Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions

Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis

BACKGROUND

Liver transplantation is the only curative treatment of end-stage liver disease. Unfortunately, a significant number of patients on the organ waitlist die waiting for an organ. Living-donor liver transplantation (LDLT) is an approach that has been used to expand organ availability. Although LDLT has excellent outcomes, biliary complications remain a significant drawback. This meta-analysis aimed to precisely assess the predictors of biliary stricture and leak after LDLT.

METHODS

PubMed, Embase, and Web of Science databases were searched from inception to January 2024. Only studies that used a multivariate model to assess risk factors for post-LDLT biliary stricture or leak in adult participants were included. Studies reporting unadjusted risk factors were excluded. Pooled adjusted odds ratios (ORs) and pooled hazard ratios (HRs) with 95% CIs for risk factors reported in ≥2 studies were obtained within a random-effects model.

RESULTS

Overall, 22 studies with 9442 patients who underwent LDLT were included. The post-LDLT biliary stricture rate was 22%, whereas the post-LDLT biliary leak rate was 14%. In addition, 13 unique risk factors were analyzed. Postoperative bile leak (OR, 4.10 [95% CI, 2.88-5.83]; HR, 3.88 [95% CI, 2.15-6.99]) was the most significant predictor of biliary stricture after LDLT. Other significant predictors of biliary stricture after LDLT were right lobe graft (OR, 2.56; 95% CI, 1.23-5.32), multiple ducts for anastomosis (OR, 1.62; 95% CI, 1.08-2.43), ductoplasty (OR, 2.07; 95% CI, 1.36-3.13), ABO incompatibility (OR, 1.45; 95% CI, 1.16-1.81), and acute cellular rejection (OR, 4.10; 95% CI, 2.88-5.83). Donor bile duct size (HR, 0.82; 95% CI, 0.74-0.91; P = .001, I2 = 0%) was found to be significantly associated with reduced risk of post-LDLT biliary stricture. Donor age, recipient age, recipient male sex, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary strictures. Multiple ducts for anastomosis (OR, 1.86; 95% CI, 1.43-2.43) was a significant predictor of post-LDLT biliary leak. Recipient age, warm ischemia time, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary leak.

CONCLUSION

In this meta-analysis, 7 unique risk factors were shown to be predictive of post-LDLT biliary stricture, one of which was associated with both post-LDLT biliary stricture and leak. Donor bile duct size was found to be protective against post-LDLT biliary strictures. Identifying reliable predictors is crucial for recognizing high-risk patients. This approach can facilitate the implementation of preventive measures, surveillance protocols, and targeted interventions to reduce the incidence of biliary strictures after LDLT.

Evaluating the yield of digital single operator cholangioscopy in posttransplant biliary strictures after unsuccessful guidewire placement with ERCP

Background and Aims

Strictures are the most common biliary complication after liver transplantation, and endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard in its management. Failure to cross the biliary anastomosis requires a repeated attempt with ERCP, referral for percutaneous transhepatic cholangiography (PTC) or surgery. We present our experience with the digital single operator cholangioscope (D-SOC) in achieving guidewire access in a liver transplant cohort with difficult biliary strictures who have failed conventional ERCP methods.

Methods

This was a retrospective study involving two adult liver transplant centers servicing the two most populated states in Australia. Deceased-donor liver transplant recipients undergoing D-SOC for biliary strictures who have failed conventional methods to achieve biliary access were included.

Results

Between July 2017 to April 2022, eighteen patients underwent D-SOC after failing to achieve guidewire placement through standard ERCP techniques. Thirteen out of eighteen (72%) had successful guidewire placement with index D-SOC. Five of eighteen patients (28%) had unsuccessful guidewire placement with D-SOC. In two of these patients, use of D-SOC informed further endoscopic management, with one avoiding PTC and the other avoiding surgery. Two of the five patients required PTC and one patient was left unstented. Three patients developed post D-SOC cholangitis.

