Role of endoscopy in the conservative management of biliary complications after deceased donor liver transplantation

Abstract

The clinical outcome of patients receiving liver trans plantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these con ditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications (mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasoundguided biliary access in patients with Roux enY choledochojejunostomy or extracorporeal shock wave lithotripsy for difficult stones. Author contributions: Lisotti A and Fusaroli P wrote the paper; Caletti G revised the final draft of the manuscript for important intellectual content.Conflictofinterest statement: All Authors declare no conflict of interest for this study and for the preparation of this manuscript.OpenAccess: This article is an openaccess article which was selected by an inhouse editor and fully peerreviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/ licenses/bync/4.0/ Role of endoscopy in the conservative management of biliary complications after deceased donor liver transplantation scopic knowledge and expertise, the interventional management of these conditions is constantly evolving toward a conservative approach. In this manuscript are summarized current evidences regarding conservative approaches to biliary complication, with an overview on future management and research areas.Lisotti A, Fusaroli P, Caletti G. Role of endoscopy in the con servative management of biliary complications after deceased donor liver transplantation.

Efficacy of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Biliary Complications following Liver Transplant: 10 Years of a Single-Centre Experience

“…Several sessions of ERCP with dilation and stent are frequently required [3] . The number of stents and sessions are not fully defined; however, recent literature suggests exchanging plastic stents every 3 months for the first 9-12 months, placing larger ones or multiple stents, until the resolution of the stricture [4] . Efficacy in this study was lower than that described in most papers, with 40% of all diagnosed AS cases being resolved, although there is one study with similar results [10] .…”

“…Several papers report ERCP outcomes in the treatment of post-LT patients, with variable percentages of efficacy in different series of patients [1,9] . Regardless of the reported outcomes, we consider that the knowledge of the experience of each centre is also important, since local expertise and availability are involved in treatment decisions [4] .…”

“…Regarding AS, balloon dilation of the stricture is usually performed followed by placement of plastic biliary stents, leading to reported long-term response in 70-100% of patients [3,4] . Several sessions of ERCP with dilation and stent are frequently required [3] .…”

“…Multiple risk factors are identified, including recipient factors (age, advanced liver dysfunction), graft factors (prolonged cold and warm ischaemia time), surgical factors (living or deceased donor, surgical technique) and postoperative course factors (hepatic artery thrombosis), among others [1] . Despite the knowledge of the risk factors and the medical and surgical improvements, biliary complications are still considered one of the most important issues in the management of post-LT patients [1,4] .…”

“…In some cases, a combination of different techniques may be necessary [4] . Nowadays, ERCP is commonly the first treatment modality and is considered the gold standard for patients with duct-toduct anastomosis [1,5] .…”