Internal biliary stenting during orthotopic liver transplantation: anastomotic complications, post-transplant biliary interventions, and survival

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The Usefulness of High-Magnification Loupe for Reducing Biliary Complications After Liver Transplantation

BACKGROUND

Despite advances in surgical techniques, biliary complications are still considered to be a technical "Achilles' heel" of liver transplantation (LT). The purpose of this study was to evaluate the effect of loupe magnification in reducing biliary complications after LT.

MATERIALS AND METHODS

From April 2017 to February 2022, LT was performed on 307 patients in our center. Among them, except for 3 patients who underwent hepaticojejunostomy, 304 adult patients with LT were enrolled. They were divided into 3 groups according to the loupe magnification: 2.5 times (×2.5 group, n = 105), 3.5 times (×3.5 group, n = 95), and 5.0 times (×5.0 group, n = 105).

RESULTS

Biliary complications occurred in 63 (20.7%) patients. Anastomosis site leakage occurred in 37 patients (12.2%), and stricture occurred in 52 patients (17.1%). Anastomosis site leakage occurred in 15 patients (14.3%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 7 patients (6.7%) in the ×5.0 group (P = .097). Biliary stricture occurred in 26 patients (24.8%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 11 patients (10.5%) in the ×5.0 group (P = .021). Total biliary complications occurred in 31 patients (29.5%) in the ×2.5 group, 19 patients in the ×3.5 group (20.2%), and 13 patients in the ×5.0 group (12.4%) (P = .009).

CONCLUSION

The use of a high magnification loupe can reduce biliary complications in liver transplantation. Further large-scale analyses of clinical data or randomized controlled trials are required to support this study.

Individualized Biliary Reconstruction Techniques in Liver Transplantation: Five Years' Experience of a Single Institution

BACKGROUND

To summarize the experience of individualized biliary reconstruction techniques in deceased donor liver transplantation and explore potential risk factors for biliary stricture.

METHODS

We retrospectively collected medical records of 489 patients undergoing deceased donor liver transplantation at our center between January 2016 and August 2020. According to anatomical and pathological conditions of donor and recipient biliary ducts, patients' biliary reconstruction methods were divided into six types. We summarized the experience of six different reconstruction methods and analyzed the biliary complications' rate and risk factors after liver transplantation.

RESULTS

Among 489 cases of biliary reconstruction methods during liver transplantation, there were 206 cases of type I, 98 cases of type II, 96 cases of type III, 39 cases of type IV, 34 cases of type V, and 16 cases of type VI. Biliary tract anastomotic complications occurred in 41 cases (8.4%), including 35 cases with biliary stricture (7.2%), 9 cases with biliary leakage (1.8%), 19 cases with biliary stones (3.9%), 1 case with biliary bleeding (0.2%), and 2 cases with biliary infection (0.4%). One of 41 patients died of biliary tract bleeding and one died of biliary infection. Thirty-six patients significantly improved after treatment, and 3 patients received secondary transplantation. Compared with patients without biliary stricture, a higher warm ischemic time was observed in patients with non-anastomotic stricture and more leakage of bile in patients with an anastomotic stricture.

CONCLUSION

The individualized biliary reconstruction methods are safe and feasible to decrease perioperative anastomotic biliary complications. Biliary leakage may contribute to anastomotic biliary stricture and cold ischemia time to non-anastomotic biliary stricture.

Do We Need to Use a Stent in Biliary Reconstruction to Decrease the Incidence of Biliary Complications in Liver Transplantation? A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Biliary complications are a significant cause of morbidity post-transplantation, and the routine use of biliary stents in liver transplantation to reduce these complications remains controversial. This study aimed to compare the incidence of biliary complications with and without the use of trans anastomotic biliary stent in liver transplantation.

METHOD

PubMed, Scopes, Web of Science, and Cochrane library were searched for eligible studies from inception to February 2022, and a systematic review and meta-analysis were done to compare the incidence of biliary complications in the two groups.

RESULTS

Seventeen studies with a total of 2623 patients were included. The pooled results from the included studies showed an equal rate of biliary complications (i.e., strictures, leaks and cholangitis) in stented and non-stented patients after liver transplantation. However, the cost and biliary intervention rates are higher in stented patients. In addition to that, our sub-group analysis showed no significant decrease in the incidence of biliary complications after using trans anastomotic biliary stent in living donor liver transplant (LDLT), deceased donor liver transplant (DDLT), Roux-en-Y hepaticojejunostomy (RYHJ), and duct-to-duct anastomosis, pediatric, and adult liver transplantation.

CONCLUSION

No added benefit on the routine use of endobiliary stent in liver transplantation. However, stented patients are at higher risk of needing multiple ERCPs.

