Biliary reconstruction during liver transplantation in patients with primary sclerosing cholangitis

Feith, MP; Klompmaker, I. J.; Maring, JK; Peeters, Pmjg; vandenBerg, AP; Dejong, K; Haagsma, EB; Gouw, A. S. H.; Slooff, Mjh

doi:10.1016/s0041-1345(96)00706-3

Cited by 21 publications

(20 citation statements)

References 4 publications

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“…Thus, the presence of an intact stomach and a long duodenojejunal limb makes access to the biliary‐enteric anastomosis more challenging 22. The rates of biliary complications in PSC patients after these 2 types of biliary reconstruction are highly variable 6, 23, 24. At our institution, the preferred method of biliary reconstruction in PSC patients is a terminolateral Roux‐en‐Y anastomosis.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

et al. 2007

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Endoscopic retrograde cholangiography (ERC) is a well-established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post-orthotopic liver transplantation (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux-en-Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux-en-Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end-stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable-stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time-consuming in OLT patients with Roux-en-Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery. Liver Transpl 13: [1168][1169][1170][1171][1172][1173] 2007. © 2007 AASLD.Received July 31, 2006; accepted March 16, 2007. Biliary complications after liver transplantation are an important cause of early and late postoperative morbidity and mortality. 1-5 The Roux-en-Y biliary reconstruction is considered the method of choice when liver transplantation is performed for intrinsic biliary disease and for patients with primary sclerosing cholangitis (PSC) because the reported rate of biliary complications is higher and the graft and patient survival worse in the latter patient population when choledochocholedochostomy is performed. 6 Percutaneous transhepatic cholangiography and surgical repair have been the primary management approaches for biliary complications after orthotopic liver transplantation (OLT) with Roux-en-Y reconstruction because the Roux-en-Y surgical bypass has routinely been considered to preclude endosc...

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Section: Discussionmentioning

confidence: 99%

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

et al. 2007

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“…The benefits include preservation of the sphincter of Oddi, less frequent colonization of the biliary tract, less operative time, fewer anastomoses, and the availability of endoscopic treatment as a back‐up option if strictures develop 96. Roux‐en‐Y hepaticojejunostomy is used only under specific conditions, including gross disparity between the sizes of the ducts and diseased or unavailable ducts, and for revision surgery 29, 97–100…”

Section: Discussionmentioning

confidence: 99%

Biliary strictures following liver transplantation: Past, present and preventive strategies

2008

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Biliary complications are still the major source of morbidity for liver transplant recipients. The reported incidence of biliary strictures is 5%-15% after deceased donor liver transplantation and 28%-32% after right-lobe live donor surgery. Presentation is usually within the first year, but the incidence is known to increase with longer follow-up. The anastomotic variant is due to technical factors, whereas the nonanastomotic form is due to immunological and ischemic events, which later may lead to graft loss. Endoscopic management of anastomotic strictures achieves a success rate of 70%-100%; it drops to 50%-75% for nonanastomotic strictures with a higher recurrence rate. Results of endoscopic maneuvers are disappointing for biliary strictures after live donor liver transplantation, and the success rate is 60%-75% for anastomotic strictures and 25%-33% for the nonanastomotic variant. Preventive strategies in the cadaveric donor include the standardization of the type of anastomosis and maintenance of a vascularized ductal stump. In right-lobe live donor livers, donor liver duct harvesting also involves a major risk. The concept of high hilar intrahepatic Glissonian dissection, dissecting the artery and the duct as one unit, use of microsurgical techniques for smaller ducts, use of ductoplasty, and flexibility in the performance of double ductal anastomosis are the critical components of the preventive strategies in the recipient. In the case of live donors, judicious use of intraoperative cholangiograms, minimal dissection of the hilar plate, and perpendicular transection of the duct constitute the underlying principals for obtaining a vascularized duct. Liver Transpl 14: 759-769, 2008.

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“…In our institution a duct‐to‐duct biliary anastomosis is preferred. In patients with primary sclerosing cholangitis, the duct‐to‐duct method is used if the recipient bile duct is suitable 23. In case of duct‐to‐duct as well as hepaticojejunostomy, as a rule a biliary drain is placed intraoperatively.…”

Section: Methodsmentioning

confidence: 99%

Anastomotic biliary strictures after liver transplantation: Causes and consequences

et al. 2006

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We retrospectively studied the prevalence, presentation, results of treatment, and graft and patient survival of grafts developing an anastomotic biliary stricture (AS) in 531 adult liver transplantations performed between 1979 and 2003. Clinical and laboratory information was obtained from the hospital files, and radiological studies were re-evaluated. Twenty-one possible risk factors for the development of AS (variables of donor, recipient, surgical procedure, and postoperative course) were analyzed in a univariate and stepwise multivariate model. Forty-seven grafts showed an anastomotic stricture: 42 in duct-toduct anastomoses, and 5 in hepaticojejunal Roux-en-Y anastomoses. The cumulative risk of AS after 1, 5, and 10 years was 6.6%, 10.6%, and 12.3% respectively. Postoperative bile leakage (P ϭ 0.001), a female donor/male recipient combination (P ϭ 0.010), and the era of transplantation (P ϭ 0.006) were independent risk factors for the development of an AS. In 47% of cases, additional (radiologically minor) nonanastomotic strictures were diagnosed. All patients were successfully treated by 1 or more treatment modalities. As primary treatment, endoscopic retrograde cholangiopancreaticography (ERCP) was successful in 24 of 36 (67%) cases and percutaneous transhepatic cholangiodrainage in 4 of 11 (36%). In the end 15 patients (32%) were operated, all with long-term success. AS presenting more than 6 months after transplantation needed more episodes of stenting by ERCP, and more stents per episode compared to those presenting within 6 months and recurred more often. Graft and patient survival were not impaired by AS. Liver Transpl 12:726-735, 2006.

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Biliary reconstruction during liver transplantation in patients with primary sclerosing cholangitis

Cited by 21 publications

References 4 publications

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

Biliary strictures following liver transplantation: Past, present and preventive strategies

Anastomotic biliary strictures after liver transplantation: Causes and consequences

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