BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION

LIVER TRANSPLANTATION IN PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS: A MULTICENTRIC STUDY

BACKGROUND

The prevalence of primary sclerosing cholangitis (PSC) in the general population has not yet been clearly established. The management of PSC should focus on delaying the progression of the disease and restraining its complications. The only curative therapy for the disease remains liver transplantation (LT). PSC is currently the fifth most common indication for LT and corresponds to 5% of all LT indications in adults.

AIMS

Our objective is to evaluate the indications and outcomes of PSC patients undergoing LT in three liver transplantation centers in southern Brazil - Hospital Santa Isabel in Blumenau, Santa Catarina state, and Hospital das Clínicas and Hospital Nossa Senhora das Graças, in Curitiba, Parana state).

METHODS

This is a longitudinal observational study of patients with PSC who underwent LT in three major Brazilian medical centers. Electronic medical records and study protocols of all patients subjected to LT from January 2011 to December 2021 were retrospectively reviewed.

RESULTS

Of the 1,362 transplants performed in the three medical centers, 37 were due to PSC. Recurrence of PSC occurred in three patients (8.1%) in 3.0±2.4 years (range, 1-4 years). The 1-year and 5-year survival rates after the first LT were 83.8 and 80.6%, respectively. The 1-year and 5-year graft survival rates were, respectively, 83.8 and 74.8%.

CONCLUSIONS

Our experience with LT in patients with PSC demonstrated good patient and graft survival results. Most deaths were due to common factors in patients undergoing LT.

Risk Factors Related to Early Biliary Complications After Liver Transplantation: a Single-Center Analysis

BACKGROUND

The aim of this study was to evaluate the risk factors of early biliary complications (EBC) after liver transplantation (LT) and seek effective treatments based on our single-center experience.

METHODS

A total of 124 adult patients were divided into a non-EBC group and EBC group. EBC usually accounts for biliary leakage, biliary stricture, biliary stones, sphincter of Oddi dysfunction, and transient jaundice within 3 months after LT. Statistical analysis including logistic regression was performed to determine EBC risk factors. All procedures complied with the Helsinki Congress and the Declaration of Istanbul.

RESULTS

Non-EBC (n = 95) and EBC (n = 29) were finally compared, which had no difference in their general characteristics. EBC occurred in 29 patients (26.92%): 1 biliary hemorrhage (3.45%), 7 biliary leakage (24.13%), and 16 biliary stricture (55.18%), and 5 others (17.24%). Of all EBC patients, endoscopic retrograde cholangiopancreatography (68.96%) was higher used to deal with complications than conservative treatment (10.35%), percutaneous transhepatic cholangial drainage (17.24%), and surgical treatment (3.45%). On univariate analyses, risk factors for EBC were bilirubin (P = .014), warm ischemia time (WIT) (P = .020), second WIT (P = .042), and operative time (OT) (P = .033). On multivariate analysis, independent risk factors for BC were WIT (P = .011) and OT (P = .049).

CONCLUSIONS

The presence of WIT and OT were the independent risk factors for the development of EBC. In addition, we also confirmed that endoscopic retrograde cholangiopancreatography was beneficial and safe in the management of EBC after LT.

Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group

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.

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.

Factors affecting anxiety, depression, and self-care ability in patients who have undergone liver transplantation

BACKGROUND

Depression, anxiety, and altered self-care ability are among the most important factors affecting the quality of life of liver transplant recipients. Depending on the severity of the underlying liver disease, signs and symptoms of anxiety and depression may become more pronounced.

AIM

To evaluate the factors affecting depression, anxiety and self-care abilities of liver transplant recipients.

METHODS

Recipients who are ≥ 18 years and who underwent liver transplantation at Inonu University Liver Transplantation Institute were included in this descriptive and cross-sectional study. Sample size analysis showed that the minimum number of recipients should be 301 (confidence level = 95%, confidence interval = 2.5, population = 1382). Three hundred and twenty recipients were interviewed and 316 recipients that have answered the questionnaires accurately were analyzed. The dependent variables were the Beck Depression Scale, State-Trait Anxiety Scale (Form I and II), and Self-Care Agency Scale. The independent variables of the study were sociodemographic characteristics, biliary complications, hepatocellular carcinoma, recommending liver transplantation to other patients, and the interval of out-patient clinic visits.

