Figure 4 - uploaded by Juan C. Camacho
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Anastomotic stricture. (a) Percutaneous transhepatic cholangiogram shows focal narrowing at the choledochojejunostomy site (arrow) and suprastenotic dilatation. (b) Maximum intensity projection (MIP) image from MRCP shows an anastomotic stricture (arrow) and severe suprastenotic dilatation.
Source publication
Orthotopic liver transplantation is becoming an increasingly routine procedure for a variety of benign and malignant diseases of the liver and biliary system. Continued improvements in surgical techniques and post-transplantation immunosuppression regimens have resulted in better graft and patient survival. A number of potentially treatable nonvasc...
Citations
... A common complication after surgery is the occurrence of intra-abdominal fluid collections [2]. These primarily consist of hematomas, seromas, bilomas, or lymphoceles [3]. They can become superinfected and can cause substantial morbidity and mortality [4]. ...
... This comprised the majority of abscesses (n = 27/44, 61.4%), bilomas (21/37, 56.8%), seromas (n = 6/8, 75.0%) and hematomas (n = 10/11, 90.9%). From the ninth year onwards, 1 : median (25%-; 75%-quartiles) (range), 2 : mean value ± standard deviation (range), 3 : numbers (percentage). A total of 64/116 (55.2%) collections were intrahepatic. ...
Purpose: Evaluation of the effectiveness of CT-guided drainage (CTD) placement in managing symptomatic postoperative fluid collections in liver transplant patients. The assessment included technical success, clinical outcomes, and the occurrence of complications during the peri-interventional period. Methods: Analysis spanned the years 2005 to 2020 and involved 91 drain placement sessions in 50 patients using percutaneous transabdominal or transhepatic access. Criteria for technical success (TS) included (a) achieving adequate drainage of the fluid collection and (b) the absence of peri-interventional complications necessitating minor or prolonged hospitalization. Clinical success (CS) was characterized by (a) a reduction or normalization of inflammatory blood parameters within 30 days after CTD placement and (b) the absence of a need for surgical revision within 60 days after the intervention. Inflammatory markers in terms of C-reactive protein (CRP), leukocyte count and interleukin-6, were evaluated. The dose length product (DLP) for various intervention steps was calculated. Results: The TS rate was 93.4%. CS rates were 64.3% for CRP, 77.8% for leukocytes, and 54.5% for interleukin-6. Median time until successful decrease was 5.0 days for CRP and 3.0 days for leukocytes and interleukin-6. Surgical revision was not necessary in 94.0% of the cases. During the second half of the observation period, there was a trend (p = 0.328) towards a lower DLP for the entire intervention procedure (median: years 2013 to 2020: 623.0 mGy·cm vs. years 2005 to 2012: 811.5 mGy·cm). DLP for the CT fluoroscopy component was significantly (p = 0.001) lower in the later period (median: years 2013 to 2020: 31.0 mGy·cm vs. years 2005 to 2012: 80.5 mGy·cm). Conclusions: The TS rate of CT-guided drainage (CTD) placement was notably high. The CS rate ranged from fair to good. The reduction in radiation exposure over time can be attributed to advancements in CT technology and the growing expertise of interventional radiologists.
... Systemic infections are prevalent in the early postoperative period because recipients are on immunosuppressive therapy to prevent graft rejection [68]. Although immunosuppression is offered during this time, because of the short duration of therapy, opportunistic infections do not declare manifestations within the initial month. ...
... Hepatic abscesses occur in 1-3% of patients undergoing liver transplantation. Variable clinical manifestations include fever, chills, fatigue, and abdominal pain [68]. Abscess as a manifestation of infection can occur in the following scenarios [36]: (1) infection of hepatic parenchymal infarction caused by hepatic artery thrombosis, significant stenosis, or biliary necrosis; (2) superimposed infection of an existing hematoma, biloma, or seroma; and (3) as a manifestation of systemic bacteremia. ...
... Abscess formation in these fluid collections shows imaging features as discussed earlier [68,70]. ...
Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.
Graphical abstract
... Rights reserved. complications include peri-transplant fluid collections (e.g., seroma, biloma, urinoma), perfusion defects, infection and other focal parenchymal lesions, such as secondary transplant or native organs malignancy [3][4][5]. Complications most frequently occur during the early postoperative period but are not uncommon up to several months or years after transplantation [1, 4, 6-11]. ...
... In a full-liver graft obtained from a deceased donor, vascular reconstruction of the graft hepatic artery and portal vein is performed with end-to-end anastomosis with the respective recipient vessels [4]. If the recipient hepatic artery is too small or too short to establish sufficient arterial inflow, then alternative arterial connections are created. ...
