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Vikash F, Vikash S, Ho S, Kotler D, Patel S. Intensive Care Unit-Related Cholangiopathy-Induced Biliary Cast Syndrome Without Liver Transplantation: A Rare Entity. ACG Case Rep J 2024; 11:e01269. [PMID: 38374925 PMCID: PMC10876252 DOI: 10.14309/crj.0000000000001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/22/2023] [Indexed: 02/21/2024] Open
Abstract
The development of biliary cast syndrome (BCS) is very rare, mostly documented in patients with liver transplantation. The etiology of BCS is unknown; however, risk factors include post-liver transplant bile duct injury, ischemia, infection, fasting, parenteral feeding, and increased bile viscosity and gallbladder dysmotility. We present the case of a 41-year-old man who developed BCS secondary to a prolonged intensive care unit course without a liver transplant. This case highlights the importance of monitoring patients with protracted intensive care unit course and abnormal aminotransferases to recognize and timely manage cholangiopathy and BCS-related complications.
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Affiliation(s)
- Fnu Vikash
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Sindhu Vikash
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Sammy Ho
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Donald Kotler
- Division of Gastroenterology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Sunny Patel
- Division of Gastroenterology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY
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2
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Bartoli A, Cursaro C, Seferi H, Andreone P. Secondary Sclerosing Cholangitis After SARS-CoV2: ICU Ketamine Use or Virus-Specific Biliary Tropism and Injury in the Context of Biliary Ischemia in Critically Ill Patients? Hepat Med 2023; 15:93-112. [PMID: 37547355 PMCID: PMC10404108 DOI: 10.2147/hmer.s384220] [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: 01/20/2023] [Accepted: 07/12/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose From the beginning of the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV2) pandemic, different cases of a cholangiopathy with features of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) have been reported. Patients developing it are generally recovering from severe Coronavirus disease 19 (COVID-19) and required intensive care unit (ICU) admission and mechanical ventilation. Many of them have been administered with ketamine during their ICU stay. The pathogenesis of this novel disease is still debated, and, since prognosis is poor, efforts are needed in order to better understand it. Patients and Methods In this review, we focused our attention on COVID-19 SSC clinical, imaging, and histology findings in order to clarify the different pathogenetic options, particularly in regard of the ischemic-direct viral damage and ketamine-related theories, beginning with a recapitulation of SSC-CIP and ketamine-induced cholangiopathy in abusers. The research has been conducted using PubMed and Google Scholar databases. Key-words were "Secondary Sclerosing Cholangiopathy", "SSC-CIP", "Secondary Sclerosing Cholangiopathy in critically ill patients", "Ketamine and cholangiopathy", "Ketamine abusers and liver disease", "Ketamine-related cholangiopathy", "SARS-CoV2 infection and liver disease", "post Covid-19 secondary sclerosing cholangitis", "Covid-19 cholangiopathy". Results Many authors, based on the clinical, histological, imaging, and prognostic features of the disease, have pointed out the similarities between post COVID-19 SSC and SSC-CIP; however, peculiar features in the former were not previously observed. Therefore, a direct viral cytopathic action and SARS-CoV2-related coagulopathy are considered the most likely causes. On the other hand, ketamine, with the available data, cannot be surely linked as the main determinant cause of cholangiopathy. Moreover, ketamine-induced cholangitis (KIC) presentation is different from post COVID-19 SSC. Its role as a cofactor precipitating the disease cannot be ruled out. Conclusion Post COVID-19 SSC is a rare clinical entity following severe COVID-19 disease. The most accepted theory is that a sum of different insults determines the disease: biliary ischemia, direct viral damage, toxic bile, possibly worsened by ketamine and hyperinflammation due to the cytokine storm. Given the severe prognosis of the disease, with persistent cholangiopathy, organ failure, and orthotopic liver transplantation (OLT), further study on this novel clinical entity is needed.
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Affiliation(s)
- Alessandra Bartoli
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
- Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Carmela Cursaro
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Hajrie Seferi
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Chief of Division of Internal Medicine and metabolism, Department of Internal Medicine, University Hospital of Modena, Modena, Italy
- Chief of Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
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3
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Dabbous H, Elsayed A, Salah M, Montasser I, Atef M, Elmetenini M. Risk factors and management of biliary stones after living donor liver transplant and its effect on graft outcome. Front Med (Lausanne) 2022; 9:927744. [PMID: 36082268 PMCID: PMC9445190 DOI: 10.3389/fmed.2022.927744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/15/2022] [Indexed: 11/26/2022] Open
Abstract
Background Bile stones are associated with numerous complications in liver transplant recipients. Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be safe and highly effective in dealing with most post-transplant biliary complications. Objective The objective of this study was to identify the possible risk factors for bile stone formation on top of biliary stricture, the effects of stones on graft outcomes, and their management. Methods This case–control study included 83 patients who underwent living donor liver transplant (LDLT) and suffered from postoperative biliary stricture with or without stones. Patients were divided into two groups. Group 1 (n = 55) included patients with biliary strictures with no stones and group 2 (n = 28) included patients who developed stones on top of biliary strictures. Data about the recipient and donor characteristics, surgical technique, blood lipid profile, immunosuppressive drugs, post-transplant complications, and interventions were collected from the medical records. Results The frequency of hepatitis C virus (HCV) was significantly higher in group 2 compared to group 1 (71.4% vs. 47.3%, p = 0.036). The body mass index (BMI) of the donors was significantly higher in group 2 than in group 1 (25.17 ± 2.53 vs. 23.68 ± 2.63, p = 0.015). Episodes of acute rejection were significantly higher in group 2 than in group 1 (21.4% vs. 5.5%, p = 0.027). The ERCP was sufficient in most of the cases (89.2%) to ensure biliary drainage. The identified independent risk factors for biliary stones included HCV, biliary drain, donor's BMI, and serum cholesterol level. Conclusion Positive HCV, biliary drain insertion, donor's BMI, and serum cholesterol level were independent risk factors for developing bile stones on top of biliary strictures. Biliary stones were associated with high episodes of acute graft rejection, and they could be successfully managed by the ERCP modality.
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Affiliation(s)
- Hany Dabbous
- Tropical Medicine Department, Ain Shams Center for Organ Transplantation, Ain Shams University, Cairo, Egypt
- *Correspondence: Hany Dabbous
| | - Ashraf Elsayed
- Tropical Medicine Department, Ain Shams Center for Organ Transplantation, Ain Shams University, Cairo, Egypt
| | - Manar Salah
- Tropical Medicine Department, Ain Shams Center for Organ Transplantation, Ain Shams University, Cairo, Egypt
| | - Iman Montasser
- Tropical Medicine Department, Ain Shams Center for Organ Transplantation, Ain Shams University, Cairo, Egypt
| | - Mohamed Atef
- Tropical Medicine Department, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elmetenini
- Hepatobiliary Surgical Department, Ain Shams Center for Organ Transplantation, Ain Shams University, Cairo, Egypt
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4
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Interventional endoscopy for abdominal transplant patients. Semin Pediatr Surg 2022; 31:151190. [PMID: 35725058 DOI: 10.1016/j.sempedsurg.2022.151190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).