RESULTS

Self-care ability scores were lower (P = 0.002) and anxiety scores were higher (P = 0.004) in recipients with biliary complications. On the other hand, in recipients with hepatocellular carcinoma, self-care scores were lower (P = 0.006) while depression (P = 0.003) and anxiety scores (P = 0.009) were higher. Liver transplantation recipients with a monthly income < 3000 Turkish liras had higher depression (P < 0.001) and anxiety (P = 0.003) scores. The recipients who stated that they would not recommend liver transplantation to others had lower self-care scores (P = 0.002), higher depression (P < 0.001), higher state anxiety (P = 0.02), and trait anxiety (P < 0.001) scores.

CONCLUSION

Presence of biliary complications and hepatocellular carcinoma, low income level, and an obligation for monthly visits to the outpatient clinic are factors that are found to affect self-care capability, depression, and anxiety.

Liver transplantation in pediatric patients under 15 kg; duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses

Back ground. Liver transplantation is an effective treatment for acute or chronic liver failure and metabolic liver disease, which is associated with good quality of life in over 80 percent of recipients. We aimed to evaluate outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in pediatric liver transplant recipients below 15-kg.

Methods. In this single-center retrospective study, all children less than 15 kg that have undergone liver transplantation at Nemazee Hospital Organ Transplant Center affiliated with Shiraz University of Medical Sciences from 2009 till 2019, were enrolled. Over a 10-yr period, 181 liver transplants were performed in patients with two techniques including duct-to-duct (Group 1) vs. Roux-en-Y hepaticojejunostomy biliary anastomoses (Group 2). All data was collected from patients’ medical records, operative notes, and post-transplant follow up notes. Data was analyzed by SPSS software V21.

Results. Overall, 94 patients had duct to duct anastomosis (group 1) and 87 cases had Roux-en-Y hepaticojejunostomy (group 2). The mean age of the patients was 2.46 ± 1.5. The most common underlying diseases was biliary atresia (32%). The most prevalent complication after the surgery was infection in both groups. cardiopulmonary problems were significantly higher in group 2 (24.1% vs 4.3%) (p < 0.001). The rate of infection was significantly higher in group 2, as well.

Conclusion. Our study showed a relatively high rate of post-operative infection which was the most among patients who had undergone Roux-en-Y hepaticojejunostomy. Except from biliary complications which were mostly observed in DD group, other complications were more common among Roux-en-Y group.

Findings encountered in percutaneous cholangiography in a case of post-transplant recurrence of hepatic Langerhans cell histiocytosis with biliary involvement

This case report describes a four-year-old boy who presented with the diagnosis of LCH with liver involvement. This required a living-related liver transplant one year later. The primary disease recurred in the transplanted liver 6 months post-transplant and led to progressive biliary dilatation. A percutaneous trans-hepatic cholangiogram was performed five years after transplant, showing a pattern of multifocal biliary duct strictures mimicking the pattern of primary sclerosing cholangitis and a stenosis of the biliary-enteric anastomosis. Despite management with an internal-external biliary drain, the stenosis of the biliary-enteric anastomosis evolved to an occlusion one year after drain removal. This was associated with progression of the changes in the biliary tree, this time associated with significant saccular dilatations secondary to the multiple areas of stenosis. Due to these findings and progressive deterioration of the function of the graft, the patient required re-transplantation. This report illustrates the findings in imaging of the biliary tree secondary to the recurrence of LCH after liver transplantation, which may help to recognize this complication to physicians facing a similar clinical scenario.

GOOD QUALITY OF LIFE AFTER MORE THAN A DECADE OF LIVING DONOR LIVER TRANSPLANTATION

BACKGROUND

Receptors of living donor liver transplantation (LDLT) have higher rate of postoperative biliary and vascular complications that may reduce posttransplant quality of life (QOL) due to the need of invasive and repetitive treatments.

OBJECTIVE

The purpose of our study is to assess the various aspects of QOL of receptors undergoing LDLT after 10 years of transplantation and to identify potential factors that might be associated with impaired QOL.

METHODS

Data of all patients with more than 10 years of LDLT were retrospectively evaluated. Patients were interviewed through a quality of life questionnaire (SF-36).