... The donor suprahepatic IVC is connected with an end-to-end anastomosis to the recipient hepatic veins confluence on the anterior or anterolateral surface of the recipient IVC. The donor infrahepatic IVC is ligated and becomes a blind-ending segment [4,31,34,35] ...
Ultrasound (US) is the first-line imaging tool for evaluating liver and kidney transplants during and after the surgical procedures. In most patients after organ transplantation, gray-scale US coupled with color/power and spectral Doppler techniques is used to evaluate the transplant organs, assess the patency of vascular structures, and identify potential complications. In technically difficult or inconclusive cases, however, contrast-enhanced ultrasound (CEUS) can provide prompt and accurate diagnostic information that is essential for management decisions. CEUS is indicated to evaluate for vascular complications including vascular stenosis or thrombosis, active bleeding, pseudoaneurysms and arteriovenous fistulas. Parenchymal indications for CEUS include evaluation for perfusion defects and focal inflammatory and non-inflammatory lesions. When transplant rejection is suspected, CEUS can assist with prompt intervention by excluding potential underlying causes for organ dysfunction. Intracavitary CEUS applications can evaluate the biliary tract of a liver transplant (e.g., for biliary strictures, bile leak or intraductal stones) or the urinary tract of a renal transplant (e.g., for urinary obstruction, urine leak or vesicoureteral reflux) as well as the position and patency of hepatic, biliary and renal drains and catheters. The aim of this review is to present current experience regarding the use of CEUS to evaluate liver and renal transplants, focusing on the examination technique and interpretation of the main imaging findings, predominantly those related to vascular complications.
... La alerta de "respuesta simpática" corresponde a la conjunción de una tendencia ascendente de la frecuencia cardíaca y presión arterial, y una tendencia descendente en la amplitud de la onda de pulso pletismográfica [18]. Defresne y cols., analizaron datos recopilados de un estudio publicado anteriormente de pacientes sometidos a anestesia general, donde evaluaron la aparición de cambios relevantes y sostenidos en el SPI (superior a 60 durante al menos 20 segundos), para determinar si esos episodios habrían generado alertas de EBMi y si fueron precedidos por cambios fisiológicos indicativos de un tono simpático aumentado [20]. Ellos observaron un número menor de alertas EBMi versus episodios SPI sobre 60. ...
... Jiménez et al. [19] shows how the ocular US is a useful tool in patients with trauma brain injury in emergency service and intensive care, highlighting that the importance of bedside US as a helpful, noninvasive and fast procedure that comes as an alternative to assess patients with intracranial pressure elevated. Also, in the field of transplantation is important the use of US as it was shown by the study made in Colombia by Camacho et al. [20]. This author mentions that some potentially treatable nonvascular complications of liver transplantation are visible at imaging techniques such as US, leading to accurate diagnosis and enabling patients to benefit from treatment options. ...
... This author mentions that some potentially treatable nonvascular complications of liver transplantation are visible at imaging techniques such as US, leading to accurate diagnosis and enabling patients to benefit from treatment options. This tool is commonly the first performed in order to identify the cause of abnormal liver function [20]. ...
... The usual presentation is an increased amount of post-operative ascites (Fig. 10b) or a newly formed fluid collection. However, with the exception of utilizing a hepatobiliary agent, routine cross-sectional imaging is unable to differentiate among different causes of postoperative fluid collections [16] which include seroma, biloma, hematoma, and abscess. Cholescintigraphy thus plays an important role in the diagnosis of bile leak as it provides functional imaging ( Fig. 10c and d), although potential pitfalls such as mistaking the blind-ending loop of the Roux limbs as biloma exist [17]. ...
... If the transplant recipient had a known or occult hepatocellular carcinoma (HCC), recurrent tumor may occur. This may be seen in 8-26% of patients after liver transplantation [16]. The most common site of recurrence is the lung, followed by the hepatic graft and then by regional or distant lymph nodes [23]. ...
... Focal anastomotic strictures respond better to treatment than multifocal strictures [26]. Additionally, ischemic strictures from hepatic arterial compromise are usually irreversible [16]. Diffuse bile leak requires stenting, while localized bile leak (biloma) is treated with percutaneous drainage. ...
Liver transplantation is one of the most commonly performed surgical procedures for the treatment of end-stage liver disease and hepatocellular carcinoma. Post-transplantation complications include vascular, nonvascular, and biliary. Common imaging techniques used to evaluate the hepatic graft are ultrasonography (US), CT, MR imaging, cholangiography, angiography, and scintigraphy. The purposes of this pictorial review are to review imaging findings of complications of liver transplantation and provide a framework for early detection of post-surgical complications.