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Saleem N, Li BH, Vuppalanchi R, Gawrieh S, Gromski MA. Critical Illness Cholangiopathy in COVID-19 Long-Haulers. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:351-353. [PMID: 35615695 PMCID: PMC9123802 DOI: 10.1016/j.tige.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/15/2022] [Indexed: 02/07/2023]
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Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques. Pediatr Radiol 2022; 52:570-586. [PMID: 34713322 DOI: 10.1007/s00247-021-05212-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction.
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Park JC, Park JG. A Case of Biliary Cast Syndrome After Endoscopic and Percutaneous Management of Common Bile Duct Stone. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:224-229. [PMID: 36237361 PMCID: PMC9238204 DOI: 10.3348/jksr.2021.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/29/2021] [Accepted: 06/04/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jae Chun Park
- Department of Radiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Jung Gu Park
- Department of Radiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
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Lemmers A, Pezzullo M, Hadefi A, Dept S, Germanova D, Gustot T, Degré D, Boon N, Moreno C, Blero D, Arvanitakis M, Delhaye M, Vandermeeren A, Njimi H, Devière J, Le Moine O, Lucidi V. Biliary cast syndrome after liver transplantation: A cholangiographic evolution study. J Gastroenterol Hepatol 2021; 36:1366-1377. [PMID: 33150992 DOI: 10.1111/jgh.15318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/20/2020] [Accepted: 10/24/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM The aim of this study is to describe the cholangiographic features and endoscopic management of biliary cast syndrome (BCS), a rare specific ischemic cholangiopathy following liver transplantation. METHODS Patients with biliary complications were identified from prospectively collected database records of patients who underwent liver transplantation at the Erasme Hospital from January 2005 to December 2014. After excluding patients with hepatico-jejunostomy or no suspicion of stricture, cholangiograms obtained during endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging were systematically reviewed. Biliary complications were categorized as anastomotic (AS) and non-AS strictures, and patients with BCS were identified. Clinical, radiological, and endoscopic data were reviewed. RESULTS Out of 311 liver transplantations, 14 cases were identified with BCS (4.5%) and treated with ERCP. Intraductal hyperintense signal on T1-weighted magnetic resonance and a "duct-in-a-duct" image were the most frequent features of BCS on magnetic resonance imaging. On initial ERCP, 57% of patients had no stricture. Complete cast extraction was achieved in 12/14, and one of these had cast recurrence. On follow-up, 85% of the patients developed biliary strictures that were treated with multiple plastic stents reaching 60% complete stricture resolution, but 40% of them had recurrence. After a median follow-up of 58 months, BCS patients had lower overall and graft survival (42.9% and 42.9%) compared with non-AS (68.8% and 56.3%) and AS (83.3% and 80.6%), respectively. CONCLUSIONS Particular magnetic resonance-cholangiographic and ERCP-cholangiographic features of BCS have been identified. Outcomes for BCS are characterized by high complete cast extraction rates, high incidence of secondary strictures, and poorer prognosis.
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Affiliation(s)
- Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Martina Pezzullo
- Department of Radiology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Séverine Dept
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Desislava Germanova
- Department of Abdominal Surgery, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Nathalie Boon
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Myriam Delhaye
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Alain Vandermeeren
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Hassan Njimi
- Biomedical Statistic, ULB (Free University of Brussels), Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Olivier Le Moine
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Valerio Lucidi
- Department of Abdominal Surgery, CUB Erasmus Hospital, ULB (Free University of Brussels), Brussels, Belgium
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Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr 2021; 10:76-92. [PMID: 33575291 DOI: 10.21037/hbsn.2019.09.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
Importance Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation. Objective The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT. Evidence Review a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment. Findings Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks. Conclusions and Relevance BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.
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Affiliation(s)
- Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
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Martins P, Verdelho Machado M. Secondary Sclerosing Cholangitis in Critically Ill Patients: An Underdiagnosed Entity. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 27:103-114. [PMID: 32266307 DOI: 10.1159/000501405] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a recently identified cholestatic liver disease occurring in patients without prior history of hepatobiliary disease, after receiving treatment in the intensive care unit (ICU) in different settings, including cardiothoracic surgery, infection, trauma, and burns. It is a rare entity, being estimated to occur in 1/2,000 patients in an ICU; however, it is a dismal condition, with up to half of the patients dying during the ICU stay and with rapid progression to liver cirrhosis over weeks to months. SSC-CIP should be considered in the differential diagnosis of cholestasis in the ICU, particularly when cholestasis persists after recovery from the critical event. Diagnosis is established with magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography showing dilations and stenoses of the intrahepatic bile ducts as well as biliary casts. No available treatment has been shown to slow the rapid progression of the disease, and liver transplant referral should be considered early after the diagnosis of SSC-CIP. Increased awareness and timely diagnosis are crucial in order to improve the current appalling outcome.
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Affiliation(s)
- Pedro Martins
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mariana Verdelho Machado
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Serviço de Gastrenterologia, Hospital de Santa Maria, CHULN, Lisbon, Portugal
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Lam E, Bashir B, Chaballa M, Kraft WK. Drug interactions between direct-acting oral anticoagulants and calcineurin inhibitors during solid organ transplantation: considerations for therapy. Expert Rev Clin Pharmacol 2019; 12:781-790. [PMID: 31242782 DOI: 10.1080/17512433.2019.1637733] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: There is a high incidence of venous thromboembolism (VTE) in solid organ transplant recipients. The safety and efficacy of direct-acting oral anticoagulants (DOAC) have been well established in clinical practice for the prevention and treatment of VTE in broad populations. However, the management of VTE in the setting of solid organ transplantation remains a challenge to clinicians due to limited evidence of DOAC usage with calcineurin inhibitors. Areas covered: The current literature available on the pharmacokinetic-pharmacodynamic interaction between DOACs and calcineurin inhibitors is presented. A comprehensive review was undertaken using PubMed, Embase, drug product labeling, and drug product review conducted by the US Food and Drug Administration using Drugs@FDA. The potential for mitigation strategies and clinical management using extant knowledge is explored. Expert opinion: Immunosuppression therapy is necessary to prevent graft rejection by the host. The sparsity of data together with the lack of well-designed prospective studies of DOAC use in solid organ transplant recipients presents a unique challenge to clinicians in determining the clinical relevance of possible drug interactions. Existing evidence suggests that with attention to concomitant drug use and renal function, the co-administration of DOACs and calcineurin inhibitors is safe and effective.
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Affiliation(s)
- Edwin Lam
- a Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University , Philadelphia , PA , USA
| | - Babar Bashir
- b Department of Medical Oncology, Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Mark Chaballa
- c Department of Pharmacy, Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Walter K Kraft
- a Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University , Philadelphia , PA , USA
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Moy BT, Birk JW. A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. J Clin Transl Hepatol 2019; 7:61-71. [PMID: 30944822 PMCID: PMC6441650 DOI: 10.14218/jcth.2018.00028] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.
