Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions

Abstract

Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial

“…Two different magnetic resonance cholangiopancreatography sequences were used (Fast‐Recovery Fast Spin‐Echo [FRFSE] for the thin slab and the Single Shot Fast Spin Echo [SSFSE] for the thick slabs). Images were prospectively assessed by 2 radiologists in consensus to detect the presence of anastomotic biliary strictures, nonanastomotic strictures, intraluminal filling defects, and graft intrahepatic bile duct dilatation (indicated by a donor duct/recipient duct diameter of more than 1.15) Endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography. Ultrasonography or computed tomography (CT) was used to identify intrahepatic biliary radical dilatation. Biliary leak: Bile leakage for the purpose of the study was defined as a fluid with an increased bilirubin concentration in the abdominal drain or in the intra‐abdominal fluid on or after postoperative day 3, or as the need for radiologic intervention (ie, interventional drainage) because of biliary collections or relaparotomy resulting from bile peritonitis. Increased bilirubin concentration: Increased bilirubin concentration in the drain or intra‐abdominal fluid was defined as a bilirubin concentration greater than the serum bilirubin concentration measured at the same time. Bile leak grade: Grading was done following the International Study Group of Liver Surgery grade of postoperative bile leak: Grade A: bile leakage requiring no or little change in a patient’s clinical management. Grade B: bile leakage requiring a change in a patient’s clinical management (eg, additional diagnostic or interventional procedures) but manageable without relaparotomy, or a Grade A bile leakage lasting for >1 week Grade C: bile leakage causing a major clinical deterioration requiring relaparotomy. …”

Endoscopic Management of Biliary Complications after Liver Transplant

“…The standard therapeutic approach to bile leaks is through equalization of pressure in the bile duct and duodenum, allowing antegrade flow of bile into the duodenum. 22,28,29,[60][61][62][63][64][65][66][67][68] to 50% of cases within 24 hours 39 with the option of continuing for prolonged periods of time in remaining cases. ERCP is the first line for management of bile leaks.…”

One-step percutaneous transhepatic cholangioscopy combined with high-frequency needle-knife electrotomy in biliary strictures after liver transplantation

“…Orthotopic liver transplantation (OLT) is the main treatment for patients with end-stage liver disease of different etiologies, hepatocellular carcinoma(HCC), and acute liver failure [1,2] Biliary strictures represent the most frequent biliary complication after liver transplantation, accounting for approximately 40% of all biliary complications [3][4][5]. Endoscopic management is usually the rst-line treatment for biliary strictures complicating OLT and includes endoscopic retrograde cholangiography(ERC), biliary sphincterotomy and stent placement (with or without balloon dilatation) [6][7][8].…”