Conclusions

D-SOC is effective at achieving guidewire access in post-liver transplant patients who fail conventional ERCP techniques and should be considered in the treatment algorithm as a step before PTC and surgery.

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy

AIM

Occurrence of anastomotic biliary stricture (AS) remains an essential issue following hepatobiliary surgeries, and percutaneous transhepatic cholangioscopy (PTCS) has great therapeutic significance in handling refractory AS for patients with altered gastrointestinal anatomy after cholangio-jejunostomy. This present study aimed to investigate feasibility of PTCS procedures in AS patients for therapeutic indications.

MATERIALS AND METHODS

This study was a single-center, retrospective cohort study with a total number of 124 consecutive patients who received therapeutic PTCS due to AS. Clinical success rate, required number, and adverse events of therapeutic PTCS procedures as well as patients survival state were reviewed.

RESULTS

These 124 patients previously underwent choledochojejunostomy or hepatico-jejunostomy, and there was post-surgical altered gastrointestinal anatomy. Overall, 366 therapeutic PTCS procedures were performed for these patients through applying rigid choledochoscope, and the median time of PTCS procedures was 3 (1-11). Among these patients, there were 34 cases (27.32%) accompanied by biliary strictures and 100 cases (80.65%) were also combined with biliary calculi. After therapeutic PTCS, most patients presented with relieved clinical manifestations and improved liver functions. The median time of follow-up was 26 months (2-86 months), and AS was successfully managed through PTCS procedures in 104 patients (83.87%). During the follow-up period, adverse events occurred in 81 cases (65.32%), most of which were tackled through supportive treatment.

CONCLUSION

PTCS was a feasible, safe and effective therapeutic modality for refractory AS, which may be a promising alternative approach in clinical cases where the gastrointestinal anatomy was changed after cholangio-jejunostomy.

A Short Fully Covered Self-Expandable Metal Stent for Management of Benign Biliary Stricture Not Caused by Living-Donor Liver Transplantation

Background: This study evaluated the effectiveness of short fully covered self-expanding metal stents (FCSEMS) with an anti-migration design in treating benign biliary strictures (BBS) not related to living donor liver transplantation (LDLT). Methods: A retrospective analysis was conducted on 75 patients who underwent FCSEMS insertion for BBS management. Stents were initially kept for 3 months and exchanged every 3 months until stricture resolution. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. Results: The study outcomes were technical success, stenosis resolution, and treatment failure. Technical success was 100%, with stricture resolution in 99% of patients. The mean onset time of BBS post-surgery was 4.4 years, with an average stent indwelling period of 5.5 months. Stricture recurrence occurred in 20% of patients, mostly approximately 18.8 months after stent removal. Early cholangitis and stent migration were noted in 3% and 4% of patients, respectively. Conclusions: This study concludes that short FCSEMS demonstrate high efficacy in the treatment of non-LDLT-related BBS, with a low incidence of interventions and complications. Although this is a single-center, retrospective study with a limited sample size, the findings provide preliminary evidence supporting the use of short FCSEMS as a primary treatment modality for BBS. To substantiate these findings, further research involving multicenter studies is recommended to provide additional validation and a broader perspective.

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Efficiency of percutaneous transhepatic cholangioscopy in the treatment of biliary complications after liver transplantation

BACKGROUND

Percutaneous transhepatic cholangioscopy (PTCS) has provided an alternative therapeutic option for handling refractory biliary complications in liver transplanted recipients. This study aimed to evaluate short-term PTCS efficiency in the management of biliary complications following liver transplantation.

METHODS

Clinical data of 25 patients who received therapeutic PTCS due to biliary complications after liver transplantation were retrospectively analyzed.