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Affiliation(s)
- Brian T. Moy
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- *Correspondence to: John W. Birk, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT 06030, USA. E-mail:
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Horvat N, Marcelino ASZ, Horvat JV, Yamanari TR, Batista Araújo-Filho JDA, Panizza P, Seda-Neto J, Antunes da Fonseca E, Carnevale FC, Mendes de Oliveira Cerri L, Chapchap P, Cerri GG. Pediatric Liver Transplant: Techniques and Complications. Radiographics 2018; 37:1612-1631. [PMID: 29019744 DOI: 10.1148/rg.2017170022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplant is considered to be the last-resort treatment approach for pediatric patients with end-stage liver disease. Despite the remarkable advance in survival rates, liver transplant remains an intricate surgery with significant morbidity and mortality. Early diagnosis of complications is crucial for patient survival but is challenging given the lack of specificity in clinical presentation. Knowledge of the liver and vascular anatomy of the donor and the recipient or recipients before surgery is also important to avoid complications. In this framework, radiologists play a pivotal role on the multidisciplinary team in both pre- and postoperative scenarios by providing a road map to guide the surgery and by assisting in diagnosis of complications. The most common complications after liver transplant are (a) vascular, including the hepatic artery, portal vein, hepatic veins, and inferior vena cava; (b) biliary; (c) parenchymal; (d) perihepatic; and (e) neoplastic. The authors review surgical techniques, the role of each imaging modality, normal posttransplant imaging features, types of complications after liver transplant, and information required in the radiology report that is critical to patient care. They present an algorithm for an imaging approach for pediatric patients after liver transplant and describe key points that should be included in radiologic reports in the pre- and postoperative settings. Online supplemental material is available for this article. ©RSNA, 2017.
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Affiliation(s)
- Natally Horvat
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Antonio Sergio Zafred Marcelino
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Joao Vicente Horvat
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Tássia Regina Yamanari
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Jose de Arimateia Batista Araújo-Filho
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Pedro Panizza
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Joao Seda-Neto
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Eduardo Antunes da Fonseca
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Francisco Cesar Carnevale
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Luciana Mendes de Oliveira Cerri
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Paulo Chapchap
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Giovanni Guido Cerri
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
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14
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Abstract
Background and study aims Bile cast syndrome (BCS) is a complication of orthotopic liver transplantation (OLT). It occurs in 4 % to 18 % of OLT recipients and can present as cholangitis and graft damage or loss. Twenty-two percent of patients with BCS require repeat OLT. The diagnosis and management of BCS can be challenging. Our aim is to share our experience with BCS and to briefly review the diagnosis and management of the condition.
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Affiliation(s)
- Fahad F. Mir
- Saint Luke’s Hospital of Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, United States
| | - Sreenivasa S. Jonnalagadda
- Saint Luke’s Hospital of Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, United States,Corresponding author Sreenivasa S. Jonnalagadda, MD, FASGE 4321Washington StreetAre 5100Kansas City, MO 64111
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15
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Kırnap M, Ayvazoğlu Soy EH, Akdur A, Yıldırım S, Harman A, Moray G, Haberal M. Incidence and Treatment of Bile Stones After Liver Transplant. EXP CLIN TRANSPLANT 2017. [PMID: 28411359 DOI: 10.6002/ect.2017.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality. MATERIALS AND METHODS We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens. RESULTS Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures. CONCLUSIONS Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.
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Affiliation(s)
- Mahir Kırnap
- Department of General Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
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16
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Roos FJM, Poley JW, Polak WG, Metselaar HJ. Biliary complications after liver transplantation; recent developments in etiology, diagnosis and endoscopic treatment. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624111 DOI: 10.1016/j.bpg.2017.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary complications are considered to be the Achilles' heel of liver transplantation. The most common complications are leaks and bile duct strictures. Strictures can arise at the level of the anastomosis (anastomotic strictures; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). Endoscopic treatment via endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the preferred therapy for these complications. This review will focus on the diagnostic modalities, new insights in etiology of biliary complications and outcomes after different endoscopic therapies, in both deceased donor transplantation and living-donor liver transplantations. Advances in recent therapies, such as the use of self-expendable metal stents (SEMS) and endoscopic therapy for patients with a bilio-digestive anastomosis will be discussed.
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17
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Mahler MA, Marcaccio F, Dumonceau JM, Macías Gómez C. Successful Endoscopic Management of Late Biliary Cast Syndrome in a Liver Transplant Recipient: A Case Report. Case Rep Gastroenterol 2017; 11:207-211. [PMID: 28512394 PMCID: PMC5422734 DOI: 10.1159/000468509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/27/2017] [Indexed: 12/03/2022] Open
Abstract
Biliary cast syndrome (BCS) is an unusual complication of liver transplantation (LT). The pathophysiology is not known, and it is thought to develop because of mucosal damage in the bile duct related to obstruction, ischemia, or bacterial infection. It occurs in 2.5–18% of LT patients and is associated with increased graft failure, need for retransplantation, and mortality. Here we report on a case of BCS of late appearance after LT who was successfully treated by endoscopic means.
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Affiliation(s)
| | - Federico Marcaccio
- aGastroenterology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Carlos Macías Gómez
- aGastroenterology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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18
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Nam K, Lee SK, Song TJ, Park DH, Lee SS, Seo DW, Kim MH. Percutaneous transhepatic cholangioscopy for biliary complications after liver transplantation: a single center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:650-657. [PMID: 27474863 DOI: 10.1002/jhbp.388] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/28/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Some biliary complications after liver transplantation (LT) are difficult to manage by endoscopic or radiologic intervention alone. In these cases, percutaneous transhepatic cholangioscopy (PTCS) can be used as an adjuvant option. METHODS Patients who underwent PTCS for post-LT biliary complications between August 1992 and January 2016 were retrospectively reviewed. RESULTS Fifteen patients underwent PTCS for post-LT biliary complications. The median age at LT was 47 years and 11 patients were male. Indications for LT were as follows: decompensated liver cirrhosis (n = 9), hepatocellular carcinoma (n = 5), and acute fulminant liver failure (n = 1). Single living donor was common (n = 11) and duct-to-duct anastomosis was performed in 11 patients. The median age at PTCS was 52 years and indications for PTCS were as follows: intrahepatic duct stone (n = 10), common bile duct stone (n = 1), biliary cast (n = 1), and biliary stricture (n = 3). There were no significant PTCS-related morbidity and mortality. However, four patients (26.7%) needed additional radiologic intervention (n = 2) or surgery (n = 2) after PTCS. CONCLUSIONS Percutaneous transhepatic cholangioscopy in conjunction with endoscopic and radiologic interventions can aid in managing post-LT biliary complications and avoiding reoperation.
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Affiliation(s)
- Kwangwoo Nam
- Division of Gastroenterology, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, South Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
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19
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Endoscopic treatment of biliary stones in patients with liver transplantation. Surg Endosc 2016; 31:1327-1335. [DOI: 10.1007/s00464-016-5116-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/12/2016] [Indexed: 01/26/2023]
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20
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Park SH, Kim KW, Kim B, Lee SJ, Lee JS, Kim HJ, Song GW, Lee SG, Jeong WK. Imaging of biliary complications in recipients of right-lobe living donor liver transplantation. Acta Radiol 2016; 57:401-12. [PMID: 25972371 DOI: 10.1177/0284185115584814] [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: 10/29/2014] [Accepted: 04/09/2015] [Indexed: 11/15/2022]
Abstract
Right-lobe living donor liver transplantation (RL-LDLT) is a common method devised in order to fulfill the demands of donor organ shortage in adult patients with end-stage liver diseases. However, biliary complications remain as the "Achilles' heel" of RL-LDLT, with wide variety of incidence among transplantation centers. Patients with biliary complications after RL-LDLT may have similar clinical presentations to those with other causes of graft dysfunction. Therefore, radiological evaluation plays a key role for differential diagnosis of such complications. In this article, we discuss the various methods of biliary reconstruction and imaging findings of common and uncommon biliary complications in recipients of RL-LDLT.
