1
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Zhang CC, Sauer P. Response. Gastrointest Endosc 2023; 97:1172. [PMID: 37208047 DOI: 10.1016/j.gie.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 05/21/2023]
Affiliation(s)
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
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2
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Michael FA, Friedrich-Rust M, Erasmus HP, Graf C, Ballo O, Knabe M, Walter D, Steup CD, Mücke MM, Mücke VT, Peiffer KH, Görgülü E, Mondorf A, Bechstein WO, Filmann N, Zeuzem S, Bojunga J, Finkelmeier F. Treatment of Non-Anastomotic Biliary Strictures after Liver Transplantation: How Effective Is Our Current Treatment Strategy? J Clin Med 2023; 12:jcm12103491. [PMID: 37240598 DOI: 10.3390/jcm12103491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/30/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Non-anastomotic biliary strictures (NAS) are a common cause of morbidity and mortality after liver transplantation. METHODS All patients with NAS from 2008 to 2016 were retrospectively analyzed. The success rate and overall mortality of an ERCP-based stent program (EBSP) were the primary outcomes. RESULTS A total of 40 (13.9%) patients with NAS were identified, of which 35 patients were further treated in an EBSP. Furthermore, 16 (46%) patients terminated EBSP successfully, and nine (26%) patients died during the program. All deaths were caused by cholangitis. Of those, one (11%) patient had an extrahepatic stricture, while the other eight patients had either intrahepatic (3, 33%) or combined extra- and intrahepatic strictures (5, 56%). Risk factors of overall mortality were age (p = 0.03), bilirubin (p < 0.0001), alanine transaminase (p = 0.006), and aspartate transaminase (p = 0.0003). The median duration of the stent program was 34 months (ITBL: 36 months; IBL: 10 months), and procedural complications were rare. CONCLUSIONS EBSP is safe, but lengthy and successful in only about half the patients. Intrahepatic strictures were associated with an increased risk of cholangitis.
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Affiliation(s)
- Florian A Michael
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Hans-Peter Erasmus
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Christiana Graf
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Olivier Ballo
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Mate Knabe
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Dirk Walter
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Christoph D Steup
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Marcus M Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Victoria T Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Kai H Peiffer
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Esra Görgülü
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Antonia Mondorf
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Wolf O Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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3
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Zhang CC, Rupp C, Exarchos X, Mehrabi A, Koschny R, Schaible A, Sauer P. Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation. Gastrointest Endosc 2023; 97:42-49. [PMID: 36041507 DOI: 10.1016/j.gie.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/13/2022] [Accepted: 08/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biliary strictures after liver transplantation are associated with significant morbidity and mortality. Although various endoscopic treatment strategies are available, consensus on a particular strategy is lacking. Moreover, the influence of endoscopic therapy on overall survival has not been studied. This retrospective study aimed to evaluate the impact of scheduled endoscopic dilatation of biliary strictures after orthotopic liver transplantation on therapeutic success, adverse events, and survival. METHODS Between 2000 and 2016, patients with post-transplant anastomotic and nonanastomotic strictures were treated with balloon dilatation at defined intervals until morphologic resolution and clinical improvement. The primary clinical endpoint was overall survival, whereas secondary outcomes were technical and sustained clinical success, adverse events, treatment failure, and recurrence. RESULTS Overall, 165 patients with a mean follow-up of 8 years were included; anastomotic and nonanastomotic strictures were diagnosed in 110 and 55 patients, respectively. Overall survival was significantly higher in patients with anastomotic strictures than in those with nonanastomotic strictures (median, 17.6 vs 13.9 years; log-rank: P < .05). Sustained clinical success could be achieved significantly more frequently in patients with anastomotic strictures (79.1% vs 54.5%, P < .001), and such patients showed significantly superior overall survival (19.7 vs 7.7 years; log-rank: P < .001). Sustained clinical success and the presence of nonanastomotic strictures were independently associated with better and worse outcomes (P < .05), respectively. CONCLUSIONS Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after liver transplantation is effective and safe, with high success rates. The implementation of this strategy controls symptoms and significantly improves survival.