RESULTS

Therapeutic PTCS was successfully performed in 25 patients. Biliary complications were anastomotic strictures in seven cases, intrahepatic cholangiolithiasis in four cases, extra-and intrahepatic cholangiolithiasis in three cases, choledocholithiasis complicated with anastomotic strictures in four cases, intrahepatic cholangiolithiasis complicated with non-anastomotic strictures in one case, intrahepatic cholangiolithiasis complicated with anastomotic strictures in five cases, intrahepatic cholangiolithiasis complicated with anastomotic strictures and ischemic cholangitis in one case. The median time between liver transplantation and first PTCS was 24 months, and median times of PTCS was 2.6. Clinical manifestations were significantly improved in most patients after PTCS, and biliary complications were successfully managed through PTCS in 15 cases, which were partially effective in eight cases and ineffective in two cases. PTCS was more effective in tackling anastomotic strictures and cholangiolithiasis.

CONCLUSION

PTCS was an effective therapeutic modality for treating refractory biliary complications following liver transplantation.

Radiologic findings of biliary complications post liver transplantation

Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.

[Indocyanine green in liver transplantation]

The purpose of this study was to evaluate the first own experience of using indocyanine green (ICG) in liver transplantation compared to literature data and to determine its potential for clinical practice. Liver transplantation is an effective option for patients with end-stage disease, but this procedure is associated with many problems such as graft rejection, graft dysfunction, surgical risk and postoperative management. Modern methods for assessing graft function have their limitations, so a more efficient method is needed. According to this review, ICG fluorescence is valuable for effective intraoperative blood flow control, assessment of graft function, intraoperative and postoperative monitoring of clinical status. ICG fluorescence can also predict clinical status of patients at all stages of liver transplantation. Routine ICG fluorescence method is advisable in liver transplantation to improve outcomes and optimize treatment process.

Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation

BACKGROUND

Biliary strictures after liver transplantation (LT) remain clinically arduous and challenging situations, and endoscopic retrograde cholangiopancreatography (ERCP) has been considered as the gold standard for the management of biliary strictures after LT. Nevertheless, in the treatment of biliary strictures after LT with ERCP, many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate. Digital single-operator peroral cholangioscopy (DSOC) is considered a valuable diagnostic modality for indeterminate biliary strictures.

AIM

To evaluate DSOC in addition to ERCP for management of biliary strictures after LT.

METHODS

Nineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital, Capital Medical University, were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis. Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.

RESULTS

Twenty-one biliary strictures were found in a total of 19 patients, among which anastomotic strictures were evident in 18 (94.7%) patients, while non-anastomotic strictures in 2 (10.5%), and space-occupying lesions in 1 (5.3%). Stones were found in 11 (57.9%) and loose sutures in 8 (42.1%). A benefit of cholangioscopy was seen in 15 (78.9%) patients. Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients. It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed. It also provided a direct vision for laser lithotripsy. A space-occupying lesion in the bile duct was diagnosed by cholangioscopy in one patient. Patients with biliary stricture after LT displayed four types: (A) mild inflammatory change (n = 9); (B) acute inflammatory change edema, ulceration, and sloughing (n = 3); (C) chronic inflammatory change; and (D) acute suppurative change. Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.

CONCLUSION

DSOC can provide important diagnostic information, helping plan and perform interventional procedures in LT-related biliary strictures.

Early laboratory values after liver transplantation are associated with anastomotic biliary strictures

Backgrounds/Aims

The aim of this study was to evaluate longitudinal changes of post-liver transplantation (LT) biliary anatomy and to assess the association of increased laboratory values after LT with the development of post-LT anastomotic biliary stricture (ABS).

Methods

Adult deceased donor LT recipients from 2008 and 2019 were evaluated. ABS was defined after blinded review of endoscopic cholangiograms. Controls were patients who underwent LT for hepatocellular carcinoma who did not have any clinical or biochemical concerns for ABS.

