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Biliary complications after liver transplantation remain common. Resources for livers are limited, and these individuals are often ill, making nonoperative treatment and management attractive options. The endoscopic route for evaluation (endoscopic retrograde cholangiopancreatography) remains preferable, due to its safety profile, as opposed to the...
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Context 1
... rarely occur in the donor. Beyond problems related to general medical and surgical care, the most frequent complication is related to the leakage of bile from the cut edge ( Figure 3) or a bile duct. [15][16][17][18] It is possible that post-transplantation complications are underreported, particularly as the symptoms are vari- able. ...
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INTRODUCTION
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Citations
... Traditionally, percutaneous transhepatic biliary drainage (PTBD) with or without cholangioplasty has been the first-line therapy for biliary strictures in LT recipients with BE anastomosis whereas ERC has been advocated as the first line therapy for those with a conventional choledocho-choledochal anastomosis [3,4]. Data suggest that PTBD with balloon cholangioplasty is an effective strategy for the management of post-LT strictures [5,6]. ...
... It often requires the use of colonoscopes, enteroscopes, and specialized accessories [20,21]. This has led to a preferential utilization of PTBD as the primary modality of biliary intervention in these patients [4]. In one of the early studies on post-LT biliary complications published in 1994, Kuo et al. [3] reported their preference of ERC in patients with duct-to-duct anastomosis and PTBD in patients with a choledocho-jejunostomy. ...
Backgrounds/aims:
Data regarding outcomes of endoscopic retrograde cholangiography (ERC) in liver transplant (LT) recipients with biliary-enteric (BE) anastomosis are limited. We report outcomes of ERC and percutaneous transhepatic biliary drainage (PTBD) as first-line therapies in LT recipients with BE anastomosis.
Methods:
All LT recipients with Roux-BE anastomosis from 2001 to 2020 were divided into ERC and PTBD subgroups. Technical success was defined as the ability to cannulate the bile duct. Clinical success was defined as the ability to perform cholangiography and therapeutic interventions.
Results:
A total of 36 LT recipients (25 males, age 53.5 ± 13 years) with Roux-BE anastomosis who underwent biliary intervention were identified. The most common indications for a BE anastomosis were primary sclerosing cholangitis (n = 14) and duct size mismatch (n = 10). Among the 29 patients who initially underwent ERC, technical success and clinical success were achieved in 24 (82.8%) and 22 (75.9%) patients, respectively. The initial endoscope used for the ERC was a single balloon enteroscope in 16 patients, a double balloon enteroscope in 7 patients, a pediatric colonoscope in 5 patients, and a conventional reusable duodenoscope in 1 patient. Among the 7 patients who underwent PTBD as the initial therapy, six (85.7%) achieved technical and clinical success (p = 0.57).
Conclusions:
In LT patients with Roux-BE anastomosis requiring biliary intervention, ERC with a balloon-assisted enteroscope is safe with a success rate comparable to PTBD. Both ERC and PTBD can be considered as first-line therapies for LT recipients with a BE anastomosis.
... This aetiology is more common with LDLT. 17 Clinicians should suspect bile leak in any post-LT patient with worsening liver enzymes of unclear aetiology, which should prompt abdominal imaging or bilious fluid noted from peritoneal drains. 9 Bile leaks can result in abdominal pain, and fever if infected; but in many instances, leaks can occur without any of these typical symptoms. ...
... 37 More frequently, percutaneous drainage performed by interventional radiology is used in this setting. 17 36 The evidence supporting ursodeoxycholic acid for BDFDs is limited and inconsistent. ...
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
... There is a significant volume of research examining the best way to manage biliary complications after transplantation [19][20][21] but robust studies describing how best to prevent them are lacking. Many clinicians feel the development of a biliary complication is a multifactorial problem and may be indicative of a poor graft or poor preservation. ...
Background:
Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC.
Methods:
The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes.
