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Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP. Surg Endosc 2023; 37:1194-1202. [PMID: 36163565 PMCID: PMC9944135 DOI: 10.1007/s00464-022-09615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/07/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome. METHODS We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP. RESULTS We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25-4.44; P = 0.008; number needed to harm 7.7). CONCLUSIONS Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.
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Robotic Hepaticojejunostomy for Late Anastomotic Biliary Stricture After Liver Transplantation: Technical Description and Case Series. Ann Surg 2021; 275:e801-e803. [PMID: 34793343 DOI: 10.1097/sla.0000000000005303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical revision. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described following liver transplantation. Robotic biliary revisions were retrospectively compared to all the historical open cases over a time period from May 2013 to October 2020. During the study period there were 3 robotic and 4 open surgical biliary revisions with a follow up of at least 6 months. All cases were hepaticojejunostomies for late choledochocholedochostomy anastomotic strictures presenting > 4 weeks after transplant and refractive to at least 3 endoscopic and/or percutaneous interventions. Median (range) case time was longer in the robotic group, 373 minutes (286-373) compared to open group, 280 minutes (163-321). The median length of stay was shorter in the robotic group, 4 days (1-4) compared to open group 7 days (4-10). Morbidity included 2 wound infections in the open group (grade II), 1 infected hematoma in the robotic group (grade IIIa) and 1 bile leak on the open group (grade IIIa). There was no biliary stricture recurrence or mortality in either group. Robotic biliary revision is a safe alternative to traditional open biliary revision for refractive biliary strictures after liver transplantation.
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Reddy S, Jagtap N, Kalapala R, Ramchandani M, Lakhtakia S, Basha J, Nabi Z, Karyampudi A, Chavan R, Tandan M, Gupta R, Reddy DN. Choledocholithiasis in acute calculous cholecystitis: guidelines and beyond. Ann Gastroenterol 2021; 34:247-252. [PMID: 33654367 PMCID: PMC7903571 DOI: 10.20524/aog.2020.0562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acute calculous cholecystitis (ACC) is the most frequent complication of gallstones requiring cholecystectomy. These patients may have coexisting choledocholithiasis. We aimed to evaluate the role of current guidelines for choledocholithiasis in patients with ACC. Methods In this retrospective study, we included all patients diagnosed with ACC between December 2018 and May 2019. These patients were substratified according to the guidelines of the American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) as having high, intermediate, or low likelihood of choledocholithiasis, and the diagnostic performance was measured. Binomial logistic regression analysis was applied to ascertain independent risk factors for choledocholithiasis. Results A total of 173 patients with ACC, mean age (±standard deviation) 49.89±15.74 years and 60.1% male, were included. Sixty-three (36.4%) had confirmed choledocholithiasis. ASGE high likelihood criteria had sensitivity and specificity of 61.9% (95% confidence interval [CI] 48.8-73.9) and 83.4% (95%CI 75.4-90.0) for predicting choledocholithiasis. ESGE high likelihood criteria had sensitivity and specificity of 49.2% (95%CI 36.4-62.1) and 87.3% (95%CI 79.6-92.9). On logistic regression analysis, an alkaline phosphatase level above the upper limit of normal (P=0.003; odds ratio [OR] 4.26, 95%CI 1.66-10.96) and a dilated common bile duct on ultrasound (P=0.001; OR 9.97, 95%CI 4.65-21.36) were independent positive predictors for choledocholithiasis, while acute biliary pancreatitis was an independent negative predictor (P=0.030; OR 0.36, 95%CI 0.14-0.91). Conclusions The performance of the ASGE and ESGE guidelines’ risk stratification criteria is inadequate in patients with ACC. We suggest the utilization of a separate predictive model for suspected choledocholithiasis in these patients.