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Affiliation(s)
- So Hyun Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyoung Won Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bohyun Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So Jung Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Seok Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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21
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Memeo R, Piardi T, Sangiuolo F, Sommacale D, Pessaux P. Management of biliary complications after liver transplantation. World J Hepatol 2015; 7:2890-2895. [PMID: 26689137 PMCID: PMC4678375 DOI: 10.4254/wjh.v7.i29.2890] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/27/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Biliary complications (BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.
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22
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Leonhardt S, Veltzke-Schlieker W, Adler A, Schott E, Eurich D, Faber W, Neuhaus P, Seehofer D. Secondary Sclerosing Cholangitis in Critically Ill Patients: Clinical Presentation, Cholangiographic Features, Natural History, and Outcome: A Series of 16 Cases. Medicine (Baltimore) 2015; 94:e2188. [PMID: 26656347 PMCID: PMC5008492 DOI: 10.1097/md.0000000000002188] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an important differential diagnosis in patients presenting with cholestasis and PSC-like cholangiographic changes in endoscopic retrograde cholangiography (ERC). As a relatively newly described entity, SSC-CIP is still underdiagnosed, and the diagnosis is often delayed. The present study aims to improve the early detection of SSC-CIP and the identification of its complications.A total of 2633 records of patients who underwent or were listed for orthotopic liver transplantation at the University Hospital Charité, Berlin, were analyzed retrospectively. The clinical presentation and outcome (mean follow-up 62.7 months) of the 16 identified SSC-CIP cases were reviewed.Cholestasis was the first sign of SSC-CIP. GGT was the predominant enzyme of cholestasis. Hypercholesterolemia occurred in at least 75% of the patients. SSC-CIP provoked a profound weight loss (mean 18 kg) in 94% of our patients. SSC-CIP was diagnosed by ERC in all patients. The 3 different cholangiographic features detected correspond roughly to the following stages: (I) evidence of biliary casts, (II) progressive destruction of intrahepatic bile ducts, and (III) picture of pruned tree. Biliary cast formation is a hallmark of SSC-CIP and was seen in 87% of our cases. In 75% of the patients, the clinical course was complicated by cholangiosepsis, cholangitic liver abscesses, acalculous cholecystitis, or gallbladder perforation. SSC-CIP was associated with worse prognosis; transplant-free survival was ∼40 months (mean).Because of its high rate of serious complications and unfavorable prognosis, it is imperative to diagnose SSC-CIP early and to differentiate SSC-CIP from other types of sclerosing cholangitis. Specific characteristics enable identification of SSC-CIP. Early cooperation with a transplant center and special attention to biliary complications are required after diagnosis of SSC-CIP.
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Affiliation(s)
- Silke Leonhardt
- From the Department of General, Visceral and Transplantation Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany (SL, DE, WF, PN, DS); Endoscopy Unit, Department of Gastroenterology and Hepatology, Endocrinology, Diabetes and Metabolic Diseases, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany (WV-S, AA, ES); and Department of Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, Düsseldorf, Germany (SL)
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23
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Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management. Hepatol Int 2015; 10:106-14. [PMID: 26603541 DOI: 10.1007/s12072-015-9685-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 11/06/2015] [Indexed: 12/14/2022]
Abstract
Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.
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24
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Senoo T, Ichikawa T, Taura N, Miyaaki H, Miuma S, Shibata H, Honda T, Takatsuki M, Hidaka M, Soyama A, Eguchi S, Nakao K. Incidence of and risk factors for bile duct stones after living donor liver transplantation: An analysis of 100 patients. Hepatol Res 2015; 45:969-975. [PMID: 25331775 DOI: 10.1111/hepr.12438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 09/25/2014] [Accepted: 10/14/2014] [Indexed: 12/13/2022]
Abstract
AIM Although bile duct stone (BDS) is one of the biliary complications of liver transplantation, analytical studies, particularly on living donor liver transplantation (LDLT) cases, are rare. This study aimed to clarify the incidence of and risk factors for BDS following LDLT. METHODS We retrospectively reviewed the medical records of 100 patients who underwent LDLT at our institute from August 2000 to May 2012, and analyzed their clinical characteristics and risk factors for BDS. RESULTS Of these, 10 patients (10.0%) developed BDS during the observation period. The median follow-up period to BDS diagnosis was 45.5 months (range, 5-84) after LDLT. Univariate analysis revealed male sex, right lobe graft and bile duct strictures as factors that significantly correlated with BDS formation. Multivariate analysis revealed bile duct strictures (odds ratio, 7.17; P = 0.011) and right lobe graft (odds ratio, 10.20; P = 0.040) to be independent risk factors for BDS formation. One patient with BDS and biliary strictures succumbed to sepsis from cholangitis. CONCLUSION In the present study, right lobe graft and bile duct strictures are independent risk factors for BDS formation after LDLT. More careful observation and monitoring are required in the patients with high-risk factors.
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Affiliation(s)
- Takemasa Senoo
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Tatsuki Ichikawa
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Naota Taura
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Hidetaka Shibata
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Takuya Honda
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
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25
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Tian H, Liao QD, Li NF, Peng J, Gong LS, Liu J. Biliary Cast Syndrome: Hepatic Artery Resistance Index, Pathological Changes, Morphology and Endoscopic Therapy. Chin Med J (Engl) 2015; 128:1910-5. [PMID: 26168832 PMCID: PMC4717921 DOI: 10.4103/0366-6999.160537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Biliary cast syndrome (BCS) was a postoperative complication of orthotopic liver transplantation (OLT), and the reason for BSC was considered to relate with ischemic type biliary lesions. This study aimed to evaluate the relationship between BCS following OLT and the hepatic artery resistance index (HARI), and to observe pathological changes and morphology of biliary casts. METHODS Totally, 18 patients were diagnosed with BCS by cholangiography following OLT using choledochoscope or endoscopic retrograde cholangiopancreatography. In addition, 36 patients who did not present with BCS in the corresponding period had detectable postoperative HARI on weeks 1, 2, 3 shown by color Doppler flow imaging. The compositions of biliary casts were analyzed by pathological examination and scanning electron microscopy. RESULTS HARI values of the BCS group were significantly decreased as compared with the non-BCS group on postoperative weeks 2 and 3 (P < 0.05). Odds ratio (OR) analysis of HARI 1, HARI 2, HARI 3 following the operation was >1 (OR = 1.300; 1.223; and 1.889, respectively). The OR of HARI 3 was statistically significant (OR = 1.889; 95% confidence interval = 1.166-7.490; P = 0.024). The compositions of biliary casts were different when bile duct stones were present. Furthermore, vascular epithelial cells were found by pathological examination in biliary casts. CONCLUSIONS HARI may possibly serve as an independent risk factor and early predictive factor of BCS. Components and formation of biliary casts and bile duct stones are different.