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Affiliation(s)
| | - Christian Rupp
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Xenophon Exarchos
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ronald Koschny
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
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4
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Kirstein MM, Voigtländer T. Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie. Zentralbl Chir 2022; 147:398-406. [DOI: 10.1055/a-1857-5775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ZusammenfassungBiliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser
machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach
Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach
Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein
exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen
und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten
wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten
Verfahren.
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Affiliation(s)
| | - Torsten Voigtländer
- Gastroenterologie, Deutsches Rotes Kreuz Krankenhaus Clementinenhaus Hannover, Hannover, Deutschland
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5
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Radiologic Classification of Distinct Patterns of Non-Anastomotic Strictures; can we Predict the Course of the Disease? Transplantation 2021; 106:1107-1108. [PMID: 34456265 DOI: 10.1097/tp.0000000000003929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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6
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Croome KP, Taner CB. Expanding Role of Donation After Circulatory Death Donors in Liver Transplantation. Clin Liver Dis 2021; 25:73-88. [PMID: 33978584 DOI: 10.1016/j.cld.2020.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Better understanding of how to utilize donation after circulatory death (DCD) liver grafts has resulted in improved national outcomes and expansion in the number of DCD liver transplants (LTs). This improvement has been driven by better donor and recipient matching, careful evaluation of hemodynamics during withdrawal of life support, and refinement of the procurement operation. Changes to liver allocation likely will result in increased utilization of DCD liver grafts. Ischemic cholangiopathy remains the Achilles heel of DCD LTs and, although rates have fallen with improved protocols, a certain rate likely is unavoidable. This review discusses contemporary issues with DCD LTs.
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Affiliation(s)
- Kristopher P Croome
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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7
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Long-term Outcomes After Controlled Oxygenated Rewarming of Human Livers Before Transplantation. Transplant Direct 2020; 6:e542. [PMID: 32309628 PMCID: PMC7145002 DOI: 10.1097/txd.0000000000000987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 02/07/2023] Open
Abstract
Controlled oxygenated rewarming (COR) has been shown to be a feasible and safe method in clinical practice and to reduce peak serum transaminases after liver transplantation. This study aimed to demonstrate further clinical experience of this method of now 18 clinical liver transplantations utilizing COR and demonstrate the long-term results. Methods In this extended series of 18 patients, cold-stored livers were subjected to machine-assisted slow COR for ≈120 minutes before transplantation. A cohort of 178 patients transplanted during the same period with similar clinical characteristics were used for comparison of key outcomes. Results All livers were perfused in accordance to the COR protocol without incidences and transplanted successfully. Early allograft dysfunction was observed in 2 (11.1%) cases after COR. Liver elasticity measurements indicated normal healthy liver parenchyma at the last follow-up. Graft survival demonstrated excellent outcomes after COR. The 1-, 3-, and 5-year patient survival rates were 100%, 100%, and 93.8% compared with 84.5%, 82.0%, and 75.8% in the control group (P = 0.12). Conclusions The present study demonstrates excellent clinical outcomes after COR before liver transplantation. Comparison with a control cohort shows superiority of graft survival. Further evidence is needed to assess this promising method to improve organ preservation, finally.
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8
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Akhter A, Pfau P, Benson M, Soni A, Gopal D. Endoscopic management of biliary strictures post-liver transplantation. World J Meta-Anal 2019; 7:120-128. [DOI: 10.13105/wjma.v7.i4.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.
