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Gheorghe G, Diaconu CC, Bungau S, Bacalbasa N, Motas N, Ionescu VA. Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050850. [PMID: 37241082 DOI: 10.3390/medicina59050850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.
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Affiliation(s)
- Gina Gheorghe
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
- Internal Medicine Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, 022328 Bucharest, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | - Nicolae Bacalbasa
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, 022328 Bucharest, Romania
| | - Natalia Motas
- Institute of Oncology "Profesor Doctor Alexandru Trestioreanu" Bucharest, 022328 Bucharest, Romania
- Department of Thoracic Surgery, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
| | - Vlad-Alexandru Ionescu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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Sissingh NJ, de Vries BA, Inderson A, van Hoek B, van der Heide F, van Hooft JE. Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation. Gastrointest Endosc 2023; 97:704-712.e2. [PMID: 36460088 DOI: 10.1016/j.gie.2022.11.018] [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: 09/25/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fully covered metal stents (FCSEMSs) are increasingly used for treatment of biliary anastomotic strictures (ASs) after liver transplantation (LT), requiring fewer endoscopic interventions than does treatment with multiple plastic stents (MPSs). Previous studies, however, have reported adverse events such as stent migration and pancreatitis. The intraductal FCSEMS (ID-FCSEMS) potentially avoids these disadvantages. This study aimed to assess the efficacy and safety of ID-FCSEMSs compared with MPSs for AS. METHODS The cohorts of LT patients treated for AS with endoscopic stenting between 2010 and 2019 from 2 Dutch liver transplantation centers were retrospectively analyzed. Patients treated with ID-FCSEMSs or MPSs were included. RESULTS 80 patients (44 with ID-FCSEMSs vs 36 with MPSs) were included, with a median follow-up time of 52 versus 64 months (P = .183). Stricture resolution was 93% in the ID-FCSEMS versus 97% in the MPS group (P = 1.000) after a median of 19 and 26 weeks, respectively (P = .031). The median number of ERCPs was 2 in the ID-FCSEMS group versus 4 in the MPS group (P < .001). Stricture recurrence occurred in 33% of ID-FCSEMS versus 29% of MPS patients (P = .653) after a median of 24 and 55 weeks (P = .403). Stent migration occurred in 16% of ID-FCSEMS versus 39% of MPS patients (P = .020). Post-ERCP fever was observed in 34% of ID-FCSEMS patients compared with 14% of MPS patients (P = .038). No significant differences were found in pancreatitis rate between the groups, being 6.8% for ID-FCSEMSs and 5.6% for MPSs (P = .816). CONCLUSION ID-FCSEMSs for the treatment of AS after LT provides similar stricture resolution and recurrence rates as MPSs, though with a significant reduction of procedures needed.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Boudewijn A de Vries
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans van der Heide
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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Conigliaro R, Pigò F, Bertani H, Greco S, Burti C, Indriolo A, Di Sario A, Ortolani A, Maroni L, Tringali A, Barbaro F, Costamagna G, Magarotto A, Masci E, Mutignani M, Forti E, Tringali A, Parodi MC, Assandri L, Marrone C, Fantin A, Penagini R, Cantù P, Di Benedetto F, Ravelli P, Vivarelli M, Agnes S, Mazzaferro V, De Carlis L, Andorno E, Cillo U, Rossi G. Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group. Liver Int 2022; 42:1861-1871. [PMID: 35302273 DOI: 10.1111/liv.15246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/05/2022] [Accepted: 03/08/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND STUDY AIM The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.