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Affiliation(s)
| | - Qian-De Liao
- Hepatobiliary and Enteric Surgery Research Center, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
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Schlesinger NH, Svenningsen P, Frevert S, Wettergren A, Hillingsø J. Percutaneous yttrium aluminum garnet-laser lithotripsy of intrahepatic stones and casts after liver transplantation. Liver Transpl 2015; 21:831-7. [PMID: 25821134 DOI: 10.1002/lt.24120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/15/2015] [Indexed: 02/07/2023]
Abstract
Bile duct stones and casts (BDSs) contribute importantly to morbidity after liver transplantation (LT). The purpose of this study was to estimate the clinical efficacy, safety, and long-term results of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in transplant recipients and to discuss underlying factors affecting the outcome. A retrospective chart review revealed 18 recipients with BDSs treated by PTCSL laser lithotripsy with a holmium-yttrium aluminum garnet laser probe at 365 to 550 µm. They were analyzed in a median follow-up time of 55 months. In all but 1 patient (17/18 or 94%), it was technically feasible to clear all BDSs with a mean of 1.3 sessions. PTCSL was unsuccessful in 1 patient because of multiple stones impacting the bile ducts bilaterally; 17% had early complications (Clavien II). All biliary casts were successfully cleared; 39% had total remission; 61% needed additional interventions in the form of percutaneous transhepatic cholangiography and dilation (17%), re-PTCSL (11%), self-expandable metallic stents (22%), or hepaticojejunostomy (6%); and 22% eventually underwent retransplantation. The overall liver graft survival rate was 78%. Two patients died during follow-up for reasons not related to their BDS. Nonanastomotic strictures (NASs) were significantly associated with treatment failure. We conclude that PTCSL in LT patients is safe and feasible. NASs significantly increased the risk of relapse. Repeated minimally invasive treatments, however, prevented graft failure in 78% of the cases.
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Affiliation(s)
- Nis Hallundbaek Schlesinger
- Departments of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark.,Department of Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Peter Svenningsen
- Departments of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Susanne Frevert
- Departments of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - André Wettergren
- Departments of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Jens Hillingsø
- Departments of Surgery and Transplantation, Rigshospitalet, Copenhagen, Denmark
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Girotra M, Soota K, Klair JS, Dang SM, Aduli F. Endoscopic management of post-liver transplant biliary complications. World J Gastrointest Endosc 2015; 7:446-459. [PMID: 25992185 PMCID: PMC4436914 DOI: 10.4253/wjge.v7.i5.446] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/15/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.
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Dechêne A, Kodde C, Kathemann S, Treckmann J, Lainka E, Paul A, Gerken G, Feldstein AE, Hoyer PF, Canbay A. Endoscopic treatment of pediatric post-transplant biliary complications is safe and effective. Dig Endosc 2015; 27:505-511. [PMID: 25545826 DOI: 10.1111/den.12420] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/19/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Biliary complications (BC) after liver transplantation (LT) are associated with significant morbidity and mortality. Incidence of BC after pediatric LT is more than 10%. In adults, treatment by endoscopic retrograde cholangiopancreaticography (ERCP) is successful. As data in pediatric patients are limited, endoscopic treatment of BC in a pediatric cohort in a German transplant center was analyzed. METHODS LT recipients <18 years of age who were endoscopically treated for BC at University Hospital Essen were retrospectively analyzed. Characteristics of LT, endoscopic treatment measures, clinical and endoscopic presentation of BC, and outcomes after endoscopic treatment were evaluated. RESULTS Seventeen patients (median age 12 years) with clinical signs of BC were treated endoscopically using ERCP. Eleven patients had received a full-size liver, and six a left-sided living-donor transplant graft. In 12 patients, the bile ducts were accessible via Vater's papilla and five patients had a bilioenteric anastomosis. Biliary sphincterotomy was done in 13 patients. Eleven patients presented with stricture of the biliary anastomosis (AST), either isolated (nine) or in combination with biliary cast syndrome (BCS) or biliary leakage (one patient each). Ischemia-type biliary lesions (ITBL) were found in two patients. Five patients suffered from BCS, either as isolated pathology (two) or in combination with AST, bile leak or ITBL. In one patient, biliary access via the major papilla was not obtainable. CONCLUSIONS BC in pediatric LT were treated safely and successfully in pediatric patients when the biliary tract was accessible. The most common complications were AST, BCS and ITBL.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Cathrin Kodde
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Simone Kathemann
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Jürgen Treckmann
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ariel E Feldstein
- Department of Pediatrics, University of California San Diego (UCSD), San Diego, USA
| | - Peter F Hoyer
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
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29
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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30
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Itri JN, Heller MT, Tublin ME. Hepatic transplantation: postoperative complications. ACTA ACUST UNITED AC 2014; 38:1300-33. [PMID: 23644931 DOI: 10.1007/s00261-013-0002-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in surgical techniques and immunosuppression have made orthotopic liver transplantation a first-line treatment for many patients with end-stage liver disease. The early detection and treatment of postoperative complications has contributed significantly to improved graft and patient survival with imaging playing a critical role in detection. Complications that can lead to graft failure or patient mortality include vascular abnormalities, biliary abnormalities, allograft rejection, and recurrent or post-transplant malignancy. Vascular abnormalities include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava, as well as hepatic artery pseudoaneurysm, arteriovenous fistula, and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not used to diagnose allograft rejection, it plays an important role in identifying complications that can mimic rejection. Ultrasound is routinely performed as the initial imaging modality for the detection and follow-up of both early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are used to characterize biliary complications and computed tomography is used to confirm abnormal findings on ultrasound or for the evaluation of postoperative collections. The purpose of this article is to describe and illustrate the imaging appearances and management of complications associated with liver transplantation.
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Affiliation(s)
- Jason N Itri
- University of Pittsburgh Medical Center, 200 Lothrop Street Presby South Tower, Suite 4896, Pittsburgh, PA, USA,
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Yang YL, Zhang C, Lin MJ, Shi LJ, Zhang HW, Li JY, Yu Q. Biliary casts after liver transplantation: Morphology and biochemical analysis. World J Gastroenterol 2013; 19:7772-7777. [PMID: 24282366 PMCID: PMC3837278 DOI: 10.3748/wjg.v19.i43.7772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the pathogenesis of biliary casts after liver transplantation relative to their morphology and biochemical markers.
METHODS: The microstructure of biliary casts was assessed using scanning electron microscopy and Hematoxylin and eosin staining assessed their histology. The expression levels of CD3, CD5, CD34, CD68 and CD79a in these biliary casts were evaluated immunohistochemically.
RESULTS: Biliary casts differed widely in their microstructure, with some containing blood vessels positive for CD34 and collagen fibers with positive Masson staining. Large numbers of neutrophils and other inflammatory cells were present, but only on the edge of the biliary casts; although the boundaries were clear without crossover. None of the biliary casts contained T-lymphocytes, B-lymphocytes, macrophages and other inflammatory cells.
CONCLUSION: The microcostructure of biliary casts differed. Bacteria and acute rejection are not clearly related to their formation.
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Dabiri R, Aghdae HA, Rajabalinia H, Mohammad Alizadeh AH. Biliary cast syndrome in an opium inhaler. Case Rep Gastroenterol 2013; 7:376-80. [PMID: 24163648 PMCID: PMC3806723 DOI: 10.1159/000355165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Biliary cast syndrome (BCS) is an uncommon complication which is mostly described in orthotopic liver transplantation. However, BCS has also been reported rarely in non-liver transplant patients. We describe a male long-term opium inhaler with BCS who underwent successful endoscopic cast removal by balloon enteroscopy-guided endoscopic retrograde cholangiopancreatography. A 52-year-old man, who was a known case of opium addiction, presented with the chief complaint of epigastric pain for 1 week prior to admission. Routine laboratory evaluation revealed cholestatic liver enzyme elevation. A cholestatic pattern was seen in radiographic modalities. Endoscopic retrograde cholangiopancreatography showed a linear filling defect in the intra- and extrahepatic duct. A long biliary cast was successfully removed using an extractor balloon. After removal of the biliary cast the patient is receiving ursodeoxycholic acid and does not report any problem 4 months after treatment. It seems that biliary dyskinesia due to long-term opium use can be a predisposing factor for biliary cast formation.
