Endoscopic treatment for biliary stricture after adult living donor liver transplantation

Abstract

Endoscopic intervention is considered to be the primary treatment for biliary stricture after adult living donor liver transplantation (LDLT) with duct-to-duct biliary reconstruction. The aim of this study was to investigate the risk factors of biliary stricture and the clinical outcomes and predictors of failure after endoscopic retrograde cholangiography with balloon dilation (ERC-D). We enrolled 239 adult patients who underwent LDLT between 2000 and 2006. Sixty-eight patients (28.4%) developed biliary stricture. Twenty-nine patients with anastomotic biliary stricture were treated with ERC-D and stenting. We retrospectively analyzed the risk factors of biliary stricture and the clinical outcomes of ERC-D. The median follow-up period was 31 months. The risk factors of biliary stricture on multiple logistic regression analysis were a graft with multiple bile ducts, a previous history of bile leakage, and hepatic artery stenosis. The overall success rate of ERC-D was 64.5%. On simple logistic regression, the failure of primary ERC-D was associated with late biliary stricture over 24 weeks and more than 8 weeks between a 2-fold increase of serum alkaline phosphatase from the stable level and ERC-D, even though these were not statistically significant on multiple logistic regression. The relapse rate of stricture after successful ERC-D was 30%. The duration of stenting in the recurrence group was shorter than that in the nonrecurrence group (11.8 Ϯ 5.03 versus 29.0 Ϯ 11.6 weeks, P ϭ 0.004). ERC-D is effective for the management of anastomotic biliary stricture. However, the failure rate of primary ERC-D may be high in patients with late onset and delayed diagnosis of biliary stricture. The recurrence seems to occur frequently in patients with a short duration of stenting. Liver Transpl 15:369-380, 2009.

Is Duct to Duct biliary Anastomosis the Rule in Orthotopic Liver Transplantation?

“…Of the four bile leaks in our study, all except one underwent ERCP and stenting. Surgery is reserved for endoscopic failure or when bile leak causes generalized peritonitis [14]. None of our patients needed urgent laparotomy.…”

New Strategy in Cases of Failed Endoscopic Intervention of Biliary Strictures after Living Donor Liver Transplantation: Percutaneous Transhepatic Biliary Stent Insertion and Subsequent Endoscopic Treatment

“…However, results of endoscopic maneuvers are disappointing for biliary strictures after LDLT, and the success rate is 60∼75% for anastomotic strictures (1,4,6,7,11-15). The causes for the low success rates of endoscopic intervention therapy are the presence of multiple ductal anastomoses, smaller size, peripheral location, and a pouched shape of biliary anastomosis (3,6,14,16). In right hemi-liver-LDLT patients with duct-to-duct biliary reconstruction, most anastomotic biliary strictures develop in a fork-shaped or trident-shaped fashion even if the biliary system had been reconstructed in a single duct-to-duct fashion (15).…”

“…The success rates of endoscopic treatment for anastomotic strictures in LDLT are significantly lower than in DDLT at 60∼75% (3)(4)(5)(6). In failed cases, a percutaneous approach can be attempted.…”

Interventional radiology for post-transplant anastomotic complications

“…Some studies have suggested that biliary stricture occurs more frequently in post-LDLT patients than in deceased liver transplantation because of the small diameter of the anastomotic portion of the bile duct, anatomical diversity of the bile ducts, or the complicated nature of the surgical procedure [9,10,18] . There are two strategies for treating anastomotic strictures: via the endoscopic retrograde approach [19] or the percutaneous transhepatic approach [20] .…”

“…Moreover, biliary complications remain common after LDLT, and some studies suggested that biliary stricture at the anastomotic site occurs more frequently in post-LDLT patients than in deceased liver transplantation. This is because of the small diameter of the anastomotic portion of the bile duct, anatomical diversity of the bile ducts or the complicated nature of the surgical procedure [9,10] .…”