Results:
Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P < 0·001) and increased chance for readmission within the first year (56 versus 32 per cent; P < 0·001). Patients with EABC had decreased estimated 5-year graft survival of 75·1 versus 84·5 per cent in those without EABC, and decreased 5-year patient survival of 76·9 versus 83·3 per cent; both P < 0.001. Adjusted Cox regression revealed that EABCs have a significant and independent impact on graft survival (leak hazard ratio (HR) 1·344, P = 0·015; stricture HR 1·513, P = 0·002; leak plus stricture HR 1·526, P = 0·036) and patient survival (leak HR 1·215, P = 0·136, stricture HR 1·526, P = 0·001; leak plus stricture HR 1·509; P = 0·043). On adjusted logistic regression, risk factors for EABC included donation after circulatory death grafts, graft aberrant arterial anatomy, biliary anastomosis type, vascular anastomosis time and recipient model of end-stage liver disease.
Conclusion:
EABCs prolong hospital stay, increase readmission rates and are independent risk factors for graft loss and increased mortality. This study has identified factors that increase the likelihood of EABC occurrence; research into interventions to prevent EABCs in these at-risk groups is vital to improve liver transplantation outcomes.
... NAS are strongly associated with hepatic artery thrombosis, ischemic damage to the duct or because of immunological factors (32,33). NAS can occur in both the extra-or intrahepatic ducts and average time to development is usually 3 to 6 month (32,34,36). ...
... Treatment strategies for BC are based on the type and severity of the complication and the biliary reconstruction technique applied at the time of LT. A MI management, PTC or ERC, is currently the first-line approach (1,4,34,43). These procedures should be considered complementary techniques, and success can be achieved in 70%-90% (1). ...
... The remainder of cases require surgical revision, especially in early leaks or when the patients are unstable. Bilomas are usually treated by insertion of a percutaneous catheter with high rates of success (32,34). Second line treatment is PTD. ...
... [5][6][7] However, the number of kidney transplant patients with a failed allograft from 1988 to 2010 in the United States has substantially increased 8 and complications following liver transplantation are common, with approximately 22% of patients in the United States developing biliary complications post-liver transplantation. 9 In addition, 20-year graft survival rates for both kidney and liver transplant patients in Europe are poor (<22%). 10,11 Due to the increasing size of transplant waiting lists (United Kingdom patients awaiting a liver transplant have tripled from 1999 to 2009) and shortage of grafts available, 12,13 maximizing the long-term survival and function of each transplant by minimizing or controlling the foremost causes of graft loss is a clinical priority. ...
Background:
Kidney and liver transplantation is the standard of care for end-stage renal or liver disease. However, long-term survival of kidney and liver grafts remain suboptimal. Our study aimed to understand the healthcare resources utilized and their associated costs in the years before graft failure.
Methods:
Two noninterventional, retrospective, observational studies were conducted in cohorts of kidney or liver transplant patients. Once identified, patients were followed using the UK Clinical Practice Research Datalink linked to the Hospital Episode Statistics databases from the date of transplantation to the date of the first graft failure. Total healthcare costs in the year before graft failure (primary endpoint) and during years 2-5 before graft failure (secondary endpoint) were collected.
Results:
A total of 269 kidney and 81 liver transplant patients were analyzed. The mean total costs were highest for all resource components in the last year before graft failure, except for mean costs of immunosuppressive therapy per patient, which decreased slightly by index date (ie, graft failure). The mean total healthcare costs in the last year before graft failure were £8115 for kidney and £9988 for liver transplant patients and were significantly (P < 0.05) higher than years 2-5 before graft failure. Mean healthcare costs for years 2, 3, 4, and 5 before graft failure were £5925, £5575, £5469, and £5468, respectively, for kidney, and £6763, £7042, £6020, and £5651, respectively, for liver transplant patients.
Conclusions:
Total healthcare costs in the last year before graft failure are substantial and statistically significantly higher than years 2-5 before graft failure, in both kidney and liver transplant patients. Our findings show the economic burden placed on healthcare services in the years before graft failure.
... There is significant evidence regarding the safety and efficacy of ERC in the management of post-transplant BLs in the last three decades, and it has become the standard care for management of such patients. [5][6][7] The primary endoscopic treatment strategy includes the placement of a trans-papillary biliary endoprosthesis that diverts the flow of bile preferentially into the duodenum, or externally. The endoprosthesis that have been used include plastic stents and nasobiliary tubes (NBTs). ...