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Affiliation(s)
- Reza Dabiri
- Shahid Beheshti University of Medical Sciences, Taleghani Hospital, Tehran, Iran
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33
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Voigtländer T, Negm AA, Strassburg CP, Lehner F, Manns MP, Lankisch TO. Biliary cast syndrome post-liver transplantation: risk factors and outcome. Liver Int 2013; 33:1287-92. [PMID: 23601581 DOI: 10.1111/liv.12181] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 03/23/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Biliary cast syndrome (BCS) is characterized by the retention of lithogenic material leading to obstructive cholangitis and subsequent liver damage. BCS after orthotopic liver transplantation (OLT) can lead to retransplantation or death. AIM Evaluation of aetiology, risk factors and outcome of BCS after OLT. METHODS In a retrospective single centre analysis between 2002 and 2011, all OLT patients with BCS diagnosed by endoscopic retrograde cholangiography were identified and compared with a matched control group at a 2:1 ratio. RESULTS Thirty patients with BCS after OLT were identified (30/887, 3.4%). Seventy per cent of those patients (21/30) underwent transplantation in the Model for Endstage Liver Disease (MELD) score era. Median time to diagnosis after OLT was 255 days (IQR 107-621). Intensive care unit treatment after OLT was significantly longer in BCS patients [16 days (IQR 8-42) vs. 9 (IQR 7-17) days; P = 0.039]. In a multivariate analysis, hepatic artery stenosis (P = 0.04), biliary strictures (P = 0.032) and need for renal replacement therapy (P = 0.002) were significantly associated with BCS. Immunosuppressant regimen, operation time, cold or warm ischaemia time, graft size, acute cellular rejection and cytomegalovirus infections were not significantly different between both groups. Retransplantation rate and 12-month mortality were significantly higher with BCS (9/30, 30% vs. 4/60, 7%, P = 0.003). CONCLUSIONS BCS is a rare, but severe complication after OLT. Patients with hepatic artery stenosis, biliary strictures or renal replacement therapy have the highest risk to develop BCS and should therefore be monitored carefully.
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Affiliation(s)
- Torsten Voigtländer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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34
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Nasr JY, Slivka A. Endoscopic approach to the post liver transplant patient. Gastrointest Endosc Clin N Am 2013; 23:473-81. [PMID: 23540971 DOI: 10.1016/j.giec.2012.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Biliary complications occur after liver transplantation. These complications can be effectively and safely managed using endoscopic approaches and can prevent unnecessary and potentially morbid surgery.
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Affiliation(s)
- John Y Nasr
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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35
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Paik WH, Lee SH, Ryu JK, Song BJ, Kim J, Kim YT, Yoon YB. Long-term clinical outcomes of biliary cast syndrome in liver transplant recipients. Liver Transpl 2013; 19:275-82. [PMID: 23213039 DOI: 10.1002/lt.23589] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 11/29/2012] [Indexed: 02/07/2023]
Abstract
Biliary cast syndrome (BCS) is an uncommon complication of orthotopic liver transplantation (OLT), so the long-term treatment outcomes of BCS are not well characterized. The purpose of this study was to evaluate the long-term treatment outcomes and prognosis of BCS after OLT. The medical records of 1097 patients who underwent OLT from January 2000 to September 2009 were reviewed. Those patients who had BCS were evaluated with respect to the treatment method, overall survival and relapse rates, and relapse-free time. Twenty-three patients (2.1%) were diagnosed with BCS with a mean overall follow-up of 59.9 months. All the patients had benign biliary strictures and repeatedly underwent balloon dilatation by an endoscopic or percutaneous approach. Primary biliary cast removal was tried with the endoscopic method from 11 patients and with the percutaneous methods from 12 patients. Casts were completely removed by repetitive procedures in 22 patients, but BCS relapsed in 12 patients (55%). Persistent biliary strictures were significantly associated with the BCS relapse frequency (0.37 versus 0.05 times per year, P = 0.006). The 5-year overall survival rate for BCS patients after OLT was 87%. The risk factors associated with early relapse were female sex, hepatic artery stenosis, and acute cellular rejection. In a multivariate analysis, acute cellular rejection was the only significant risk factor for early relapse (hazard ratio = 11.1, 95% confidence interval = 1.9-63.2, P = 0.007). In conclusion, patients with BCS frequently relapse, and multiple interventions and the treatment of biliary strictures are needed. Acute cellular rejection after OLT is a significant risk factor for early relapse.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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36
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Koo JW, Jang NE, Lee HJ, Joo KR, Cha JM, Shin HP, Lee JI, Lim SJ. A case of biliary cast developed in a patient with long-standing biliary sludge. Clin Endosc 2013; 46:98-101. [PMID: 23423962 PMCID: PMC3572362 DOI: 10.5946/ce.2013.46.1.98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 03/29/2012] [Accepted: 03/29/2012] [Indexed: 12/03/2022] Open
Abstract
Development of biliary casts is very unusual, especially in patients who have not undergone liver transplantation. Variable causes of biliary cast formation in nonliver transplantation patients have been suggested. However, stasis of bile flow and/or gallbladder hypocontractility is known to eventually result in the promotion of biliary sludge and subsequent cast formation. Here we present one case of biliary cast syndrome, which developed in a nonliver transplant patient who had biliary sludge for a long period of time, providing evidence that long-standing biliary sludge may lead to cast formation.
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Affiliation(s)
- Ja Won Koo
- Department of Gastroenterology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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37
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Lucey MR, Terrault N, Ojo L, Hay JE, Neuberger J, Blumberg E, Teperman LW. Long-term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl 2013; 19:3-26. [PMID: 23281277 DOI: 10.1002/lt.23566] [Citation(s) in RCA: 327] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 10/20/2012] [Indexed: 02/06/2023]
Affiliation(s)
- Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-5124, USA.
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Ha SI, Choi JS, Kim YH, Jun HS, Jo YG, Lee WH, Park SG, Lee SH. [Biliary cast syndrome in non-liver surgery patients]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 60:382-5. [PMID: 23242023 DOI: 10.4166/kjg.2012.60.6.382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Biliary cast describes the presence of casts within the biliary tree. It is resultant sequel of cholangitis and hepatocyte damage secondary to bile stasis and bile duct injury. Biliary cast syndrome was first reported in patient undergone liver transplantation. The pathogenesis of biliary cast is not clearly identified, but proposed etiologic factors include post-transplant bile duct damage, ischemia, biliary infection, or post-operative biliary drainage tube. Although biliary casts are uncommon, most of biliary cast syndrome are reported in the liver transplant or hepatic surgery patients. A few reports have been published about non-transplant or non-liver surgery biliary cast. We report two cases of biliary cast syndrome in non-liver surgery patients.
