Biliary complications occur after liver transplantation. These complications can be effectively and safely managed using endoscopic approaches and can prevent unnecessary and potentially morbid surgery.
Key points
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Management of biliary complications following liver transplant.
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Methods of stone extraction following liver transplant.
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Management of bile leak following liver transplant.
Introduction
Liver transplant has evolved as the treatment of choice for selected patients with end-stage liver disease, fulminant hepatic failure, and early stage hepatoma.
As the number of liver transplants has increased, so has the number of postoperative biliary complications requiring endoscopic treatment and management using endoscopic retrograde cholangiopancreatography (ERCP).
Biliary complications occur in up to 5%–25% of patients after liver transplant and can be categorized based on time of onset as early, occurring within 30 days of transplant, or late, occurring more than 30 days after transplant.
Although some postoperative biliary complications require surgical reintervention or percutaneous transhepatic cholangiography, the advancement of endoscopic techniques has made endoscopic therapy a safe and effective first approach to managing postoperative biliary complications in most patients.
This review focuses on the endoscopic diagnosis and treatment of post-liver transplant complications.
Introduction
Liver transplant has evolved as the treatment of choice for selected patients with end-stage liver disease, fulminant hepatic failure, and early stage hepatoma.
As the number of liver transplants has increased, so has the number of postoperative biliary complications requiring endoscopic treatment and management using endoscopic retrograde cholangiopancreatography (ERCP).
Biliary complications occur in up to 5%–25% of patients after liver transplant and can be categorized based on time of onset as early, occurring within 30 days of transplant, or late, occurring more than 30 days after transplant.
Although some postoperative biliary complications require surgical reintervention or percutaneous transhepatic cholangiography, the advancement of endoscopic techniques has made endoscopic therapy a safe and effective first approach to managing postoperative biliary complications in most patients.
This review focuses on the endoscopic diagnosis and treatment of post-liver transplant complications.
Types of biliary complications after transplant
Biliary complications after liver transplant commonly include biliary strictures, biliary leaks, choledocholithiasis, ischemic biliary injury, biliary cast syndrome, and sphincter of Oddi dysfunction (SOD). Hemobilia, mucocele formation, and bactobilia are less commonly seen.
Liver transplant anatomy
Liver transplant success and graft survival are highly dependent on adequate blood flow through both the hepatic artery and the portal vein. Any injury to the vasculature will result in ischemic injury and potential graft failure.
Knowledge of the biliary reconstruction after transplant is critical when considering posttransplant endoscopic therapy. Around 75%–88% of transplants are performed using a choledochocholedochostomy. The remaining 12%–25% of reconstructions are performed using a Roux-en-Y choledochojejunostomy. The benefits of creating a choledochocholedochostomy may include shorter operating times, use of a T-tube for access, maintenance of intestinal integrity and continuity, sterility of the biliary tract, and ease of access for ERCP. As recipient sphincter of Oddi function is preserved, the incidence of reflux-associated biliary injury and disease are less compared with Roux-en-Y choledochojejunostomy reconstruction. In cases in which the donor bile duct is inadequate to perform a choledochocholedochostomy, or when the native common bile duct is diseased or absent (eg, primary sclerosing cholangitis, biliary atresia), a Roux-en-Y choledochojejunostomy is performed.
Biliary tract complications after liver transplant depend on the type of biliary reconstruction, injury during donor harvesting, cold ischemic time, surgical technique, and the integrity of the portal vein and hepatic artery anastomosis.
Biliary strictures
One of the most common complications is a biliary stricture ( Fig. 1 ). Biliary strictures constitute around 40%–45% of posttransplant biliary complications. Strictures occur in around 5%–15% of deceased donor liver transplants and have been reported in up to 32% of live-donor–related transplants. Biliary strictures are divided into early biliary strictures, which are usually secondary to technical surgical complications, and late biliary strictures, which are usually secondary to ischemic injury.