Background/Aims
Bile leak is one of the most common complications of liver transplantation. The treatment options for bile leaks include conservative management, surgical re-intervention, percutaneous drainage and endoscopic drainage. We aimed to perform a systematic review to identify the efficacy of endoscopic treatment in the resolution of post-transplant bile leaks.
Methods
Two independent reviewers performed systematic literature search in PubMed, ISI Web of Science, grey literature and relevant references in May 2017. Human studies in English with documented post-liver transplant bile leaks were included.
Results
Thirty-four studies were included in the final analysis. The pooled efficacy of biliary stents for the resolution of post-transplant bile leaks was 82.43% compared with 87.15% efficacy of nasobiliary tubes. The efficacy of biliary stents was lower for anastomotic leaks (69.23%) compared to T-tube (90.9%) or cut-surface/ cystic duct stump related leaks (92.8%). Similarly, the efficacy of nasobiliary tube was also lower for anastomotic leaks (58.33%) compared to T-tube or cut-surface related leaks (100%).
Conclusions
In this systematic review, the overall efficacy was 82.43% in biliary stent group, and 87.15% in nasobiliary tube group. Both biliary stent and nasobiliary tube were more effective in managing non-anastomotic leaks compared to anastomotic leaks.
... Fluid and electrolyte disturbances, deficiency of fat soluble vitamins, protein/calorie malnutrition and even coagulopathy are the secondary consequences of high output EBF persisting for >3 weeks. Bile mixed with some sweetened drink may be reefed do obviate such complications related to EBF [11]. ...
... Other factors associated with biliary complications are acute graft rejection, immunosuppression, ABO incompatibility, cytomegalovirus infection, and technical factors [20][21][22]. Acute rejection causes reduced blood flow and increased hepatic volume, leading to predisposition to thrombosis. Immunosuppression impairs the inflammatory response necessary for healing and formation of firm and mature fibrotic tissue [23]. ...
Introduction: Biliary complications after hepatic transplantation have a variable incidence of 10 to 25% among all complications after hepatic transplantation and mortality reported up to 10%, have an important impact on the patient’s quality of life, since it implies the need for hospitalizations and multiple interventions for treatment. They are more frequent in the first year after transplantation, with progressive reduction of the frequency after 1 year.Objective: To evaluate the risk factors of greater impact in the development of bile duct stenosis in patients after liver transplantation.Methods: One hundred and eighty-eight charts of liver transplant patients were retrospectively evaluated. Inclusion criteria: liver transplanted patients from 2011 to December 2017. Exclusion criteria: deaths that occurred between the first month after transplantation, incomplete medical records and most cases of retransplants, except for patients who retransplanted as a consequence of their own complication.Results: Biliary complications were present in 14% (N=26) of the patients. Of these, 52% (N=21) presented stenosis of the biliary tract, followed by other complications such as cholangitis (20%), fistula calculation (10%), bilioma (3%). Among patients with bile duct stenosis, 19% (N=4) presented non-anastomotic stenosis and 81% (N=17) anastomotic stenosis. The cause of hepatopathy was in 42% of patients (N=9) ethanolic, followed by other causes such as: viral hepatitis, cryptogenic, autoimmune, fulminant hepatitis, NASH, CEP, glycogenosis and 1 case of secondary retransplantation to the bile complication itself.Conclusion: The incidence of biliary complications is comparable with the incidence reported in other institutions. The low incidence of bile duct stenosis reduces the power of the study to identify the most impacting risk factors.
... The main post-transplant complications seen after RESLG procedures were bile leaks and HAT, followed by the bile duct strictures [19,20]. Those results are in agreement with the manuscripts published by Doyle et al, who reported 2 of 23 RESLG recipients with bile leaks, which was comparable to WLG patients [21]. ...