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Affiliation(s)
- Ahmed Akhter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Patrick Pfau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Mark Benson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Anurag Soni
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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9
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Larghi A, Tringali A, Rimbaş M, Barbaro F, Perri V, Rizzatti G, Gasbarrini A, Costamagna G. Endoscopic Management of Benign Biliary Strictures After Liver Transplantation. Liver Transpl 2019; 25:323-335. [PMID: 30329213 DOI: 10.1002/lt.25358] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
Biliary strictures represent some of the most frequent complications encountered after orthotopic liver transplantation. They comprise an array of biliary abnormalities with variations in anatomical location, clinical presentation, and different pathogenesis. Magnetic resonance cholangiography represents the most accurate noninvasive imaging test that can provide detailed imaging of the whole biliary system-below and above the anastomosis. It is of particular value in those harboring complex hilar or intrahepatic strictures, offering a detailed roadmap for planning therapeutic procedures. Endoscopic therapy of biliary strictures usually requires biliary sphincterotomy plus balloon dilation and stent placement. However, endoscopic management of nonanastomotic biliary strictures is much more complex and challenging as compared with anastomotic biliary strictures. The present article is a narrative review presenting the results of endoscopic treatment of biliary strictures occurring after liver transplantation, describing the different strategies based on the nature of the stricture and summarizing their outcomes.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Mihai Rimbaş
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Federico Barbaro
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Instituts Hospitalo-Universitaires - University of Strasbourg Institute of Advanced Study, Strasbourg, France
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10
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Peñas-Herrero I, Perez-Miranda M. Hepatic artery disease and anastomotic bile leaks after liver transplantation: shining the light on the true Achilles' heel. Gastrointest Endosc 2017; 85:993-995. [PMID: 28411765 DOI: 10.1016/j.gie.2016.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/01/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Irene Peñas-Herrero
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
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11
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Lee HW, Shah NH, Lee SK. An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clin Endosc 2017; 50:451-463. [PMID: 28415168 PMCID: PMC5642064 DOI: 10.5946/ce.2016.139] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 02/07/2023] Open
Abstract
Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.
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Affiliation(s)
- Hyun Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Najmul Hassan Shah
- Division of Gastroenterology and Hepatology, Liver Transplant Program, Shifa International Hospital Ltd., Shifa College of Medicine, Islamabad, Pakistan
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Aparício DPDS, Otoch JP, Montero EFDS, Khan MA, Artifon ELDA. Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis. United European Gastroenterol J 2016; 5:827-845. [PMID: 29026597 DOI: 10.1177/2050640616681909] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022] Open
Abstract
The most common biliary complication after liver transplantation is anastomotic stricture (AS) and it can occur isolated or in combination with other complications. Liver graft from a cadaveric donor or a living donor has an influence on the incidence of biliary strictures as well as on the response to endoscopic treatment. Endoscopic treatment using balloon dilation and insertion of biliary stents by endoscopic retrograde cholangiopancreatography (ERCP) is the initial approach to these complications. AIM The aim of this article is to compare different endoscopic techniques to treat post-liver transplantation biliary strictures. METHODS The search was carried out on MEDLINE, EMBASE, Scielo-LILACS and Cochrane Library databases through June 2015. A total of 1100 articles were retrieved. Ten clinical trials were analyzed, and seven were included in the meta-analysis. CONCLUSIONS The endoscopic treatment of AS was equally effective when compared the use of fully covered self-expandable metal stents (FCSEMS) vs. plastic stents, but the use of FCSEMS was associated with a lower complication risk. The treatment of AS with balloon dilation or balloon dilation associated with plastic stents presented similar results. Deceased donor liver transplantation reduced the risk of biliary stenosis and the endoscopic treatment in these patients was more effective when compared with Living donor liver transplantation.