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Affiliation(s)
- Rita Conigliaro
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Flavia Pigò
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Helga Bertani
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
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Ding S, Wu W, Lu J, Zhu H, Zheng S, Li Q. Migration of fully covered self-expandable metallic stents used to treat anastomotic strictures after orthotopic liver transplantation: A single-center, retrospective analysis. Medicine (Baltimore) 2022; 101:e28685. [PMID: 35089220 PMCID: PMC8797473 DOI: 10.1097/md.0000000000028685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 01/04/2022] [Indexed: 01/05/2023] Open
Abstract
Insertion of a fully covered self-expandable metallic stent (FCEM) through endoscopic retrograde cholangiopancreatography is an effective solution for biliary anastomotic stricture following orthotopic liver transplantation (OLT). However, FCEM migration continues to plague patients. This study aimed to evaluate the FCEM migration rate in our center, and to investigate the factors increasing the migration risk for FCEM.The study enrolled 43 post-OLT patients with confirmed duct-to-duct AS. The effects of age, gender, albumin, alanine aminotransferase, aspartate aminotransferase (AST), γ-glutamyl transpeptidase, alkaline phosphatase, total bilirubin, direct bilirubin, ABO (blood group system consists of four antigens) incompatibility, stricture length, FCEM brand, FCEM length, donor liver and recipient bile duct diameters, size mismatches between the donor and recipient bile ducts >2 mm, diabetes and/or hypertension status, endoscopic sphincterotomy status, the use of plastic stents or nasobiliary drainage prior to FCEM implantation, duration from OLT to FCEM placement, and OLT etiology on FCEM migration were retrospectively analyzed.The FCEM migration rate was 48.8% (21/43) at 6 months. The serum AST level was significantly higher in the migration group than that in the nonmigration group (52.48 vs 29.50 U/L, P < .05). A lower serum AST level was associated with a decreased risk of FCEM migration in post-OLT patients with duct-to-duct anastomotic stricture (hazard ratio = 0.968, 95% confidence interval: 0.940-0.996, P = .028).In this single-center, retrospective cohort study, we showed that an elevated serum AST level was a potential risk factor for FCEM migration.
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Jang SI, Chung TR, Cho JH, Lee KH, Joo SM, Choi JH, Kim SI, Lee DK. Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation. Dig Endosc 2021; 33:840-848. [PMID: 33043522 DOI: 10.1111/den.13871] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/08/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs. METHODS Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. RESULTS A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%). CONCLUSIONS The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.
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Affiliation(s)
- Sung Ill Jang
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Ryong Chung
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Moon Joo
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hye Choi
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sae In Kim
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Efficacy of Different Endoscopic Stents in the Management of Postoperative Biliary Strictures: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2019; 53:418-426. [PMID: 30807403 DOI: 10.1097/mcg.0000000000001193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Endoscopic stents are the first-line treatment in the management of benign biliary stricture (BBS) which include multiple plastic stents (MPSs), fully covered self-expandable metal stents (FCSEMS) including the conventional and modified ones (FCSEMS-C and FCSEMS-M) and biodegradable stents. However, different stents have their distinct advantages and disadvantages. We aim to conduct this systematic review to compare the efficacy of different stents in the management of BBS. METHODS Several databases were searched from inception through March 2018. Studies including >10 patients with postoperative stricture treated with endoscopic stents were enrolled. Pooled odds ratio of outcomes were calculated to compare MPS with FCSEMS. Weighted pooled rates were calculated to show the efficacy of FCSEMS-M, FCSEMS-C, and MPS. RESULTS Twenty-two articles were reviewed including 4 randomized controlled studies, 4 cohort studies, and 14 case series studies. Comparing FCSEMS with MPS, the pooled odds ratio was 0.48 [95% confidence interval (CI): 0.22-1.05] (P=0.07) for stricture resolution, 0.3 (95% CI: 0.1-0.92) (P=0.03) for adverse event, 1.9 (95% CI: 0.3-12) (P=0.49) for stent migration, and 1.38 (95% CI: 0.36-5.3) (P=0.34) for stricture recurrence. The pooled rates for stricture recurrence of MPS, FCSEMS-C, and FCSEMS-M were 19%, 19%, and 7%, respectively. The pooled rates for stent migration were 4% of MPS, 25% of FCSEMS-C, and 3% of FCSEMS-M. CONCLUSIONS FCSEMS-M is more favorable in the management of BBS comparing with MPS or FCSEMS-C. The biodegradable stent may be a promising option but currently available data is insufficient to draw a firm conclusion.
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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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