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Affiliation(s)
- Siddhartha Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Rakesh Kalapala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Arun Karyampudi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India (Siddhartha Reddy, Nitin Jagtap, Rakesh Kalapala, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Zaheer Nabi, Arun Karyampudi, Radhika Chavan, Manu Tandan, Rajesh Gupta, D. Nageshwar Reddy)
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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Kohli DR, Pannala R, Crowell MD, Fukami N, Faigel DO, Aqel BA, Harrison ME. Interobserver Agreement for Classifying Post-liver Transplant Biliary Strictures in Donation After Circulatory Death Donors. Dig Dis Sci 2021; 66:231-237. [PMID: 32124198 DOI: 10.1007/s10620-020-06169-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/20/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Biliary strictures are a common complication of donation after circulatory death (DCD) liver transplantation (LT) and require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. Three classification systems, based on cholangiograms, have been proposed for categorizing post-LT biliary strictures. We examined the interobserver agreement for each of the three classifications. METHODS DCD LT recipients from 2012 through March 2017 undergoing ERCP for biliary strictures were included in the study. Initial cholangiograms delineating the entire biliary tree prior to endoscopic intervention were selected. One representative cholangiogram was selected from each ERCP. Five interventional endoscopists independently viewed each anonymized cholangiogram and classified the post-LT stricture according to each of the three classification systems. The Ling classification proposes four types of post-LT strictures based on their location. The Lee classification proposes four classes based on location and number of intrahepatic strictures. The binary system classifies strictures into anastomotic or non-anastomotic types. The Krippendorff's alpha reliability estimate was used to grade the strength of agreement as "poor," "fair," "moderate," "good," or "excellent" for values between 0-0.20, 0.21-0.4, 0.41-0.6, 0.61-0.08, and 0.81-1, respectively. RESULTS One hundred DCD LT recipients (age 57.07 ± 8.8 years; 71 males) were initially evaluated. Of these, 49 patients who underwent 206 ERCP procedures for biliary strictures were included in the analysis. One hundred thirty-nine cholangiograms were selected and subsequently classified by five endoscopists. Interobserver agreement for post-LT biliary strictures was 0.354 for Ling classification (fair agreement), 0.405 for Lee classification (fair agreement), and 0.421 for the binary classification (moderate agreement). The binary classification provided the least amount of detail regarding the location and number of biliary strictures. DISCUSSION The currently available classification systems for assessing post-LT biliary strictures have sub-optimal interobserver agreement. A better-designed classification system is needed for categorizing post-LT biliary strictures.
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Affiliation(s)
- Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA, 4801 E Linwood Blvd, Kansas City, MO, 64128, USA. .,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
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Abstract
INTRODUCTION Liver transplantation is a life-changing event for patients and survival following transplantation has improved significantly since the first transplantation in 1967. Following liver transplantation, patients face a unique set of healthcare management decisions including transplantation-specific complications, recurrence of primary liver disease, as well as metabolic and malignancy concerns related to immunosuppression. As more patients with liver disease receive transplantation and live longer, understanding and managing these patients will require not only transplant specialist but also local subspecialist and primary care physicians. AREAS COVERED This review covers common issues related to the management of patients following liver transplantation including immunosuppression, liver allograft dysfunction, metabolic complications, as well as routine health maintenance such as immunizations and cancer screening. EXPERT OPINION Optimizing medical care for patients following liver transplant will benefit from ensuring all providers, not just transplant specialist, have a basic understanding of the common issues encountered in the post-transplant patient. This review provides an overview of common healthcare concerns and management options for patients following liver transplantation.
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Affiliation(s)
- Nicholas Hoppmann
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
| | - Omar Massoud
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
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Chisholm PR, Patel AH, Law RJ, Schulman AR, Bedi AO, Kwon RS, Wamsteker EJ, Anderson MA, Elta GH, Govani SM, Prabhu A. Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis. Gastrointest Endosc 2019; 89:977-983.e2. [PMID: 30465770 DOI: 10.1016/j.gie.2018.11.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation. METHODS We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%. RESULTS A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL. CONCLUSIONS The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.