Results

Of 534 patients who underwent LT, 57 patients had ABS and 57 patients served as controls. On MRI, ABS patients had a narrower anastomosis (2.47 ± 1.32 mm vs. 3.38 ± 1.05 mm; p < 0.01) and wider bile duct at 1-cm proximal to the anastomosis (6.73 ± 2.45 mm vs. 5.66 ± 1.95 mm; p = 0.01) than controls. Association between labs at day 7 and ABS formation was as follows: aspartate aminotransferase hazard ratio (HR): 1.014; 95% confidence interval (CI): 1.008–1.020, p = 0.001; total bilirubin HR: 1.292, 95% CI: 1.100–1.517, p = 0.002; and conjugated bilirubin HR: 1.467, 95% CI: 1.216–1.768, p = 0.001. Corresponding analysis results for day 28 were alanine aminotransferase HR: 1.004, 95% CI: 1.002–1.006, p = 0.001; alkaline phosphatase HR: 1.005, 95% CI: 1.003–1.007, p = 0.001; total bilirubin HR: 1.233, 95% CI: 1.110–1.369, p = 0.001; and conjugated bilirubin HR: 1.272, 95% CI: 1.126–1.437, p = 0.001.

Conclusions

Elevation of laboratory values early after LT is associated with ABS formation.

Biliary complications in recipients of living donor liver transplantation: A single-centre study

BACKGROUND

Biliary complications (BCs) after liver transplantation (LT) remain a considerable cause of morbidity, mortality, increased cost, and graft loss.

AIM

To investigate the impact of BCs on chronic graft rejection, graft failure and mortality.

METHODS

From 2011 to 2016, 215 adult recipients underwent right-lobe living-donor liver transplantation (RT-LDLT) at our centre. We excluded 46 recipients who met the exclusion criteria, and 169 recipients were included in the final analysis. Donors’ and recipients’ demographic data, clinical data, operative details and postoperative course information were collected. We also reviewed the management and outcomes of BCs. Recipients were followed for at least 12 mo post-LT until December 2017 or graft or patient loss.

RESULTS

The overall incidence rate of BCs including biliary leakage, biliary infection and biliary stricture was 57.4%. Twenty-seven (16%) patients experienced chronic graft rejection. Graft failure developed in 20 (11.8%) patients. A total of 28 (16.6%) deaths occurred during follow-up. BCs were a risk factor for the occurrence of chronic graft rejection and failure; however, mortality was determined by recurrent hepatitis C virus infection.

CONCLUSION

Biliary complications after RT-LDLT represent an independent risk factor for chronic graft rejection and graft failure; nonetheless, effective management of these complications can improve patient and graft survival.

Sump syndrome of the remnant common bile duct following a living donor liver transplant

Sump syndrome – a collection of digested food, debris, stones, bile, and bacteria in a poorly drained, bile duct reservoir – occurs most commonly after a side-to-side choledochoduodenostomy. As choledochoduodenostomies are now less common, sump syndrome is more often characterized as a complication of Roux-en-Y hepaticojejunostomies; however, most cases occur at the hepaticojejunostomy anastomosis. We report a rare case of sump syndrome in the intra-pancreatic remnant common bile duct in a patient with primary sclerosing cholangitis following living donor liver transplant via Roux-en-Y hepaticojejunostomy. Our patient had a history of end-stage liver disease secondary to primary sclerosing cholangitis but presented with recurrent bacteremia and symptoms of acute cholangitis following her transplant. While this complication has not been reported in this population, we know that those with primary sclerosing cholangitis and those undergoing liver transplantation are at very high risk for biliary complications and strictures. Liver transplant is currently our only treatment for primary sclerosing cholangitis, and more than any other group, they are referred for living donor liver transplantation, preferably via Roux-en-Y hepaticojejunostomy. Thus, our patient’s clinical scenario is not uncommon and demonstrates a source of serious infection of which providers must be aware.