CAQ Corner: Surgical evaluation for liver transplantation

The evaluation of a liver transplantation candidate is a complex and detailed process that in many cases must be done in an expedited manner because of the critically ill status of some patients with end-stage liver disease. It involves great effort from and the collaboration of multiple disciplines, and during the evaluation several studies and interventions are performed to assess and potentially prepare a patient for liver transplant. Here we review the liver transplantation evaluation from a surgical perspective.

Are short-term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

Maximizing patient and allograft survival after liver transplant (LT) is important from both a patient care and organ utilization perspective. Although individual studies have addressed the effects of short-term post-LT complications on a limited scale, there has not been a systematic review of the literature formally assessing the potential effects of early complications on long-term outcomes.

OBJECTIVES

To identify whether short-term complications after LT affect allograft and overall survival, to identify short-term complications of particular clinical interest and significance, and to provide recommendations to improve post-LT graft and patient survival.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.

RESULTS

The literature review and analysis provided show that short-term complications have a large impact on allograft and patient survival after LT. The complications with the strongest effect on survival are acute kidney injury (AKI), biliary complications, and early allograft dysfunction (EAD).

CONCLUSION

This panel recommends taking measures to reduce the risk and incidence of short-term complications post-LT. Clinicians should pay particular attention to preventing or ameliorating AKI, biliary complications, and EAD (Quality of evidence; Moderate | Grade of Recommendation; Strong).

Anastomotic biliary stricture following liver transplantation and management analysis: 15 years of experience at a high-volume transplant center

INTRODUCTION

The occurrence of anastomotic biliary stricture (BS) remains an essential issue following liver transplantation (LT). The present study aimed to compare our findings regarding the incidence of anastomotic BS to what is known.

METHODS

The present study is a single-center, retrospective cohort study of a total number of 717 consecutive patients (426 men and 291 women) who had undergone LT from January 2001 to March 2016. Multivariable Cox regression analysis was conducted to evaluate the risk factors associated with anastomotic BS development.

RESULTS

Post-transplant anastomotic BS developed in 70 patients (9.8%). In the Cox multivariate analysis (a stepwise forward conditional method), factors including biliary leak (hazard ratio [HR]: 6.61, 95% confidence interval [CI]: 3.08-17.58, p < 0.001), hepatic artery thrombosis (HR: 2.29, 95% CI: 1.03-5.88; p = 0.003), and acute rejection (HR: 2.18, 95% CI: 1.16-3.37; p = 0.006) were identified as independent risk factors for the development of anastomotic BS. Surgery in 6 cases (66.7%), followed by endoscopic retrograde cholangiopancreatography (ECRP) with a metal stent in 18 cases (62.1%), percutaneous transhepatic biliary drainage in 9 (20.9%), and ERCP with a single plastic stent in 8 (18.2%), had the highest effectiveness rates in the management of BS, respectively.

CONCLUSIONS

Risk factors including biliary leak, hepatic artery thrombosis, and acute rejection were independently associated with an anastomotic BS. ERCP with a metal stent may be considered as an effective treatment procedure with a relatively low complication rate in the management of benign post-LT anastomotic BS.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Iatrogenic Bilothorax: A Rare Complication of Orthotopic Liver Transplant

Bilothorax is a rare condition involving drainage of bile from the biliary system into the lung's pleural space. Several cases have been reported in the literature, where the most commonly reported cause is iatrogenic injury. To date, no cases of bilothorax as a complication of liver transplantation have been reported. Given its rarity and concurrent morbidity, early recognition is paramount as this condition can quickly deteriorate into adult respiratory distress syndrome.

The application of Compont gel in chronic obstructive jaundice rats model

PURPOSE

To establish a new rat model, the pathogenesis of which is closer to the clinical occurrence of chronic obstructive jaundice with liver fibrosis.

METHODS

90 SD rats were randomly divided into 3 groups. Group A common bile duct ligation, group B common bile duct injection compont and group C injection saline. The serum of three groups was extracted, and the liver function was detected by ELISA. HE staining, Masson staining and immunohistochemistry were used to detect liver pathology.

RESULTS

Group B showed a fluctuant development of jaundice, obstructive degree reached a peak at 2 weeks, and decreased from 3 weeks. HA, LA and PCIII were significantly higher than control group. 3 weeks after surgery, liver tissue fibrosis occurred in group B, and a wide range of fiber spacing was formed at 5 weeks. Immunohistochemistry showed that hepatic stellate cells were more active than the control group.

CONCLUSION

Intra-biliary injection of Compont gel is different from the classic obstructive jaundice animal model caused by classic bile duct ligation, which can provide an ideal rat model of chronic obstructive jaundice with liver fibrosis.