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Affiliation(s)
| | - Arpan H Patel
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Ryan J Law
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | | | - Arti O Bedi
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Richard S Kwon
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Erik J Wamsteker
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | | | - Grace H Elta
- University of Michigan Health Care System, Ann Arbor, Michigan, USA
| | - Shail M Govani
- University of Michigan Health Care System, Ann Arbor, Michigan, USA; South Texas VA Healthcare System, San Antonio, Texas, USA; UT Health San Antonio, San Antonio, Texas, USA
| | - Anoop Prabhu
- University of Michigan Health Care System, Ann Arbor, Michigan, USA; VA Healthcare System, Ann Arbor, Michigan, USA
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Crismale JF, Ahmad J. Endoscopic Management of Biliary Issues in the Liver Transplant Patient. Gastrointest Endosc Clin N Am 2019; 29:237-256. [PMID: 30846151 DOI: 10.1016/j.giec.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- James F Crismale
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jawad Ahmad
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, 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: 56] [Impact Index Per Article: 11.2] [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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Significant infections in liver transplant recipients undergoing endoscopic retrograde cholangiography are few and unaffected by prophylactic antibiotics. Dig Liver Dis 2018; 50:1220-1224. [PMID: 29907534 DOI: 10.1016/j.dld.2018.05.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 05/18/2018] [Accepted: 05/19/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Current practice guidelines recommend prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography (ERCP) in liver transplant recipients (LTR). This study evaluated the risk of clinically significant infections after ERCP in LTR who received antibiotic prophylaxis compared to those who did not. METHODS This retrospective case-cohort study evaluated all LTR who underwent elective, outpatient ERCP from 2008 to 2015. Hospitalized patients, pediatric allograft recipients and patients with cholangitis or incomplete biliary drainage were excluded. The primary outcome was unanticipated hospitalization from procedure-related clinically significant infection occurring within 3 days of ERCP. RESULTS Sixty-nine patients (48 males; mean age 60.5 ± 7.4 years) underwent 191 ERCPs after liver transplantation. Prophylactic antibiotics were administered during 82 ERCPs and not administered for 109 ERCPs. Unscheduled admissions for fever within 3 days occurred in 4 patients. Only 2 patients had documented bacteremia, of which only 1 patient received prophylactic antibiotics and also met primary outcome. Interventions during ERCP, patient demographics, and time from transplantation were not associated with increased risk of hospitalization from infections or bacteremia. CONCLUSIONS The risk of infectious complications after ERCP in LTR is low and not affected by administration of prophylactic antibiotics. A tailored approach to antibiotic prophylaxis may be more appropriate than universal prophylaxis in selected LTR at low risk of infections.
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Leerhøy B, Elmunzer BJ. How to Avoid Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2018; 28:439-454. [PMID: 30241637 DOI: 10.1016/j.giec.2018.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatitis remains the most common and potentially devastating complication of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Recent advances in prophylaxis have improved but not eliminated this problem, underscoring the importance of ongoing research toward this goal. This review aims to provide an evidence-based approach to post-ERCP pancreatitis prevention through patient selection, risk stratification, procedural technique, and multimodality prophylaxis, and discusses ongoing and future research initiatives in this important area.
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Affiliation(s)
- Bonna Leerhøy
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen Nielsine Nielsens Vej 11, entrance 8, Copenhagen DK-2400, Denmark
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty Street, Suite 249, Charleston, SC 29425, USA.
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12
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The gastroenterologist's guide to management of the post-liver transplant patient. Am J Gastroenterol 2018; 113:819-828. [PMID: 29748558 DOI: 10.1038/s41395-018-0049-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/11/2018] [Indexed: 12/11/2022]
Abstract
The management of the post-liver transplant patient is complex and involves a large interdisciplinary team. After referral to a transplant center, evaluation and listing, and eventual transplantation, the patient is cared for closely by the transplant center. Once deemed ready for discharge, the patient returns to the primary care provider for ongoing management of the various issues that increase in incidence post transplant such as osteoporosis, cardiovascular, and renal diseases, as well as metabolic syndrome. The role of the gastroenterologist is not well defined, but certainly, he or she may be called upon for the initial evaluation and ongoing management of gastrointestinal as well as hepatobiliary issues. This includes but is not limited to the investigation of abnormal liver tests, non-specific gastrointestinal complaints such as nausea, vomiting, or diarrhea, biliary complications, and even recurrent hepatic disease. Having familiarity with post-transplant immunosuppressive agents, drug interactions, and potential infectious and malignancy-related complications of transplant is essential, as the primary gastroenterologist may be expected in some situations to field the initial work-up, if patient access to the transplant center is limited. The aim of this review is to summarize the gastroenterologist's role in the management of the post-liver transplant patient.
