractory perihilar benign biliary strictures: A multicenter prospective study with long-term observation

BACKGROUND

Endoscopic fully-covered self-expandable metal stents (FCSEMSs) are used to treat benign biliary strictures (BBSs); however, treatment for perihilar BBSs is technically challenging. The aim of this study was to evaluate the usefulness of an unflared FCSEMS designed for intraductal placement in patients with refractory perihilar BBS.

METHODS

Twenty-two consecutive patients with perihilar BBS unresolved by endoscopic plastic stent placement at 13 tertiary medical centers were prospectively enrolled. The FCSEMS was placed above the papilla and removed after 4 months. The primary outcome was stricture resolution at 4 months, and the secondary outcomes were technical success, stent removal, adverse events, and recurrence.

RESULTS

The technical success rate of intraductal FCSEMS placement was 100%, and plastic stent placement at contralateral or side branch was performed in 86% of patients. The rate of successful stent removal at 4 months was 100%, and stricture resolution was observed in 91% of patients. Stent migration or stent-induced de novo stricture did not occur in any patient. The stricture recurrence rate was 16%, and the median (interquartile range) follow-up duration was 2.8 (1.6-3.3) years.

CONCLUSIONS

Intraductal placement of unflared FCSEMS is effective treatment for refractory perihilar BBS.

Short-term and long-term outcomes in living donors for liver transplantation: Cohort study

BACKGROUND

Although perioperative outcomes following donor hepatectomy (DH) have been reported, little is known about the long-term outcomes in living donors of liver transplantation. The aim of this study was to investigate the short-term and long-term outcomes following DH.

METHODS

A total of 408 living donors who underwent DH between 1996 and 2019 were analyzed in this retrospective study, focusing on short-term outcomes with respect to the operation period (era) and the graft type, as well as long-term outcomes.

RESULTS

The overall incidence of postoperative complications was 40.4%. These included minor (30.4%), major (10.0%), and biliary (14.0%) complications. Short-term outcomes after DH slightly improved over time, and outcomes did not differ significantly between the graft types. With regards to long-term outcomes, the incidence of surgery-related complications such as keloids, incisional hernias, and mechanical bowel obstructions was 6.6% over a median follow-up of 7.2 years. In addition, some donors developed comorbidities such as lifestyle diseases and cancers during the follow-up period.

CONCLUSIONS

Our study confirmed an improvement of perioperative outcomes in living donors. There was no significant association between the graft type and postoperative outcomes. Donors could develop various morbidities during long-term follow-up. Therefore, a careful perioperative management and long-term follow-up should be provided to living donors.

Long-term Outcome of the Rendezvous Technique in Patients With Severe Biliary Anastomotic Stricture That Cannot Cannulate After Liver Transplant

BACKGROUND

Nearly all publications related to endoscopic treatment of biliary anastomotic stricture after liver transplant have reported cases that can be cannulated. However, very few publications discuss endoscopic treatment of biliary anastomotic stricture (BAS) in which the guide wire does not pass through the stricture site. The purpose of this article is to analyze the long-term outcome of the Rendezvous technique in severe strictures through which guide wires cannot cannulate.

METHODS

Between 2010 and 2017, a total of 29 patients who underwent Rendezvous technique because of severe BAS after liver transplant were included in the study.

RESULTS

Twenty-nine patients who underwent the Rendezvous technique showed a 100% technical success rate. Ten patients (34.4%) required stent removal; the mean stenting period was 14.9 (SD, 5.6) months (range, 6.65-24.14 months). A total of 19 patients were maintained without stent removal; the stent-maintaining period was 13.1 (SD, 8.4) months (range, 3.48-38.61 months). Two patients receiving left lobe grafts maintained the stents for 27.1 (SD, 16.2) months. In left lobe graft, the duct anastomosis position moves to the right posteroinferior side of the patient.

CONCLUSIONS

Our results suggest that the stenting period of the Rendezvous technique was longer in severe BAS than in cannulated endoscopic retrograde cholangiopancreatography cases. Especially in the left liver, the position of the duct anastomosis changed to the right posteroinferior of the patient. Thus, the donor duct and the recipient duct are angulated, kinking worsens, and the stenting period becomes longer.

Efficacy of a Biliary Splint at the Anastomosis in Living Donor Liver Transplantation−With a Special Reference to Postoperative Endoscopic Treatment for Biliary Stricture

Objective:

For successful biliary anastomosis in living donor liver transplantation (LDLT), the efficacy of a biliary splint at the anastomosis remains controversial. In the case of biliary anastomotic stricture (BAS), endoscopic intervention is mostly performed as the initial treatment. In this study, we evaluated the efficacy of endoscopic treatment for BAS in patients with placement of splints.

Methods:

A retrospective study was conducted with 148 adult patients who underwent LDLT with duct-to-duct biliary anastomosis from 2005 to 2015. A biliary splint was placed in all cases; the splint was removed 3 months after the LDLT. Patients who postoperatively underwent endoscopic treatment for BAS were divided into successful and failed groups.

Results:

A total of 24 patients (16.2%) underwent endoscopic treatment postoperatively. The successful group included 14 patients (63.6%) and the failed group included 8 (36.4%). Comparison between the 2 groups in terms of demographic, pretransplant, intraoperative, and posttransplant data did not show any significant differences. Two patients developed BAS within 3 months after LDLT. In these 2 patients, the splint was dislocated, and endoscopic intervention was not successful. Twenty patients developed BAS later than 3 months after LDLT. In contrast to the success rate of endoscopic intervention of 73.3% in patients without splint dislocation (n = 15), it was 60% in the patient with dislocation of the splint (n = 5).

Conclusion:

The prevention of early biliary stricture by placing a splint may lead to an improved success rate of endoscopic intervention, since endoscopic intervention was difficult in the cases of early biliary stricture within 3 months.