... After liver resections, intraabdominal fluid collections frequently occur [1]. The most frequent pathologies are seroma, lymphocele, hematoma or biloma [2]. If infected, abscess formations can cause substantial morbidity and mortality [3]. ...
Purpose:
To retrospectively evaluate the technical and clinical outcome of patients with symptomatic postoperative fluid collections following liver resection treated with CT-guided drainage (CTD).
Methods:
143 suitable patients were examined between 2004 and 2017. Technical success was defined as (a) sufficient drainage of the fluid collection and (b) the non-occurrence of peri-interventional complications requiring surgical treatment with minor or prolonged hospitalization. Clinical success was defined as (a) decreasing or normalization of specific blood parameters within 30 days after intervention and (b) no surgical revision in addition to intervention required. C-reactive protein (CRP), leukocytes and Total Serum Bilirubin (TSB) were assessed. Dose length product (DLP) for the intervention parts was determined.
Results:
Technical success was achieved in 99.5% of 189 performed interventions. Clinical success was reached in 74% for CRP, in 86.7% for Leukocytes and in 62.1% for TSB. The median of successful decrease was 6.0 days for CRP, 3.5 days for Leukocytes and 5.5 days for TSB. In 90.2%, no surgical revision was necessary. Total DLP was significantly lower in the second half of the observation period (median 536.0 mGy*cm between years 2011 and 2017 vs. median 745.5 mGy*cm between years 2004 and 2010).
Conclusions:
Technical success rate of CTD was very high, and clinical success rate was fair to good. Reduction of the radiation dose reflects developments of CT technology and increased experience of the interventional radiologists.
... Билиарные осложнения, встречающиеся в 14-18 % случаев, нередко на начальном этапе протекают бессимптомно [37]. ...
... Факторами риска возврата этих заболеваний является общее ожирение и наличие диабета. При УЗИ эхографическая картина повышения эхогенности печеночной паренхимы сопровождается значительным дорзальным ослаблением эхосигнала [37]. ...
Liver transplantation is rightly considered the only radical treatment for terminal chronic liver diseases and patients with acute liver failure. However, despite the accumulated experience in the management of patients in this group, the level of complications development remains at a fairly high level. The success of the correction of emerging pathological conditions largely depends on the timing of their diagnosis. Since complications developing after liver transplantation most often do not have specific clinical and biochemical manifestations, the use of imaging research methods plays a key role in assessing the state of the transplanted organ at all stages of the postoperative period. Among all instrumental methods, ultrasound examination using Doppler techniques, carried out hourly directly in the intensive care unit, with an accuracy of 97 % and a specificity of up to 100 %, makes it possible to detect vascular post-transplant complications as soon as possible. Their timely correction avoids the loss of the graft. The use of dynamic observation contributes to differential diagnosis in identifying non-vascular complications at different stages of the postoperative period. The use of modern techniques greatly expands the possibilities of echography. Thus, the use of contrast enhancement not only shortens the study time, but also increases the sensitivity of Dopplerography in assessing the patency of the vascular bed, especially in patients with decreased central hemodynamics. The use of ARFI-elastography techniques in patients in the late postoperative period makes it possible to objectively assess the severity of hepatic graft fibrosis.
... Perihepatic collections may represent simple postoperative seromas or hematomas or alternatively more concerning collections like bilomas or abscesses. Bile leak is best confirmed with hepatobiliary scintigraphy or contrast-enhanced MRI utilizing a hepatobiliary contrast agent, the latter of which offers high spatial resolution to identify the exact site of bile leak [38]. Biliary ductal dilatation should prompt further evaluation of biliary anastomotic stricture and poor hepatic arterial flow. ...
... Pneumobilia is common in the post-transplant period. Acute graft rejection has no reliable ultrasound imaging findings [38]. ...
Purpose of Review
Right upper quadrant ultrasound is often the first step in the evaluation of hepatobiliary disease. An in-depth knowledge of the ultrasound findings of common and important diseases, as well as the limitations of and new advances in ultrasound technology, is key to helping patients and referring providers reach diagnostic and management decisions.
Recent Findings
The utility of contrast-enhanced ultrasound is expanding, shear wave elastography is emerging as a sophisticated quantitative measure of fibrosis, and the new US LI-RADS reporting standard is changing surveillance practices for patients with cirrhosis.
Summary
This article will provide a review of hepatobiliary ultrasound interpretation with an emphasis on diagnostic accuracy and new techniques.
... With a combination of these tools, many patients can be spared the morbidity and potential mortality associated with repeat operation or retransplantation. [15,16,17,9] (See the images below of transplantation complications.) ...