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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14
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Öcal S, Harmancı Ö, Ensaroğlu F, Korkmaz M, Selçuk H, Hilmioğlu F, Moray G, Haberal M. Endoscopic Retrograde Cholangiopancreatography in Kidney Transplant Patients: Results From a Single Center. EXP CLIN TRANSPLANT 2015; 13 Suppl 3:93-6. [PMID: 26640924 DOI: 10.6002/ect.tdtd2015.p51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We report the outcomes of endoscopic retrograde cholangiopancreatography procedures performed for diagnostic and therapeutic purposes in patients who had undergone kidney transplant. MATERIALS AND METHODS We retrospectively evaluated the records of kidney transplant patients for January 1993 to December 2014. Endoscopic retrograde cholangiopancreatography was carried out using an Olympus JF240 duodenoscope (tip outer diameter 12.6 mm, working channel diameter 3.2 mm). The procedures were performed by Department of Anesthesiology staff while the patients were deeply sedated, given a combination of midazolam plus propofol. RESULTS Data from 21 kidney transplant patients (16 men and 5 women; mean age at endoscopic retrograde cholangiopancreatography 42.6 ± 23.4 y) were evaluated. A total of 23 endoscopic retrograde cholangiopancreatography procedures were performed. The indications were choledocholithiasis in 6 patients (28.6%), common bile duct dilatation plus liver enzyme elevations in 4 patients (19%), liver enzyme elevation alone in 4 (19%), biliary necrotizing pancreatitis in 2 (9.6%), and cholangitis in 5 (23.8%). Hepatobiliary ultrasonography findings showed that 3 patients (14.3%) had absence of gallbladder owing to cholecystectomy, 14 (66.7%) had gallstones, 1 (4.7%) had gallstones with cholecystitis findings, and 3 (14.3%) were normal. Endoscopic retrograde cholangiopancreatography findings were normal in 4 patients (19%), showed cholangitis in 2 (9.6%), choledocholithiasis in 10 (47.6%), bile duct wall irregularities in 2 (9.6%), dilated common bile duct in 2 (9.6%), and cholangiocarcinoma in 1 (4.7%). Sphincterotomy was performed in 16 patients. None of the patients who underwent endoscopic retrograde cholangiopancreatography developed any complications, for example, acute pancreatitis, bleeding, duodenal, or bile duct perforation. CONCLUSIONS In kidney transplant patients, endoscopic retrograde cholangiopancreatography is safe and able to provide substantial information for managing biliopancreatic diseases.
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Affiliation(s)
- Serkan Öcal
- From the Department of Gastroenterology, Başkent University Faculty of Medicine, Ankara, Turkey
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Elmunzer BJ. Preventing Postendoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:725-36. [PMID: 26431600 DOI: 10.1016/j.giec.2015.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postendoscopic retrograde cholangiopancreatography pancreatitis is a common and potentially devastating complication of endoscopic retrograde cholangiopancreatography. Advances in risk-stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the ability to prevent this complication. This article presents the evidence-based approaches to preventing postendoscopic retrograde cholangiopancreatography pancreatitis and discusses timely research questions in this important area.
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Affiliation(s)
- B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, MSC 702, 114 Doughty Street, Suite 249, Charleston, SC 29425, USA.
