Nonanastomotic biliary strictures after liver transplantation, part 2: Management, outcome, and risk factors for disease progression

Abstract

Nonanastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT) are associated with high retransplant rates. The aim of the present study was to describe the treatment of and identify risk factors for radiological progression of bile duct abnormalities, recurrent cholangitis, biliary cirrhosis, and retransplantation in patients with NAS. We retrospectively studied 81 cases of NAS. Strictures were classified according to severity and location. Management of strictures was recorded. Possible prognostic factors for bacterial cholangitis, radiological progression of strictures, development of severe fibrosis/cirrhosis, graft survival, and patient survival were evaluated. Median follow-up after OLT was 7.9 years. NAS were most prevalent in the extrahepatic bile duct. Twenty-eight patients (35%) underwent some kind of interventional treatment, leading to a marked improvement in biochemistry. Progression of disease was noted in 68% of cases with radiological follow-up. Radiological progression was more prevalent in patients with early NAS and one or more episodes of bacterial cholangitis. Recurrent bacterial cholangitis (Ͼ3 episodes) was more prevalent in patients with a hepaticojejunostomy. Severe fibrosis or cirrhosis developed in 23 cases, especially in cases with biliary abnormalities in the periphery of the liver. Graft survival, but not patient survival, was influenced by the presence of NAS. Thirteen patients (16%) were retransplanted for NAS. In conclusion, especially patients with a hepaticojejunostomy, those with an early diagnosis of NAS, and those with NAS presenting at the level of the peripheral branches of the biliary tree, are at risk for progressive disease with severe outcome. Liver Transpl 13: [725][726][727][728][729][730][731][732] 2007. © 2007 AASLD.Received September 19, 2006; accepted February 15, 2007. Biliary complications are common after orthotopic liver transplantation (OLT). Biliary strictures and leakage of bile are most frequently encountered. Strictures are often referred to as anastomotic or nonanastomotic. Nonanastomotic biliary strictures (NAS) are generally considered to be the most troublesome type of biliary complications after liver transplantation, with a graft loss rate of up to 46% after 2 years. 1In a separate study, we have analyzed the radiological characteristics of NAS at the time of diagnosis and risk factors for the development of NAS.2 In this study, we were able to identify statistically significant differences in risk factors for the development of NAS depending on the time of initial presentation. In addition, large variations in anatomical localization and severity of NAS at the time of presentation were found, indicating that NAS is not a single disease but rather a group of biliary abnormalities with different pathogenesis. It is unAbbreviations: NAS, nonanastomotic biliary strictures; OLT, orthotopic liver transplantation; PTCD, percutaneous transhepatic cholangiodrainage; ERCP, endoscopic retrograde cholangiopancreaticography; RR, relati...

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…The viscosity of the UW solution hinders adequate perfusion of the small biliary arteries (57), and therefore doubles the risk for NAS (53,55,67). Moreover, arterial pressure perfusion significantly reduces NAS (55,68) but the effective pressure in the hepatic artery is difficult to control.…”

“…Up to 50% manifest within the first year (54). In two-third of cases progressive forms are observed (53), eventually leading to fibrosis and cirrhosis. Thus, 10-year graft failure rates of 20-50% are reported (53,66).…”

“…In two-third of cases progressive forms are observed (53), eventually leading to fibrosis and cirrhosis. Thus, 10-year graft failure rates of 20-50% are reported (53,66). The most unfavorable prognosis is seen in patients with manifestation <1 year after LT and/or recurrent episodes of cholangitis (53).…”

End‐ischemic machine perfusion reduces bile duct injury in donation after circulatory death rat donor livers independent of the machine perfusion temperature

“…Patients with NAS may suffer from recurrent jaundice and episodes of cholangitis, and retransplantation may be the only curative treatment. 1 The combination of ischemia and ischemia/ reperfusion (I/R) injury has been shown to be a major Additional supporting information may be found in the online version of this article. …”

Endoscopic Management of Biliary Complications After Liver Transplantation

“…The exact pathophysiological mechanism of ITBL is still unclear, however, several risk factors have been identified and strongly suggested a multifactorial origin. Ischemia-reperfusion and preservation injury related variables are well-described risk factors for non-anastomotic strictures including prolonged cold ischemia time (>12 hours) or warm ischemia time (>60 minutes) and variables related to the efficacy of preservation of the peribiliary plexus, such as viscosity and perfusion pressure of the preservation fluid (Guichelaar et al, 2003;Verdonk et al, 2007). Generally speaking, as suggested by Buis et al, risk factors for ITBL can be divided into three categories: ischemia-related injury to the biliary epithelium, immunologically mediated injury, and cytotoxic injury induced by bile salts .…”