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Affiliation(s)
| | | | | | - Muhammad Ali Khan
- Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN 38103, USA
| | - Everson Luiz de Almeida Artifon
- University of São Paulo, Pancreatic and Biliary Endoscopy Department/Hospital das Clínicas, University of São Paulo, SP, Brazil
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13
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Sauer P, Rupp C, Flechtenmacher C. Sekundär sklerosierende Cholangitis bei Intensivpatienten. GASTROENTEROLOGE 2016. [DOI: 10.1007/s11377-016-0098-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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14
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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15
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Stojkovic M, Junghanss T, Veeser M, Weber TF, Sauer P. Endoscopic Treatment of Biliary Stenosis in Patients with Alveolar Echinococcosis--Report of 7 Consecutive Patients with Serial ERC Approach. PLoS Negl Trop Dis 2016; 10:e0004278. [PMID: 26910822 PMCID: PMC4766234 DOI: 10.1371/journal.pntd.0004278] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/13/2015] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Biliary vessel pathology due to alveolar echicococcosis (AE) results in variable combinations of stenosis, necrosis and inflammation. Modern management strategies for patients with cholestasis are desperately needed. The aim is proof of principle of serial ERC (endoscopic retrograde cholangiography) balloon dilation for AE biliary pathology. Methods Retrospective case series of seven consecutive patients with AE-associated biliary pathology and ERC treatment in an interdisciplinary endoscopy unit at a University Hospital which hosts a national echinococcosis treatment center. The AE patient cohort consists of 106 patients with AE of the liver of which 13 presented with cholestasis. 6/13 received bilio-digestive anastomosis and 7/13 patients were treated by ERC and are reported here. Biliary stricture balloon dilation was performed with 18-Fr balloons at the initial and with 24-Fr balloons at subsequent interventions. If indicated 10 Fr plastic stents were placed. Results Six patients were treated by repeated balloon dilation and stenting, one by stenting only. After an acute phase of 6 months with repeated balloon dilation, three patients showed “sustained clinical success” and four patients “assisted therapeutic success,” of which one has not yet reached the six month endpoint. In one patient, sustained success could not be achieved despite repeated insertion of plastic stents and balloon dilation, but with temporary insertion of a fully covered self-expanding metal stent (FCSEMS). There was no loss to follow up. No major complications were observed. Conclusions Serial endoscopic dilation is a standard tool in the treatment of benign biliary strictures. Serial endoscopic intervention with balloon dilation combined with benzimidazole treatment can re-establish and maintain biliary duct patency in AE associated pathology and probably contributes to avoid or postpone bilio-digestive anastomosis. This approach is in accordance with current ERC guidelines and is minimally disruptive for patients. Alveolar echinococcosis (AE) is a zoonosis causing infiltrative liver lesions. A subgroup of patients presents with central liver lesions and biliary obstruction. At present there is no clear concept for the treatment of biliary obstruction in AE of the liver, and data from high quality trials to base treatment decisions on evidence are missing. In rare neglected infectious diseases with very low prevalence, clinical data can mainly be generated from case series. In our study we aim at the proof of principle of serial ERC balloon dilation for biliary pathology associated to alveolar echinococcosis. This approach is in accordance with current ERC guidelines and is minimally disruptive for patients.
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Affiliation(s)
- Marija Stojkovic
- Section Clinical Tropical Medicine, University Hospital Heidelberg, INF 324, Heidelberg, Germany
- * E-mail:
| | - Thomas Junghanss
- Section Clinical Tropical Medicine, University Hospital Heidelberg, INF 324, Heidelberg, Germany
| | - Mira Veeser
- Interdisciplinary Endoscopy Unit, University Hospital Heidelberg, Department of Internal Medicine, INF 410, Heidelberg, Germany
| | - Tim F. Weber
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 410, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Endoscopy Unit, University Hospital Heidelberg, Department of Internal Medicine, INF 410, Heidelberg, Germany
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16
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Semenkov AV, Filin AV, Kim ÉF, Ushakova IA, Goncharova AV. [The results of biliary reconstructions after liver fragments transplantation]. Khirurgiia (Mosk) 2015:22-28. [PMID: 26356055 DOI: 10.17116/hirurgia2015822-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To analyze the results of repeated reconstructions of choleresis after living related liver fragments transplantation. MATERIAL AND METHODS The study included 268 recipients (145 women and 123 men) aged 5 months - 61 years (mean age 16,11 ± 14,62 years) who underwent liver fragments transplantation in the department of liver transplantation of cad. B.V. Petrovskiy Russian Research Surgery Center from 1997 to 2012. Biliary reconstructions were performed at different terms after transplantation in 37 patients (13.81%). Complications followed repeated reconstructions, the initial conditions for biliary anastomosis formation during transplantation, the results of biliary reconstructions after transplantation were analyzed. RESULTS In most cases despite the prevailing complications there is a combination of various biliary complications requiring biliary reconstruction. It was found that live rfragment used for transplantation, type of primary reconstruction of choler sis, number of bile ducts orifices of graft and biliary anastomoses do not demonstrate statistically significant effect on the incidence of post-transplant biliary reconstructions (p>0.05). Poor prognosis in patients with biliary complications required biliary reconstructionsis determined by the development of graft dysfunction. Early reconstruction before development of liver transplant dysfunction is necessary condition of successful treatment. In the case of graft dysfunction liver retransplantation is unique method of treatment.