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Affiliation(s)
- Seung In Ha
- Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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Zhu XD, Shen ZY, Chen XG, Zang YJ. Pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant. EXP CLIN TRANSPLANT 2012. [PMID: 23190361 DOI: 10.6002/ect.2012.0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To summarize the pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant. MATERIALS AND METHODS The clinical manifestations, auxiliary examination, therapeutic regimen, and clinical efficacy of 103 biliary cast syndrome patients who underwent an orthotopic liver transplant were retrospectively analyzed. Patients were divided into 6 groups from type 1 to type 6, according to the injury level of the biliary duct epithelium. RESULTS Many biliary cast syndrome patients showed symptoms including jaundice, dark urine, argillaceous stool, itchy skin, and fever. Serum levels of alanine aminotransferase, γ-glutamyl transpeptidase, alkaline phosphatase, and total bilirubin were increased. In addition, total white cell counts in peripheral blood also were increased. T-tube cholangiography showed filling defects of various amounts. Optical fiber choledochoscope examination revealed that the biliary tract was filled with solid substances, and necrosis of the biliary tract epithelium was observed in some biliary cast syndrome patients. From type 1 to type 6 biliary cast syndrome patients, the probability of clinical symptoms and biliary tract stricture gradually increased, the time needed for supporting gradually prolonged after removal of the biliary cast, and T-tube cholangiography showed that the filling defects gradually expanded. CONCLUSIONS Clinical manifestations and cholangiography presentations mainly depend on pathotyping.
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Affiliation(s)
- Xiao-dan Zhu
- From the Liver Transplantation Institute of Armed Police Force, General Hospital of Chinese Armed Police Force, Beijing 100039, China.
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40
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Affiliation(s)
- Carlos Apestegui
- Starzl Abdominal Transplant Unit, Department of Abdominal and Transplantation Surgery (Prof. JF. Gigot), University Hospitals Saint-Luc, Université Catholique de Louvain - UCL, Brussels, Belgium
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Zoepf T, Maldonado de Dechêne EJ, Dechêne A, Malágo M, Beckebaum S, Paul A, Gerken G, Hilgard P. Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation. Gastrointest Endosc 2012; 76:556-63. [PMID: 22898414 DOI: 10.1016/j.gie.2012.04.474] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 04/30/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary strictures are the most common complication after liver transplantation. A particular problem is ischemic-type biliary lesions (ITBLs), which are often responsible for graft failure and early retransplantation. Although some encouraging results of successful endoscopic treatment have been reported, this has not yet resulted in a standardized therapeutic approach to date. OBJECTIVE To evaluate an optimized algorithm for the endoscopic treatment of ITBLs. SETTING AND PATIENTS All adult patients who underwent liver transplantation at the University of Essen between April 1998 and July 2006. DESIGN Retrospective outcome analysis. MAIN OUTCOME MEASUREMENTS Success or failure of 2 different therapeutic algorithms in terms of normalization of cholestasis parameters and graft survival. RESULTS Forty-eight patients who had undergone liver transplantation and had an endoscopically determined diagnosis of ITBL were identified. The median interval between liver transplantation and first endoscopic intervention was 242.5 (range, 16-3677) days. Patients received a median of 6 treatment sessions (range 2-13) every 8 to 10 weeks. In 16 of 48 patients, a combination of balloon dilation (BD) and implantation of a plastic endoprosthesis (BD+EP) was performed; in the remaining 32 patients, BD alone was performed. Overall, endoscopic therapy was successful in 73%. BD+EP was successful in 5 of 16 (31%) and BD alone in 30 of 32 patients (91%; P = .0027). In the BD+EP group, severe cholangitis developed in 25% of patients, but only 12% of the BD group (P = .01). The median duration of therapy was 374 (range 11-808) days. Six of 48 patients underwent retransplantation because of chronic graft rejection at a median of 1288 (range 883-4204) days after the primary liver transplantation. Six of 48 patients underwent hepaticojejunostomy because of unsuccessful endoscopic therapy, and 1 patient underwent surgery because of portal vein thrombosis. LIMITATIONS Retrospective design. CONCLUSIONS An endoscopic treatment regimen for ITBLs, preferably BD alone, could prolong the time to or could completely avoid surgical revision and early retransplantation and seems to be superior to endoscopic stenting.
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Affiliation(s)
- Thomas Zoepf
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Kinner S, Umutlu L, Dechêne A, Ladd SC, Barkhausen J, Gerken G, Lauenstein TC, Hunold P. Biliary complications after liver transplantation: addition of T1-weighted images to MR cholangiopancreatography facilitates detection of cast in biliary cast syndrome. Radiology 2012; 263:429-36. [PMID: 22517958 DOI: 10.1148/radiol.12111625] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of T2-weighted magnetic resonance (MR) cholangiopancreatography pulse sequences in comparison with MR cholangiopancreatography sequences combined with nonenhanced T1-weighted images in the detection of biliary cast syndrome in liver transplant recipients. MATERIALS AND METHODS This retrospective study was conducted in accordance with the declaration of Helsinki. Institutional review board approval was obtained. MR images in 95 patients who were examined after liver transplantation and who presented with symptoms of biliary obstruction were examined. Two separate sets of images, MR cholangiopancreatograms and MR cholangiopancreatograms plus T1-weighted images, were evaluated independently by three readers. Sensitivities, specificities, and positive and negative predictive values for biliary cast syndrome were calculated, and receiver operating characteristic curves were generated. The results of endoscopic retrograde cholangiopancreatography served as the reference standard. To determine interobserver agreement, κ values were calculated. RESULTS Cast appeared hyperintense on nonenhanced T1-weighted images. Sensitivities for T2-weighted MR cholangiopancreatography data alone were 0.65, 0.70, and 0.55 for the three readers. Adding unenhanced T1-weighted images resulted in sensitivities of 0.95, 0.90, and 0.90, respectively. Specificities for MR cholangiopancreatography alone and for MR cholangiopancreatography plus T1-weighted images were high on average (0.98, 0.97, and 0.97 vs 1.0 for all readers, respectively). Interobserver agreement was good for T2-weighted MR cholangiopancreatography (κ for readers 1 and 2 = 0.589, κ for readers 2 and 3 = 0.593, κ for readers 1 and 3 = 0.734) and was excellent for MR cholangiopancreatography plus T1-weighted images (κ for readers 1 and 2 = 0.806, κ for readers 2 and 3 = 0.881, κ for readers 1 and 3 = 0.848). CONCLUSION The combination of T2-weighted MR cholangiopancreatography and T1-weighted imaging yields higher diagnostic performance than MR cholangiopancreatography alone. Therefore, readers evaluating liver MR images with regard to biliary complications after liver transplantation should also look at the bile ducts on unenhanced T1-weighted images, as biliary cast might be more easily depicted on these images.
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Affiliation(s)
- Sonja Kinner
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany.
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Atwal T, Pastrana M, Sandhu B. Post-liver Transplant Biliary Complications. J Clin Exp Hepatol 2012; 2:81-5. [PMID: 25755409 PMCID: PMC3940277 DOI: 10.1016/s0973-6883(12)60085-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 03/13/2012] [Indexed: 12/12/2022] Open
Abstract
Biliary tract complications remain a common source of morbidity and mortality in liver transplant (LT) recipients with an estimated incidence of 5-30% after orthotopic LT and a mortality rate of up to 10%. Biliary complications after LT may be related to various factors including hepatic artery thrombosis or stenosis, ischemia reperfusion injury, immunologic injury, infections, donor pool, and technical issues which include imperfect anastomosis and T-tube-related complications. Management of the detected biliary complications includes nonsurgical and surgical methods. A majority of these post transplant biliary complications can be treated with endoscopic retrograde cholangiography. If unsuccessful, a percutaneous intervention or surgery may be required. In this article, we review the incidence, clinical presentation, and management of the main types of biliary complications.
