Role of MRCP in Diagnosing Biliary Anastomotic Strictures After Liver Transplantation: A Single Tertiary Care Center Experience

Percutaneous Transhepatic Sphincterotome-Guided Management of Post-Living Donor Liver Transplant Biliary Anastomotic Stricture: An Innovative Approach

Post-liver transplantation biliary complications remain a serious concern and are associated with reduced patient and graft survival. Among various biliary complications, anastomotic stricture (AS) is the most frequent and challenging one. The frequency of AS after living donor liver transplantation (LDLT) is higher as compared to deceased donor liver transplantation. The management involves endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage, but refractory cases necessitate surgical revision. We present a case of complex biliary AS in a 63-year-old man after LDLT. The conventional approaches including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and cholangioscope-guided interventions remained unsuccessful. An innovative approach using a wire-guided sphincterotome through percutaneous transhepatic route successfully managed the complex post-LDLT AS. This is perhaps the first reported case of novel utilization of sphincterotome through transhepatic route for the management of AS in LDLT, averting major surgical interventions with related morbidity and mortality.

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of post-transplant strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent for extrahepatic strictures. In patients with unclear diagnoses or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be ensured.

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.

Serum bile acid levels assist the prediction of biliary stricture and survival after liver transplantation in children

Biliary stricture is an important biliary complication after liver transplant in children. We aimed to investigate the utility of serum bile acid levels for prediction of biliary stricture in children after liver transplant. This study enrolled 60 children who underwent liver transplantation at a mean age of 2.04±0.30 years; serum bile acid levels were surveyed in a cross-sectional design. These patients were followed regularly at our institute, and the clinical data were collected prospectively. The major indication of liver transplant in this pediatric cohort was biliary atresia (78.33%). During the follow-up period (3.08±0.30 years), nine patients (15%) developed biliary stricture after the check of serum bile acid. A receiver operating characteristic curve analysis yielded a serum bile acid cutoff of >40 μM for the prediction of biliary stricture (P = 0.002). A serum bile acid level >40 is the most important predictor of a biliary stricture after liver transplant (odds ratio=65.65, P = 0.003) after adjusting for gender and GGT levels. The phenomenon remained on Cox's proportional hazard survival analysis (hazard ratio =15.42, P = 0.001). The mortality risk after liver transplant was significantly higher in subjects with serum bile acid levels >40 μM than in those with levels ≤40 μM (log-rank test, P = 0.004).Conclusion: Serum bile acid levels can be used for non-invasive screening and prediction of biliary stricture and mortality in children after liver transplantation. What is Known: • Biliary stricture is a major biliary complication after pediatric liver transplantation, and we showed the serum bile acid level significantly associates with biliary stricture. What is New: • In this study, we demonstrated the serum bile acid level may assist in the early detection of biliary stricture and mortality non-invasively.

Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation

BACKGROUND

Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.

AIM

To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.

METHODS

This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.

RESULTS

Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).

CONCLUSION

In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

Right lobe (RL) living donor liver transplantation (LDLT) usually includes 2 bile duct anastomosis sites, namely, the right anterior and the right posterior segmental ducts. This study aimed to evaluate the optimal treatment for biliary strictures following RL LDLT with respect to unilateral or bilateral drainage techniques. From January 2005 to December 2017, 883 patients at Seoul National University Hospital underwent RL LDLT. Of these, 110 patients were enrolled who had 2 duct-to-duct anastomosis sites and who were considered at risk of developing biliary anastomotic strictures. Unilateral or bilateral biliary drainage during the follow-up period was identified by endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD). The clinical success, complication, and 180-day mortality rates were compared between the unilateral and bilateral biliary drainage groups according to the initial ERCP findings. The mean age at the time of LDLT was 54.2 ± 8.2 years. The median time from LDLT to initial biliary anastomotic strictures was 177 (interquartile range, 18-1085) days. At the initial ERCP, unilateral drainage was performed in 55 (50.0%) patients, and bilateral drainage was performed in 11 (10.0%) patients. Of the patients who underwent unilateral drainage, 35 (63.6%) patients required conversion to bilateral drainage during follow-up. Overall, 71 (64.5%) patients required bilateral drainage more than once, whereas only 27 (24.5%) patients reached a resolution with unilateral biliary drainage. In this study, most patients required bilateral biliary drainage more than once during follow-up. An active attempt should be made to drain bilaterally in patients with biliary anastomotic strictures following RL LDLT.

Impact of machine perfusion of the liver on post-transplant biliary complications: A systematic review

AIM

To review the clinical impact of machine perfusion (MP) of the liver on biliary complications post-transplantation, particularly ischaemic-type biliary lesions (ITBL).

METHODS

This systematic review was performed in accordance with the Preferred Reporting Systematic Reviews and Meta-Analysis (PRISMA) protocol. The following databases were searched: PubMed, MEDLINE and Scopus. The keyword “liver transplantation” was used in combination with the free term “machine perfusion”. Clinical studies reporting results of transplantation of donor human livers following ex situ or in situ MP were analysed. Details relating to donor characteristics, recipients, technique of MP performed and post-operative biliary complications (ITBL, bile leak and anastomotic strictures) were critically analysed.

RESULTS

Fifteen articles were considered to fit the criteria for this review. Ex situ normothermic MP was used in 6 studies, ex situ hypothermic MP in 5 studies and the other 4 studies investigated in situ normothermic regional perfusion (NRP) and controlled oxygenated rewarming. MP techniques which have per se the potential to alleviate ischaemia-reperfusion injury: Such as hypothermic MP and NRP, have also reported lower rates of ITBL. Other biliary complications, such as biliary leak and anastomotic biliary strictures, are reported with similar incidences with all MP techniques. There is currently less clinical evidence available to support normothermic MP as a mitigator of biliary complications following liver transplantation. On the other hand, restoration of organ to full metabolism during normothermic MP allows assessment of hepatobiliary function before transplantation, although universally accepted criteria have yet to be validated.

CONCLUSION

MP of the liver has the potential to have a positive impact on post-transplant biliary complications, specifically ITBL, and expand extended criteria donor livers utilisation.