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Affiliation(s)
- A V Semenkov
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Filin
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - É F Kim
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - I A Ushakova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Goncharova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
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Visrodia KH, Tabibian JH, Baron TH. Endoscopic management of benign biliary strictures. World J Gastrointest Endosc 2015; 7:1003-1013. [PMID: 26322153 PMCID: PMC4549657 DOI: 10.4253/wjge.v7.i11.1003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/25/2015] [Accepted: 08/03/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic management of biliary obstruction has evolved tremendously since the introduction of flexible fiberoptic endoscopes over 50 years ago. For the last several decades, endoscopic retrograde cholangiopancreatography (ERCP) has become established as the mainstay for definitively diagnosing and relieving biliary obstruction. In addition, and more recently, endoscopic ultrasonography (EUS) has gained increasing favor as an auxiliary diagnostic and therapeutic modality in facilitating decompression of the biliary tree. Here, we provide a review of the current and continually evolving role of gastrointestinal endoscopy, including both ERCP and EUS, in the management of biliary obstruction with a focus on benign biliary strictures.
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Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: An evidence-based review. World J Gastrointest Endosc 2015; 7:606-616. [PMID: 26078829 PMCID: PMC4461935 DOI: 10.4253/wjge.v7.i6.606] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/21/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
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Dechêne A, Kodde C, Kathemann S, Treckmann J, Lainka E, Paul A, Gerken G, Feldstein AE, Hoyer PF, Canbay A. Endoscopic treatment of pediatric post-transplant biliary complications is safe and effective. Dig Endosc 2015; 27:505-511. [PMID: 25545826 DOI: 10.1111/den.12420] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/19/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Biliary complications (BC) after liver transplantation (LT) are associated with significant morbidity and mortality. Incidence of BC after pediatric LT is more than 10%. In adults, treatment by endoscopic retrograde cholangiopancreaticography (ERCP) is successful. As data in pediatric patients are limited, endoscopic treatment of BC in a pediatric cohort in a German transplant center was analyzed. METHODS LT recipients <18 years of age who were endoscopically treated for BC at University Hospital Essen were retrospectively analyzed. Characteristics of LT, endoscopic treatment measures, clinical and endoscopic presentation of BC, and outcomes after endoscopic treatment were evaluated. RESULTS Seventeen patients (median age 12 years) with clinical signs of BC were treated endoscopically using ERCP. Eleven patients had received a full-size liver, and six a left-sided living-donor transplant graft. In 12 patients, the bile ducts were accessible via Vater's papilla and five patients had a bilioenteric anastomosis. Biliary sphincterotomy was done in 13 patients. Eleven patients presented with stricture of the biliary anastomosis (AST), either isolated (nine) or in combination with biliary cast syndrome (BCS) or biliary leakage (one patient each). Ischemia-type biliary lesions (ITBL) were found in two patients. Five patients suffered from BCS, either as isolated pathology (two) or in combination with AST, bile leak or ITBL. In one patient, biliary access via the major papilla was not obtainable. CONCLUSIONS BC in pediatric LT were treated safely and successfully in pediatric patients when the biliary tract was accessible. The most common complications were AST, BCS and ITBL.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Cathrin Kodde
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Simone Kathemann
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Jürgen Treckmann
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ariel E Feldstein
- Department of Pediatrics, University of California San Diego (UCSD), San Diego, USA
| | - Peter F Hoyer
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
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20