Posttransplant biliary strictures can occur at the anastomotic site or at nonanastomotic regions. Anastomotic strictures are defined as strictures that occur at the site of the anastomosis between the donor and recipient bile duct. Anastomotic strictures usually develop within 1 year after transplant. These strictures appear as a narrowing at the area of the surgical choledochal anastomosis. Dilation of the donor ducts can be seen. The anastomotic narrowing can be related to postsurgical edema, usually seen in the first few weeks after transplant, or to fibrotic or ischemic injury at the anastomosis, which are persistent or delayed in onset. Care should be taken to avoid incorrectly diagnosing anastomotic strictures in patients who have mismatch in size between the donor and the recipient duct ( Fig. 2 ). In these cases, the donor or recipient duct is usually larger in size, but no narrowing or stricture is seen at the anastomosis.
Patients who present with anastomotic strictures usually require balloon dilation and biliary stent placement across the stricture. Conventionally, plastic biliary stents have been used with great success. Preliminary studies have reported on the effectiveness of off-label covered metal stents in managing anastomotic biliary strictures. A recent prospective study, including 54 patients, concluded that covered metal stents should not be used as a primary treatment modality for post–liver transplant biliary complications, although they may be effective in three-quarters of patients who do not respond to standard therapy. The authors concluded that stent migration remains a major complication.
For early strictures, which may be caused by postoperative edema, placing a single plastic stent without balloon dilation is preferred to avoid both injury to the anastomosis and unnecessary therapy in patients who might have a resolution to their obstruction in several weeks. For strictures that persist beyond the first month, the authors’ practice is to place a guide wire across the stricture and to dilate the stricture with a biliary balloon. The balloon diameter is sized to the smallest duct on either side of the stricture to prevent perforation. We then place plastic biliary stents, preferably of 10F. The number of stents placed usually depends on the size of the ducts, the diameter of the stricture, and the number of sessions the patient has undergone for stricture treatment. We tend to exchange the stents every 3 months, because these stents tend to occlude, and repeat procedures will allow assessment of response to stenting.
Treatment for most patients with biliary anastomotic strictures will require more than one endoscopic procedure over a period of 9–12 months. Fluoroscopic resolution of the stricture indicates successful therapy, but recurrences have been reported. The long-term success of biliary stenting has been reported at 65%–100%.
Patients who received a choledochojejunostomy also have strictures at the anastomosis between the donor bile duct and the recipient jejunum. These are usually treated with balloon dilation and placement of plastic biliary stents across the anastomosis. Endoscopic access to the anastomosis can be attempted but may be difficult and usually requires longer front-viewing instruments. Percutaneous approaches represent an acceptable alternative for these patients. Follow-up interval blood work is mandatory for all patients who have had endotherapy for anastomotic strictures to monitor for recurrence.
Patients may also have nonanastomotic strictures after liver transplant. These are usually related to hepatic ischemia from vascular injury or thrombosis or from recurrence of primary liver disease, as in primary sclerosing cholangitis. The incidence of nonanastomotic strictures has been reported to be as high as 25%.
Ischemic strictures tend to be diffuse, multiple, and intrahepatic ( Fig. 3 ). Nonanastomotic strictures are usually more difficult to treat, with studies reporting 50%–75% rate of response to biliary stenting. These strictures are usually treated with a combination of endoscopic dilation and stenting, in addition to percutaneous biliary stenting and draining of any fluid collections or abscesses that may form secondary to biliary obstruction. Ultimately, patients with severe ischemic strictures will require retransplantation.
Bile duct stones
Biliary lithiasis is common after liver transplant, and the stones are typically of the pigmented or mixed type ( Fig. 4 ). Bile duct stones develop in around 4%–30% of patients after transplant.
Related posts:
Endoscopic Advances in Biliary Disease
Pre-ERCP Imaging of the Bile Duct and Gallbladder
Endoscopic Evaluation of Bile Duct Strictures
Endoscopic Management of Benign Bile Duct Strictures
Endoscopic Approach to the Patient with Motility Disorders of the Bile Duct and Sphincter of Oddi
Endoscopic Ultrasonographic Access and Drainage of the Common Bile Duct
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