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Affiliation(s)
| | | | - Bimaljit Sandhu
- Address for correspondence: Bimaljit Sandhu, Division of Gastroenterology, Hepatology and Nutrition, VCU Medical Center, Richmond, VA – 23298, USA
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Giampalma E, Renzulli M, Mosconi C, Ercolani G, Pinna AD, Golfieri R. Outcome of post-liver transplant ischemic and nonischemic biliary stenoses treated with percutaneous interventions: the Bologna experience. Liver Transpl 2012; 18:177-87. [PMID: 22006838 DOI: 10.1002/lt.22450] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In liver transplantation (LT), biliary strictures (BSs) are among the most common complications. The aim of this study was to evaluate the efficacy of percutaneous treatments in the management of post-LT BSs. Between 1999 and 2007, 48 patients underwent percutaneous treatments for posttransplant BSs. We divided the population into 2 groups according to the cause [ischemic (n = 14) or nonischemic (n = 34)] and into further subgroups according to the site [anastomotic (n = 34) or nonanastomotic (n = 14)]. All patients were treated with bilioplasty; in 9 patients who were refractory to bilioplasty, metallic stents were implanted. A technical success rate of 90% was achieved without differences between the ischemic and nonischemic groups or between the anastomotic and nonanastomotic subgroups (P = 0.10). The major complication rate was 4%. The overall 1- and 3-year primary patency rates were 94% and 45%, respectively, and better results were found for patients with nonischemic stenoses versus patients with ischemic stenoses (P = 0.032). The overall secondary patency rates were 94% and 83% at 1 and 3 years, respectively, and there were no statistical differences between the ischemic and nonischemic groups or between the anastomotic and nonanastomotic groups. In the stent subgroup, the overall primary 1- and 2-year patency rates were 100% and 71%, respectively, and the secondary patency rates were 100% and 100%, respectively. In conclusion, a percutaneous approach is highly effective for the treatment of post-LT BSs, and the best results are obtained for patients with simple, nonischemic BSs (technical success rate = 94%, 3-year primary patency rate = 81%, 3-year secondary patency rate = 75%). For patients with ischemic BSs, closer follow-up and retreatment are more frequently needed to achieve secondary patency rates comparable to (or even better than) those for patients with nonischemic stenoses.
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Affiliation(s)
- Emanuela Giampalma
- Radiology Unit, Department of Digestive Diseases and Internal Medicine,University of Bologna, Bologna, Italy.
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Oustecky DH, Riera AR, Rothstein KD. Long-term management of the liver transplant recipient: pearls for the practicing gastroenterologist. Gastroenterol Clin North Am 2011; 40:659-81. [PMID: 21893279 DOI: 10.1016/j.gtc.2011.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Liver transplantation is becoming more common and patients are surviving longer after transplantation. Special care must be paid to the long-term management of these patients because they are at increased risk for medical problems, malignancies, and adverse effects from immunosuppression. A stable and continuing relationship must be developed between the physician and the patient to optimize the long-term outcomes for these individuals.
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Affiliation(s)
- David H Oustecky
- Drexel University College of Medicine, Department of Gastroenterology and Hepatology, Mail Stop 913, 219 N. Broad Street, 5th Floor, Philadelphia, PA 19107, USA
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Aberg F, Mäkisalo H, Höckerstedt K, Isoniemi H. Infectious complications more than 1 year after liver transplantation: a 3-decade nationwide experience. Am J Transplant 2011; 11:287-95. [PMID: 21219571 DOI: 10.1111/j.1600-6143.2010.03384.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Because few reports have addressed infections late (≥1 year) after liver transplantation (LT), we evaluated the incidence, risk factors and pathogens involved. Infection data were from the Finnish LT registry, with starting date, type and relevant pathogens for 501 Finnish adult LT patients surviving ≥1 year post-transplant. Follow-up end points were end of study, death or retransplantation. Logistic regression to assess risk factors was adjusted for age, gender and follow-up time. With 3923 person-years of follow-up, overall infection incidence was 66/1000 person-years; 155 (31%) suffered 259 infections, and two-thirds experienced only one infection. Cholangitis (20%), pneumonia (19%) and sepsis (14%) were most common. The most frequent bacteria were Enterococcus spp. and Escherichia coli, and the most frequent viruses cytomegalovirus and varicella zoster virus. Fungal infections were rare (n = 7). With 13 fatal infections, 17% of all late deaths involved infection. Primary sclerosing cholangitis (PSC) and Roux-en-Y-type biliary anastomosis were associated with cholangitis; 18% of PSC patients suffered late cholangitis. Late acute rejection was associated with sepsis. Age, gender or cytomegalovirus did not significantly influence late infections. In conclusion, although infection risk under maintenance immunosuppression therapy is relatively low, particular vigilance regarding cholangitis, pneumonia and sepsis seems appropriate.
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Affiliation(s)
- F Aberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland.
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Percutaneous Treatment of Biliary Cast Syndrome After Orthotopic Liver Transplantation: Comparison of Mechanical Versus Hydraulic Rheolytic Cast Extraction. Cardiovasc Intervent Radiol 2010; 34:998-1005. [DOI: 10.1007/s00270-010-9998-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 09/09/2010] [Indexed: 12/12/2022]
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Ayoub WS, Esquivel CO, Martin P. Biliary complications following liver transplantation. Dig Dis Sci 2010; 55:1540-6. [PMID: 20411422 DOI: 10.1007/s10620-010-1217-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 03/22/2010] [Indexed: 02/08/2023]
Abstract
The aphorism that reconstruction of the biliary anastomosis is the "Achilles heel" of liver transplantation remains valid as biliary complications following liver transplantation remain a major source of morbidity with an incidence of 5-32%. Biliary complications include biliary strictures, biliary leaks, and stones. Biliary strictures can be divided into anastomotic and non-anastomotic. The management of biliary complications previously relied on surgical intervention. However, advances in endoscopic and radiological interventions have resulted in less-invasive options. The management of biliary complications post-liver transplantation requires a multidisciplinary approach and continues to evolve. Biliary complications also reflect the continued expansion of the donor pool with extended, live, and non-heart beating donors.
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Affiliation(s)
- Walid S Ayoub
- Department of Gastroenterology and Hepatology, Stanford University, Suite 210, Palo Alto, CA 94304, USA.
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Abstract
Complications of the biliary tract are an important cause of morbidity and mortality after liver transplantation. The most frequent complications are anastomotic biliary tract strictures, bile leaks, and bile duct stones. The estimated incidence of these complications ranges between 5% and 25%, although rates have been decreasing in recent years. Most complications can be managed successfully with endoscopic retrograde cholangiography. This article reviews the various biliary complications after liver transplantation (both deceased donor and living-related donor) and their endoscopic management.
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Saleem A, Baron TH. Successful endoscopic treatment of biliary cast syndrome in an orthotopic liver transplant patient with a Roux-en-Y anastomosis via balloon enteroscopy. Liver Transpl 2010; 16:527-9. [PMID: 20213831 DOI: 10.1002/lt.22007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Atif Saleem
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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