RESULTS

From a total of 440 LT performed in 17 years (from September 1991 through December 2008), 78 patients underwent LDLT, of which 27 were alive and 25 answered completely the questionnaire. There were 17 (68%) men and 8 (32%) women, with a mean age of 38.6±18.5 years at the time of transplantation and mean follow up time of 15.1±1.9 years. The average MELD was 16.4±4.9 and the main indication for LT was hepatic cirrhosis caused by hepatitis B virus (32%). When compared to the general po-pulation, LDLT patients had lower mental health score (66.4 vs 74.5, P=0.0093) and higher vitality score (87.8 vs 71.9, P<0.001), functional aspects (94.6 vs 75.5, P=0.002), social aspects (93 vs 83.9, P=0.005), physical aspects (92 vs 77.5, P=0.006), and emotional aspects (97.33 vs 81.7, P<0.001). General health status (73.28 vs 70.2, P=0.074) and pain (78.72 vs 76.7, P=0.672) scores were similar in both groups.

CONCLUSION

It is concluded that the various aspects LDLT recipients' QOF are similar to those of the general population more than a decade after the transplant, except for the mental health domain which is lower.

Platelet-rich fibrin can accelerate the healing of common bile duct anastomosis in a rat

Objectives

This study aimed to evaluate the effect of platelet-rich fibrin (PRF) concentrate on the bile duct anastomosis healing process in rats.

Material and Methods

Thirty male Sprague Dawley (SD) rats were used for the study. The animals were allocated into three groups: Group I Control Group (n=10): Anastomosis to the common bile duct (CBD) with a stent. Group II PRF Group (n=10): Anastomosis to the CBD with a stent and covered with PRF. Group III Sham Group (n=10): Preparation of the common bile duct, no anastomosis. The animals were followed up for 1 month, then sacrificed. Study parameters were adhesions around the anastomosis, thickness of the bridging bile duct tissue over the stent, and histopathologic examination of the bridging bile duct tissue.

Results

CBD anastomosis using a stent caused severe adhesion around the anastomosis, bridging bile duct tissues were weak and histopathologically, healing was incomplete in most of the control animals. However, PRF application significantly reduced the adhesions, increased the quality of the bridging bile duct tissues, and caused complete healing histologically.

Conclusion

PRF is an autologous, easily prepared membrane. The present study findings show that PRF prevents local complications and increases the healing capacity of the bile duct after CBD anastomosis. Therefore, it might be a new treatment option for preventing complications following common bile duct anastomosis in liver transplantation patients.

Imaging post liver transplantation part II: biliary complications

Biliary complications post liver transplantation are a significant source of morbidity and mortality and early recognition is paramount to the long-term success of the liver graft. Part II of this series will focus on liver transplant biliary anatomy, including the blood supply to the biliary system and potential problems if it is interrupted. The imaging rationale for investigating suspected biliary complications, potential pitfalls, and treatment options will be discussed. The various biliary complications will be illustrated using a collection of cases.

Complications Following Liver Transplant at a Teaching Hospital

OBJECTIVE

The objective of this study is to analyze the liver transplant complications in a reference transplant hospital in southern Brazil.

METHODS

The researchers used a cross-sectional, quantitative, exploratory, and descriptive study, conducted using 103 medical records of patients who underwent liver transplantation from 2011 to 2018. Data were analyzed through median, mean, and standard deviation, and the Kruskal-Wallis test was used.

RESULTS

There was a higher proportion of men (70.9%), with a mean age of 53.3 years, who had hepatitis C (43.7%). The indication for the procedure was hepatocellular carcinoma (34%). The most frequent complications included pulmonary (26.7%), graft-related complications such as rejection (21.1%), and viral infections (14.4%). In addition, infectious complications, such as pneumonia (45%) and septicemia (29%), occurred. The main causes of death were septic shock (15.6%) and multiple organ failure (21.9%). There was statistical significance between the recipient's age and the Model for End-Stage Liver Disease value at the time of transplantation for the development of complications.

CONCLUSIONS

The data from the present study provide important information about liver transplant. These data may enable the team to propose strategies for practice improvements, which will certainly offer better living conditions and transplant survival.