Endoscopic management of high-grade biliary strictures complicating living donor liver transplantation using soehendra stent retrievers

BACKGROUND

Biliary strictures following living donor liver transplantation (LDLT) are usually managed by endoscopic retrograde cholangiography (ERC) with stricture dilation and stent placement. While current endoscopic techniques are successful in most cases, high-grade biliary strictures (HGBS) pose a challenge using currently employed techniques which have a low rate of technical success.

AIMS

In this study, we have explored the safety and efficacy of Soehendra stent retrievers (SSR) for the dilation of HGBS complicating LDLT.

METHODS

This was a prospective cohort study where all patients with anastomotic biliary strictures following LDLT from January 2016 till February 2018 were included. Patients with HGBS defined as the exclusive passage of 0.018-inch guidewire, were included in Group 1. In these patients, 5 Fr Soehendra stent retrievers were used to dilate HGBS over guidewire, using torsional movements. Technical success, safety and clinical response was compared with patients who required Per-cutaneous transhepatic cholangiography (PTC) with rendezvous procedure due to a failed ERC, before the commencement of the study (Group 2).

RESULTS

Ten patients with HGBS were included into Group 1. Technical success defined as successful placement of a biliary stent across the stricture was achieved in all the patients in group 1. Favorable response to endotherapy was higher in group 1(8/10 patients (80%)) as compared to group 2(6/14 patients (42.8%)). There were no post procedure complications in patients of group 1, while 3 patients developed cholangitis in group 2.

CONCLUSIONS

HGBS can be successfully treated with SSR for stricture dilation. It is safe with no significant complications and requires fewer procedures.

Intractable Biliary Strictures After Living Donor Liver Transplantation: A Case Series

BACKGROUND

Biliary stricture (BS) is a severe complication after liver transplantation. It is difficult to treat, especially after living donor liver transplantation (LDLT). We successfully treated 4 patients for intractable BS after LDLT. All patients had developed cholangitis with stenosis of bile ducts anastomosis. CASE 1: . A 65-year-old woman underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Internal plastic stents inserted by endoscopic retrograde cholangiography (ERC) were changed quarterly for the next 2 years. CASE 2: A 55-year-old man underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Insertion of internal plastic stents by ERC was attempted; however, the posterior bile duct branch showed complete obstruction. After percutaneous transhepatic biliary drainage (PTCD), the stents were inserted using the rendezvous technique of ERC and were changed by ERC quarterly for the next 3 years. CASE 3: A 22-year-old man underwent LDLT with left lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and stents were changed quarterly for the next 2 years. CASE 4: A 60-year-old man underwent LDLT with right lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and changed to a metallic stent after 1 year. Three months later the stent was extracted using the rendezvous technique of double balloon enteroscopy.

CONCLUSION

BS of complete obstruction type after LDLT is difficult to treat. Appropriate procedures should be chosen based on the types of strictures and biliary reconstruction methods.

One-step Percutaneous Transhepatic Cholangioscopy Combined With High-frequency Needle-knife Electrotomy in Biliary Strictures After Liver Transplantation

BACKGROUND

Endoscopic management is the mainstay for biliary strictures after liver transplantation. However, this method is often failed in cases associated with hepatolithiasis or refractory strictures. The aim of this study is to investigate whether 1-step percutaneous transhepatic biliary cholangiography (PTC) combined with high-frequency needle-knife electrotomy can be an alternative method in biliary strictures after liver transplantation that could not be treated by endoscopic management.

METHODS

Clinical data of 14 patients suffering from biliary strictures after liver transplantation from June 2014 to January 2018 were retrospectively analyzed. One-step PTC combined with high-frequency needle-knife electrotomy was used to resolve the strictures.

RESULTS

One-step PTC was successfully performed in all 14 patients. In 10 of 12 (83.3%) patients with hepatolithiasis, the stones were removed completely. Stricture resolution was detected in 13 of 14 (92.9%) patients at first postoperative choledochoscopy. Three mild adverse events occurred (cholangitis, 2 patients; delayed hemobilia, 1 patient), but were resolved with conservative treatment. The follow-up after supporting catheter removal was 15.7±4.5 months. Only 1 patient (8.3%) had stone recurrence and no stenosis occurred during supporting-catheter-free follow-up.