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Nacif LS, Bernardo WM, Bernardo L, Andraus W, Torres L, Chaib E, D'Albuquerque LC, Maluf-Filho F. Endoscopic treatment of post-liver transplantation anastomotic biliary stricture: systematic review and meta-analysis. ARQUIVOS DE GASTROENTEROLOGIA 2015; 51:240-9. [PMID: 25296086 DOI: 10.1590/s0004-28032014000300014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/14/2014] [Indexed: 12/11/2022]
Abstract
CONTEXT Biliary strictures after liver transplantation are recognized as its Achilles' heel. The strictures are classified in anastomotic and ischemic or non-anastomotic biliary strictures, and they figure among the most common complications after liver transplantation. There are some treatment options including balloon dilation, the placement of multiple plastic stents and the placement of self-expandable metal stents and all of them seem to have good results. OBJECTIVES The aim of this study was to systematically review the literature concerning the results of the endoscopic treatment of anastomotic biliary strictures after liver transplantation. METHODS A systematic review of the literature was performed on the management of anastomotic biliary strictures post- orthotopic liver transplantation. The Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were electronically searched from January 1966 to April 2013. RESULTS No well-designed randomized controlled trial was found. Most studies were retrospective or prospective comparisons in design. One study (86 patients) compared the endoscopic and the percutaneous accesses. The sustained clinical success rates were similar but the treatment duration was longer in the percutaneous group access. Two studies (56 patients) compared balloon dilation with balloon dilation and multiple plastic stents. There were no differences concerning sustained clinical success and complication rates. CONCLUSIONS Balloon dilation is as effective as balloon dilation plus multiple plastic stenting for the resolution of the anastomotic biliary strictures. Well-designed randomized trials are still needed to compare balloon dilation versus multiple plastic stenting versus metallic stenting.
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Affiliation(s)
- Lucas Souto Nacif
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | | | - Luca Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil
| | - Wellington Andraus
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Lucas Torres
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Eleazar Chaib
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Luiz Carneiro D'Albuquerque
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
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22
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Lankisch TO, Voigtländer T, Manns MP, Holzmann A, Dangwal S, Thum T. MicroRNAs in the bile of patients with biliary strictures after liver transplantation. Liver Transpl 2014; 20:673-8. [PMID: 24648209 DOI: 10.1002/lt.23872] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 02/17/2014] [Indexed: 12/14/2022]
Abstract
Biliary complications after liver transplantation remain a major cause of morbidity and reduced graft survival. Ischemic-type biliary lesions (ITBLs) are common and difficult to treat. The pathophysiology of ITBLs remains unclear, and diagnostic markers are still missing. The analysis of microRNA (miRNA) profiles is an evolving field in hepatology. Our aim was to identify specific miRNA patterns in the bile of patients with ITBLs after liver transplantation. Liver transplant patients with biliary complications were included in a cross-sectional study. Patients with ITBLs (n = 37), anastomotic strictures (ASs; n = 39), and bile duct stones (BDSs; n = 12) were compared. Patients with ITBLs were categorized by disease severity. The miRNA concentrations in bile were determined with global miRNA profiling and subsequent miRNA-specific polymerase chain reaction-mediated validation. The concentrations of microRNA 517a (miR-517a), miR-892a, and miR-106a* in bile were increased for patients with ITBLs versus patients with ASs or BDSs (P < 0.05). Categorization by ITBL severity showed higher median concentrations in patients with intrahepatic and extrahepatic strictures (P > 0.05). miR-210, miR-337-5p, miR-577, and miR-329 displayed no statistical differences. In conclusion, miR-517a, miR-892a, and miR-106a* are increased in the bile fluid of patients with ITBLs versus patients with ASs or BDSs. An analysis of miRNA profiles may be useful in the diagnosis and management of patients with ITBLs. Future studies are needed to prove the potential prognostic value of these miRNAs.