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Mathur AK, Nadig SN, Kingman S, Lee D, Kinkade K, Sonnenday CJ, Welling TH. Internal biliary stenting during orthotopic liver transplantation: anastomotic complications, post-transplant biliary interventions, and survival. Clin Transplant 2015; 29:327-35. [PMID: 25604635 DOI: 10.1111/ctr.12518] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary complications are a leading source of surgical morbidity following orthotopic liver transplantation (OLT). METHODS We examined how prophylactic internal biliary stent placement during OLT affected post-transplant morbidity and mortality in a single-center retrospective cohort study of 513 recipients (2006-2012). Recipient and donor covariates were collected. Biliary complications included major and minor anastomotic leaks, strictures, or stenoses. Multivariate regression models were created to estimate how operative biliary stents affected outcomes. RESULTS About 87.3% (n = 448) of recipients had a duct-to-duct biliary anastomosis, and 43.1% (n = 221) had biliary stents placed. The biliary complication rate was <15% at five yr, and 44.8% (n = 230) overall. Stenting was not protective from anastomotic biliary complications (p = 0.06). Stenting was associated with a 74% higher adjusted risk of needing multiple endoscopic retrograde cholangiographies (ERCs; odds ratio [OR] 1.74, p = 0.011), and trended toward a lower adjusted risk for repetitive percutaneous transhepatic cholangiography (PTCs; OR 0.56, p = 0.063). Stenting had no effect on the cumulative freedom from biliary complications (p = 0.94). Biliary complications were associated with mortality (HR 1.86, p = 0.014) and was unaffected by stenting (aHR = 0.72, p = 0.246). CONCLUSIONS Biliary stenting during OLT does not deter biliary complications and is associated with higher risk of multiple invasive biliary interventions, particularly ERCs. Surgeons should evaluate the utility of biliary stents at OLT within this context.
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Affiliation(s)
- Amit K Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA; Mayo Clinic Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Charleston, SC, USA
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Fernández-Simon A, Díaz-Gonzalez A, Thuluvath PJ, Cárdenas A. Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis 2014; 18:913-26. [PMID: 25438291 DOI: 10.1016/j.cld.2014.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.
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Affiliation(s)
- Alejandro Fernández-Simon
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Alvaro Díaz-Gonzalez
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Paul J Thuluvath
- Medical Director, Institute for Digestive Health & Liver Disease, Mercy Medical Center, 301 Street, Paul Place, Baltimore, MD 21202, USA
| | - Andrés Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain.
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Safety and yield of diagnostic ERCP in liver transplant patients with abnormal liver function tests. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2014; 2014:314927. [PMID: 25110455 PMCID: PMC4119651 DOI: 10.1155/2014/314927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 06/19/2014] [Indexed: 12/16/2022]
Abstract
Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8–48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48–62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic.
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DeBenedet AT, Scheiman JM, Elta GH, Elmunzer BJ. Peritoneal fluid bilirubin to serum bilirubin ratio for the diagnosis of bile leaks in orthotopic liver transplant recipients. Dig Dis Sci 2013; 58:3044-8. [PMID: 23812826 DOI: 10.1007/s10620-013-2730-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 05/29/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND A peritoneal fluid-to-serum bilirubin ratio (FSBR) of >5 has been shown to be accurate for the detection of bile leaks in post-cholecystectomy and trauma patients; however, there are no studies evaluating the accuracy of this threshold ratio in orthotopic liver transplant (OLT) recipients. METHODS We performed a nested case-control analysis to determine the optimal FSBR threshold for diagnosing bile leaks in OLT recipients and the relationship between FSBR and likelihood of bile leak. Adult OLT patients undergoing ERCP for suspected bile leak were divided into 2 groups: those with cholangiographic evidence of a bile leak and those without evidence of leak. Of 57 included patients, 37 were found to have a bile leak on cholangiogram (64.9 %). RESULTS We found a relationship between higher FSBR and the presence of a bile leak (OR 2.84, 95 % CI 1.37-5.88, p = 0.005). A FSBR of >3.25 produced the optimal sensitivity and specificity for identifying bile leaks in OLT recipients (area under ROC curve 0.8865, sensitivity 72.97 %, specificity 95.00 %). CONCLUSIONS We conclude FSBR is an easily accessible, moderately accurate test to diagnose bile leaks in liver transplant recipients. This test can inform clinical decision-making with regard to the utilization of ERCP in lower suspicion transplant recipients with a suspected bile leak.
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Affiliation(s)
- Anthony T DeBenedet
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical Center, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA,
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Kubiliun NM, Elmunzer BJ. Preventing pancreatitis after endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23:769-86. [PMID: 24079789 DOI: 10.1016/j.giec.2013.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists' ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.
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Affiliation(s)
- Nisa M Kubiliun
- Division of Gastroenterology, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109, USA
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