CONCLUSIONS

One-step PTC combined with high-frequency needle-knife electrotomy seems to be a useful for treating biliary strictures after liver transplantation.

Extraluminal Recanalization for Biliary Duct-to-Duct Anastomotic Obstruction After Living Donor Liver Transplantation: Experience in Eight Patients

PURPOSE

To investigate clinical outcomes and safety of extraluminal recanalization for duct-to-duct anastomotic obstruction after living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Extraluminal recanalization was performed as a salvage procedure after failure of intraluminal cannulation in eight patients who underwent percutaneous transhepatic treatment of duct-to-duct anastomotic obstruction 11.0 ± 5.27 months after LDLT between October 2012 and April 2019. Technical details, safety, and outcomes of extraluminal recanalization were investigated.

RESULTS

Total ten sessions of extraluminal recanalization were performed in the eight patients with the stiff backend of a 0.035 inch hydrophilic guide wire, 22-gauge Chiba needle, or Colapinto needle. Percutaneous common bile duct access was performed in three sessions to obtain a straight course for the puncture. There was one instance of subcapsular and intraparenchymal hematoma requiring placement of an additional drainage catheter and conservative treatment. During a follow-up period ranging from 18.4 to 100.7 months, the drainage catheter was removed in seven of the eight patients, including three patients who had recurrent stricture requiring repeat percutaneous treatment and one who underwent a routine change of an endoscopic retrograde biliary drainage catheter.

CONCLUSIONS

Extraluminal recanalization can be an effective and safe salvage procedure after failed intraluminal cannulation of duct-to-duct anastomotic obstruction in LDLT.

Optimal drainage of anastomosis stricture after living donor liver transplantation

BACKGROUND

Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD).

METHODS

Patients with biliary ASs after an LDLT (mean age: 57.3 years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4 months. Patients were followed-up for at least 1-year post-stent removal.

RESULTS

Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2 months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4 months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59).

CONCLUSIONS

EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.

Severe complications of chronic cholelithiasis treatment

BACKGROUND

Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible.

CASE PRESENTATION

We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management.

CONCLUSION

Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation

BACKGROUND

/Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates.

METHODS

Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis.

RESULTS

At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p = 0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p = 0.018).

CONCLUSION

This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.

Complications of liver transplant

Liver transplantation has become a definitive treatment for patients with end-stage liver disease and those meeting Milan criteria for hepatocellular carcinoma. The morbidity and mortality associated with liver transplantation continues to decrease thanks to refinements in surgical technique, immunosuppression, and imaging. In particular, imaging plays a vital role by facilitating early detection of post-operative complications and enabling prompt treatment. Post-operative complications that lead to graft failure and patient morbidity/mortality can be generally categorized as vascular, biliary, parenchymal, and malignant. Vascular complications include stenosis and thrombosis of the hepatic artery, portal vein, and inferior vena cava; hepatic artery pseudoaneurysm; arteriovenous fistula; and celiac stenosis. Biliary abnormalities include strictures, bile leak, obstruction, recurrent disease, and infection. While imaging is not primarily utilized to diagnose allograft rejection, it plays an important role in excluding mechanical causes of graft dysfunction that can mimic rejection. Ultrasound is routinely performed as the first-line imaging evaluation for the detection and follow-up of early and delayed complications. Cholangiography and magnetic resonance cholangiopancreatography are useful in detecting and characterizing biliary complications. Computed tomography is often used to further evaluate abnormal findings on ultrasound or for the characterization of post-operative fluid collections. The aim of this review is to discuss and illustrate the imaging findings of complications associated with liver transplantation and their role in facilitating treatment.