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Affiliation(s)
- Tim O Lankisch
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany; Integrated Research and Treatment Center-Transplantation, Hannover Medical School, Hannover, Germany
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Luo Y, Ji WB, Duan WD, Ye S, Dong JH. Graft cholangiopathy: etiology, diagnosis, and therapeutic strategies. Hepatobiliary Pancreat Dis Int 2014; 13:10-7. [PMID: 24463074 DOI: 10.1016/s1499-3872(14)60001-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Graft cholangiopathy has been recognized as a significant cause of morbidity, graft loss, and even mortality in patients after orthotopic liver transplantation. The aim of this review is to analyze the etiology, pathogenesis, diagnosis and therapeutic strategies of graft cholangiopathy after liver transplantation. DATA SOURCE A PubMed database search was performed to identify articles relevant to liver transplantation, biliary complications and cholangiopathy. RESULTS Several risk factors for graft cholangiopathy after liver transplantation have been identified, including ischemia/reperfusion injury, cytomegalovirus infection, immunological injury and bile salt toxicity. A number of strategies have been attempted to prevent the development of graft cholangiopathy, but their efficacy needs to be evaluated in large clinical studies. Non-surgical approaches may offer good results in patients with extrahepatic lesions. For most patients with complex hilar and intrahepatic biliary abnormalities, however, surgical repair or re-transplantation may be required. CONCLUSIONS The pathogenesis of graft cholangiopathy after liver transplantation is multifactorial. In the future, more efforts should be devoted to the development of more effective preventative and therapeutic strategies against graft cholangiopathy.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China.
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24
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Arain MA, Attam R, Freeman ML. Advances in endoscopic management of biliary tract complications after liver transplantation. Liver Transpl 2013; 19:482-98. [PMID: 23417867 DOI: 10.1002/lt.23624] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 02/04/2013] [Indexed: 12/11/2022]
Abstract
Biliary tract complications after liver transplantation (LT) most commonly include biliary leaks, strictures, and stone disease. Living donor recipients and donation after cardiac death recipients are at an increased risk of developing biliary complications. Biliary leaks usually occur early after transplantation, whereas strictures and stone disease occur later. The diagnosis of biliary complications relies on a combination of clinical presentation, laboratory abnormalities, and imaging modalities. Biliary leaks are usually diagnosed on the basis of bilious output from a surgical drain, fluid collections on imaging, or a cholescintigraphy scan demonstrating a leak. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive, does not require the administration of an intravenous contrast agent, and provides detailed imaging of the entire biliary system both above and below the anastomosis. The latter not only helps in the diagnosis of biliary strictures and stones before patients undergo invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) but also allows treating physicians to plan the optimal treatment approach. MRCP has, therefore, replaced invasive therapeutic modalities such as ERCP as the modality of choice for the diagnosis of biliary strictures and stones. There have been significant advances in endoscopic accessories, including biliary catheters, wires, and stents, as well as endoscopic technologies such as overtube-assisted endoscopy over the last decade. These developments have resulted in almost all patients, including those with difficult strictures or altered surgical anatomies (eg, Roux-en-Y hepaticojejunostomy), being treated via an endoscopic approach with percutaneous transhepatic cholangiography, which is more invasive and associated with significant morbidity, with surgery being reserved for a small minority of patients. Advances in the diagnosis and endoscopic management of patients with biliary complications after LT are discussed in this review.
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Affiliation(s)
- Mustafa A Arain
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
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