The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures

PURPOSE OF REVIEW

Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage.

RECENT FINDINGS

Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.

Anastomotic Biliary Stricture Development after Liver Transplantation in the Setting of Retained Prophylactic Intraductal Pediatric Feeding Tube: Case and Review

The biliary anastomosis remains a common site of postoperative complications in liver transplantation (LT). Biliary complications have indeed been termed the "Achilles' heel" of LT, and while their prevention, diagnosis, and treatment have continued to evolve over the last two decades, various challenges and uncertainties persist. Here we present the case of a 33-year-old man who, 10 years after undergoing LT for idiopathic recurrent intrahepatic cholestasis, was noted to have developed pruritus and abnormalities in serum liver biochemistries during routine post-liver transplant follow-up. Abdominal ultrasound revealed a linear, 1.5 mm hyperechoic filling defect in the common bile duct; magnetic resonance cholangiopancreatography demonstrated a curvilinear filling defect at the level of the choledochocholedochostomy, corresponding to the ultrasound finding, as well as an anastomotic biliary stricture (ABS). On endoscopic retrograde cholangiography (ERC), a black tubular stricture with overlying sludge was encountered and extracted from the common bile duct, consistent with a retained 5 Fr pediatric feeding tube originally placed at the time of LT. The patient experienced symptomatic and biochemical relief and successfully underwent serial ERCs with balloon dilatation and maximal biliary stenting for ABS management. With this case, we emphasize the importance of ensuring spontaneous passage or removal of intraductal prostheses placed prophylactically at the time of LT in order to minimize the risk of chronic biliary inflammation and associated sequelae, including cholangitis and ABS formation. We also provide herein a brief review of the use of prophylactic internal transanastomotic prostheses, including biliary tubes and stents, during LT.

To stent or not to stent: the use of transanastomotic biliary stents in liver transplantation and patient outcomes

BACKGROUND

There is no substantial evidence for the use of biliary stents in bile duct reconstruction during liver transplantation.

METHOD

A longitudinal, retrospective cohort study was performed to compare biliary complications between stented and non-stented patients between 2011 and 2015 at the Princess Alexandra Hospital, Brisbane, Australia.

RESULTS

We found no significant difference in biliary complications between stented and non-stented groups. Stented patients were 3.31 times as likely to require subsequent intervention, mainly in the form of stent removal.

CONCLUSION

These results suggest that there is limited benefit in the placement of endobiliary stents in liver transplantation. Given that this was purely an observational study, causality cannot be proven and a prospective cohort trial would be beneficial in further defining these relationships.

Biliary Complications After Liver Transplantation: Incidence, Risk Factors and Impact on Patient and Graft Survival

INTRODUCTION

Biliary complications (BC) are one of the most frequent surgical complications after liver transplantation. They include biliary stenosis, leaks, choledocolitiasis and sphincter of Oddi dysfunction. These complications can cause graft dysfunction, retrasplantation, or even death. The purpose of this study was to identify factors related to BC.

MATERIALS AND METHODS

The medical records of all adult patients who underwent their first liver transplantation in our institution from 2005 to 2013 were reviewed, and any BC that required management was recorded. Cumulative incidence of BC was estimated using Kaplan-Meier. Patient and graft survival was compared using the log-rank test. The Cox regression model was used to establish associated factors.

RESULTS

Of the 236 patients who underwent liver transplantation, 41 patients (17.8%) developed BC. Cumulative incidence was 12.9%, 17.2%, and 20%, after 1, 3 and 5 years of the transplantation, respectively. Twenty-six cases of biliary stenosis, 11 of leaks, and 4 of choledocolitiasis were identified. Most patients were managed endoscopically (82.9%). There were no differences in patient or graft survival.

DISCUSSION

Biliary stenosis is the most frequent BC. Patients with higher risk of BC were of blood type AB (P < .001), had viral hepatitis (P = .049), or had alcoholic cirrhosis (P = .036). The success with the endoscopic treatment reduced the need for surgical interventions.

CONCLUSIONS

The incidence of BC in our institution is comparable with the incidence reported in other institutions. Further prospective studies with larger series of patients are warranted to identify other factors associated with development of BC.

Management issues in post living donor liver transplant biliary strictures

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.

Technical Aspects of Orthotopic Liver Transplantation for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) remains a significant malignancy and is the second leading cause of cancer death worldwide. Multiple therapeutic strategies exist for patients with HCC including locoregional therapy, liver resection, and liver transplantation. In many instances locoregional therapy is used to decrease tumor burden and "bridge" patients to liver transplant. Surgical technique during liver transplantation may need to be altered in light of these preoperative therapies used for treating HCC. In this review we discuss the technical aspects of liver transplantation and how they are impacted in patients with HCC.