Liver Transplantation in Children: An Overview of Organ Allocation and Surgical Management

Liver transplantation is the standard treatment for children with end-stage liver disease, primary hepatic neoplasms, or liver-localized metabolic defects. Perioperative mortality is almost absent, and long-term survival exceeds 90%. Organ shortage is managed thanks to advances in organ retrieval techniques; living donation and partial liver transplantation almost eliminated waiting list mortality, thus leading to expanding indications for transplantation. The success of pediatric liver transplantation depends on the prompt and early referral of patients to transplant Centers and on the close and integrated multidisciplinary collaboration between pediatricians, hepatologists, surgeons, intensivists, oncologists, pathologists, coordinating nurses, psychologists, and social workers.

Technical review of a single-center experience of biliary recanalization for liver transplantation-related benign biliary stricture

Purpose

To review a single-center experience of percutaneous biliary recanalization for liver transplantation-related benign biliary stricture, particularly focusing on the technical aspect

Method

Twenty-three recipients of liver transplantation (LT) with 27 benign biliary strictures underwent percutaneous recanalization using a step-by-step technique from June 2017 to March 2020. The step-by-step technique includes a hairy wire or an usual 0.035-inch wire passage, a coaxial system, supporting catheters of various shapes and wires, and an extraluminal passage. The success rate of percutaneous biliary recanalization, degree of stricture, interval between LT and biliary recanalization, procedure time, number of sessions, and recanalization techniques were analyzed.

Results

Among the 27 lesions, 26 (96 %) were successfully recanalized using a percutaneous approach without major complications. Of the 27 lesions, 8 were complete obstructions and 19 were partial obstructions. Consequently, the average interval between LT and biliary recanalization was 28.8 ± 42.7 months (range, 2–192 months). The average procedure time was 50 ± 65 min (range, 8–345 min). The average number of sessions was 1.4 ± 1 (range, 1–6). The case distribution for the used recanalization techniques was as follows: twelve cases utilized step 1, 10 utilized step 2, 4 utilized step 3, and only 1 case utilized step 4. The complete obstruction group required a more advanced technique and spent more recanalization time than the partial obstruction group.

Conclusions

The step-by-step percutaneous biliary recanalization technique had a high success rate without major complications. According to the patient’s biliary anatomy appropriate selection of an angled 5-Fr support catheter and wire is essential in increasing the recanalization success rate.

Management of Post-Transplant Anastomotic Stricture Using Self-Expandable Metal Stent

Anastomotic stricture (AS) is one of the complications of liver transplantation (LT) and can occur in up to 40% of living-donor LTs. Endoscopic management has become the first-line treatment of AS, and multiple plastic stents insertion has been mainly used in the past. Recently, many treatments utilizing fully covered self-expandable metal stents (cSEMSs) have been attempted, and results showing adequate treatment outcome have been reported. In this review, we look into the treatment performance and cautionary steps needed when using cSEMS as a treatment for AS.

Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.

The devil is in the detail: current management of perioperative surgical complications after liver transplantation

PURPOSE OF REVIEW

Despite advances in the field, perioperative morbidity is common after liver transplantation. This review examines the current literature to provide up-to-date management of common surgical complications associated with liver transplantation.

RECENT FINDINGS

Research focuses on problems with anastomoses of the vena cava, portal vein, hepatic artery, and bile ducts. Interventional endoscopic and radiological techniques are used more frequently to avoid reoperation.

SUMMARY

Advances in the management of perioperative surgical complications have focused on minimally invasive measures that successfully treat technical problems with implantation of liver allografts from both living and deceased donors.