Background:
Despite the progressively increasing gap between patients waiting for liver transplant under the Model for End-stage Liver Disease MELD system and the availability of deceased donor organs, the use of right extended split liver grafts (RESLG) has not been accepted by all centers. In this study, we compared the results obtained using RESLG vs a group of matched whole liver graft (WLG) recipients at a single center in Latin America.
Methods:
A single-center retrospective review performed between August 2009 and December 2015.
Results:
Fifteen RESLGs were implanted to recipients between 13 and 70 years of age; 80% were performed ex situ. The "biological MELD" score for the RESLG group was 17.5 ± 5.6, and it was 12.8 ± 4.5 for the WLG group (P = .01). Cold ischemia times were significantly longer in RESLG recipients compared with WLG recipients (528 minutes vs 420 minutes; P < .01). No significant differences were found in biliary (leak or strictures P = .40) and arterial complications (hepatic artery thrombosis, P = .06). RESLG patients benefited from a considerable reduction on their waiting time in list. The 1-, 3-, and 5-year patient survival rates were 93%, 93%, and 93% respectively, for RESLG recipients vs 100%, 95.7%, and 86.1%, respectively, for WLG recipients. The 1-, 3-, and 5-year graft survival rates were 79.4%, 79.4%, and 79.4% for RESLG recipients and 89.7%, 89.7%, and 89.7% for WLG recipients, respectively. No statistical differences were observed.
Conclusion:
RESLG allows expeditious transplantation for low MELD recipients. Its use should be expanded in Latin America and worldwide as a valid alternative to increase the donor pool as it has been used in other regions.
... However, nowadays, they are rarely employed duct-to-duct anastomosis, which is the preferred anastomosis technique and thus, bile leaks most frequently occur at cut sites, anastomosis site or cystic duct stump. 33,34 In our patients, the observed bile leak sources in Gd-EOB-DTPA-enhanced MRC were at the cut surface of the transplanted liver (n 5 2) and at the duct-to-duct anastomosis site (n 5 3). In both cases with bile leak source at the cut edge of the liver, T-tube cholangiogram and ERCP revealed no positive diagnosis. ...
Objective:
To assess the diagnostic value of dynamic T1-weighted (T1w) gadolinium ethoxybenzyl diethylentriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced MR Cholangiography (MRC) for the detection of active bile leaks.
Methods:
A total of 28 patients with suspected biliary leakage who underwent routine T2w-MRC and T1w-GD-EOB-DTPA-enhanced MRC at our institution from February 2013 to June 2016 were included in this study. The image sets were retrospectively analysed in consensus by 3 radiologists. T1w-Gd-EOB-DTPA-enhanced MRC findings were correlated with clinical data, follow-up examinations and findings of invasive-/surgical procedures. Patients with positive bile leak findings in Gd-EOB-DTPA-enhanced MRC were divided in hepatobiliary phase (HBP) (20-30 min) and delayed phase (DP) (60-390 min) group according to elapsed time between Gd-EOB-DTPA injection and initial bile leak findings in MRC images. These groups were compared in terms of laboratory test results (total bilirubin, liver enzymes) and presence of bile duct dilatation in T2w-MRC images.
Results:
In each patient visualization of bile ducts was sufficient in the HBP. The accuracy, sensitivity and specificity of dynamic Gd-EOB-DTPA-enhanced T1w-MRC in detection of biliary leaks were 92.9%, 90.5%, and 100%; respectively (P<0.001). Nineteen of 28 patients had bile leak findings in T1w-Gd-EOB-DTPA-enhanced MRC (HBP group: N = 7(36.8%), DP group: N = 12 (63.2%)). There was no statistically significant difference in terms of laboratory test results and presence of bile duct dilatation between HBP and DP group (P>0.05). Three patients, each of them in DP group, showed normal laboratory test results and bile duct diameters.
Conclusion:
Dynamic T1w Gd-EOB-DTPA-enhanced MRC is a useful non-invasive diagnostic tool to detect bile leak. Advances in knowledge: Prolonged delayed phase imaging may be required for bile leak detection even if visualization of biliary tree is sufficient in HBP and liver function tests, total bilirubin levels and bile duct diameters are normal.
