Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes

Safety and yield of diagnostic ERCP in liver transplant patients with abnormal liver function tests

Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8–48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48–62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic.

Tratamento endoscópico das lesões biliares

As técnicas cirúrgicas convencionais ofertam uma apropriada condição de cura na maioria dos pacientes com estreitamento biliar benigno. Nesta condição, no entanto, o reparo cirúrgico está associado com recorrência tardia da re-estenose em 10% a 30% dos pacientes. Neste contexto, os avanços tecnológicos na endoscopia terapêutica promoveram a possibilidade alternativa do tratamento efetivo destas obstruções benignas. Considerações em relação ao tempo de reospitalização e de procedimentos devem ser averiguados em detalhes e ponderados em relação á cirurgia. Estenoses malignas estão relacionadas á colangite, icterícia e dor e, consequentemente, com as alterações sistêmicas relacionadas com a sepsis biliar. A conduta endoscópica cria uma derivação do suco biliar para o duodeno, sendo uma verdadeira derivação biliodigestiva endoscópica e utilizando-se próteses plásticas ou metálicas. O propósito desta revisão é ofertar aos leitores a eficácia do tratamento endoscópico na estenose benigna e maligna biliopancreática.

Role of endoscopic retrograde cholangiopancreatography in the diagnosis and treatment of biliary tract complications after orthotopic liver transplantation

BACKGROUND

Biliary complications are a major drawback of liver transplantation.

AIM

To analyse, in a single centre, experience in endoscopic diagnosis and management of biliary complications after liver transplantation.

PATIENTS

A total of 147 consecutive liver transplantations performed on 132 patients over a 5-year period.

METHODS

Evaluation of the incidence and type of biliary-related complications and analysis of their diagnosis and endoscopic treatment by cholangiopancreatography in terms of success of the endoscopic approach, conversion to surgery and long-term patient and graft survival.

RESULTS

Endoscopic retrograde cholangiopancreatography was performed on 30 patients (23%). Overall incidence of biliary complications as confirmed by endoscopic retrograde cholangiopancreatography was 17% (25 cases). Endoscopic retrograde cholangiopancreatography was negative in 5 cases (16%). Biliary complications were successfully treated by endoscopy in 84% of cases (21 out of 25 patients); 4 cases (16%) required a surgical approach (2 choledochojejunostomy, 2 retransplantation) due to failure to correct the problem endoscopically. Stenoses and biliary sludge associated with retained internal stent were almost always successfully managed by endoscopic retrograde cholangiopancreatography, while anastomotic leakage more frequently required a surgical approach.

CONCLUSIONS

Endoscopic retrograde cholangiopancreatography is a safe and effective approach for diagnosis and treatment of biliary-related complications after liver transplantation thereby reducing morbidity and mortality related to re-operation which is, however, required in selected cases.

Routine endoscopic retrograde cholangiography in the detection of early biliary complications after liver transplantation

The value of routinely performing endoscopic retrograde cholangiography (ERC) to detect biliary complications in patients undergoing orthotopic liver transplantation (OLT) with duct-to-duct anastomosis without a T-tube is not known. Eighty-nine of 171 liver transplant recipients (61 men; mean age, 49.9 years) underwent ERC 14.5 +/- 4.5 (SD) days after surgery between January 1997 and August 1999. Findings of ERC and need for intervention for biliary complications were noted. ERC was successful in 71of 89 patients (80%). Nineteen patients (21%) required intervention for biliary complications (stricture, 13 patients; bile leak, 6 patients). Protocol ERC detected eight of these complications (42%). In 4 patients, ERC failed, and 7 patients with a normal ERC result subsequently required intervention (2 patients in the same admission, and 5 patients after discharge). Sensitivity, specificity, and positive and negative predictive values for successful ERC in detecting early biliary complications were 80%, 98%, 89%, and 97%, whereas those for predicting the overall rate of biliary complications were 53%, 98%, 89%, and 89%, respectively. Although highly specific and moderately sensitive in detecting early biliary complications, ERC performed routinely has low sensitivity in predicting the overall risk for biliary complications in patients undergoing OLT with unsplinted duct-to-duct anastomosis.