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial

Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine-tryptophan-ketoglutarate solution either via both the HA and portal vein (DP group, n = 62) or only through the portal vein (standard perfusion [SP] group, n = 62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09-0.95; P = 0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2 groups. The 3-year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P = 0.004 and P = 0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P = 0.04 and P < 0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

Pre-hepatic and pre-pancreatic transplant donor evaluation

Innovations in surgical techniques coupled with advances in medical and pharmacological management in the past few decades have enabled organ transplantation to become integral to the management of end stage organ failure. In this review article, we will review the role of the radiologist in the work up of liver and pancreas donors during evaluation of their donor candidacy. The critical role of imaging in assessing the parenchymal, biliary and vascular anatomy in liver donor candidates will be reviewed, as well as highlighting the anatomical findings that may pose a contraindication to transplantation. The limited role of imaging in pancreas donor evaluation is also covered, as well as a brief overview of the surgical techniques available and how the radiologist's findings influence operative technique selection.

Adult-to-adult living-donor liver transplantation: The experience of the Université catholique de Louvain

BACKGROUND

Liver transplantation is the treatment for end-stage liver diseases and well-selected malignancies. The allograft shortage may be alleviated with living donation. The initial UCLouvain experience of adult living-donor liver transplantation (LDLT) is presented.

METHODS

A retrospective analysis of 64 adult-to-adult LDLTs performed at our institution between 1998 and 2016 was conducted. The median age of 29 (45.3%) females and 35 (54.7%) males was 50.2 years (interquartile range, IQR 32.9-57.5). Twenty-two (34.4%) recipients had no portal hypertension. Three (4.7%) patients had a benign and 33 (51.6%) a malignant tumor [19 (29.7%) hepatocellular cancer, 11 (17.2%) secondary cancer and one (1.6%) each hemangioendothelioma, hepatoblastoma and embryonal liver sarcoma]. Median donor and recipient follow-ups were 93 months (IQR 41-159) and 39 months (22-91), respectively.

RESULTS

Right and left hemi-livers were implanted in 39 (60.9%) and 25 (39.1%) cases, respectively. Median weights of right- and left-liver were 810 g (IQR 730-940) and 454 g (IQR 394-534), respectively. Graft-to-recipient weight ratios (GRWRs) were 1.17% (right, IQR 0.98%-1.4%) and 0.77% (left, 0.59%-0.95%). One- and five-year patient survivals were 85% and 71% (right) vs. 84% and 58% (left), respectively. One- and five-year graft survivals were 74% and 61% (right) vs. 76% and 53% (left), respectively. The patient and graft survival of right and left grafts and of very small (<0.6%), small (0.6%-0.79%) and large (≥0.8%) GRWR were similar. Survival of very small grafts was 86% and 86% at 3- and 12-month. No donor died while five (7.8%) developed a Clavien-Dindo complication IIIa, IIIb or IV. Recipient morbidity consisted mainly of biliary and vascular complications; three (4.7%) recipients developed a small-for-size syndrome according to the Kyushu criteria.

CONCLUSIONS

Adult-to-adult LDLT is a demanding procedure that widens therapeutic possibilities of many hepatobiliary diseases. The donor procedure can be done safely with low morbidity. The recipient operation carries a major morbidity indicating an important learning curve. Shifting the risk from the donor to the recipient, by moving from the larger right-liver to the smaller left-liver grafts, should be further explored as this policy makes donor hepatectomy safer and may stimulate the development of transplant oncology.

Endoscopic Management of Biliary Issues in the Liver Transplant Patient

Biliary complications remain a common problem after liver transplantation (LT). The therapeutic endoscopist encounters a variety of situations in LT including strictures at the duct-to-duct biliary anastomosis, strictures elsewhere in the biliary tree caused by an ischemic injury, and bile leaks at the anastomosis or from the cut surface and stone disease. Biliary complications lead to significant morbidity and occasionally reduced graft and patient survival. Several factors increase the risk of strictures and leaks. Endoscopic intervention in experienced hands is successful in the management of biliary complications following LT and percutaneous or surgical correction should seldom be required.

Endoscopic management of anastomotic stricture after living-donor liver transplantation

The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.