Background
Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era
of organ shortage. However, biliary strictures are a common complication of LDLT,
and these strictures frequently require surgical revision after unsuccessful endoscopic
therapy. The optimal endoscopic treatment for anastomotic biliary strictures (ABSs)
after LDLT is undefined.
Objective
To determine the outcome of an aggressive endoscopic approach to ABSs after LDLT that
uses endoscopic dilation followed by maximal stent placement.
Design
A retrospective study.
Setting
A tertiary-care academic medical center.
Patients
Forty-one patients with a diagnosis of ABS.
Interventions
Endoscopic retrograde cholangiography with balloon dilation and maximal stenting.
Main Outcome Measurements
Stricture resolution, stricture recurrence, and complication rates.
Results
Of 110 LDLTs completed, a biliary stricture developed after transplantation in 41
(37.3%), which included 38 patients with duct-to-duct anastomosis. The median (interquartile
range [IQR]) follow-up time is 74.2 (2.5-120.8) months. Among them, 23 (60.5%) were
male, and 20 (52.6%) had bile leakage associated with ABSs. The median time (IQR)
to the development of an ABS after LDLT was 2.1 (1.2-4.1) months. Endoscopic retrograde
cholangiography was attempted as initial therapy in all patients: 32 were managed
entirely by endoscopic therapy, and 6 required initial percutaneous transhepatic cholangiography
(PTC) to cross the biliary stricture, with endoscopic therapy performed thereafter.
A median (IQR) of 4.0 (3.0-5.3) endoscopic interventions and 7.0 (4.0-10.3) stents
were required to resolve the stricture. The time from the first intervention to stricture
resolution was 5.3 (range 3.8-8.9) months. Biochemical markers including aspartate
transaminase (76 vs 39 U/L, P = .001), alanine transaminase (127.5 vs 45.5 U/L, P < .001), alkaline phosphatase (590 vs 260 IU/L, P < .001), and total bilirubin (2.57 vs 1.73 mg/dL, P = .017) significantly improved after intervention. Recurrent stricture was observed
after initial treatment in 8 (21%) patients. All recurrences were successfully re-treated
endoscopically. All patients have been managed without surgical revision or retransplantation,
resulting in 100% success by an intention-to-treat analysis.
Limitations
Retrospective study, small sample size.
Conclusions
In this series, aggressive endoscopy-based treatment with maximal stent placement
strategy allows 100% resolution of all duct-to-duct ABSs after LDLT without the need
for surgical intervention or retransplantation.
Abbreviations:
ABS (anastomotic biliary stricture), DDLT (deceased donor liver transplantation), ERC (endoscopic retrograde cholangiography), HIDA (hepatobiliary iminodiacetic acid), IQR (interquartile range), LDLT (living donor liver transplantation), PTC (percutaneous transhepatic cholangiography)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 12, 2012
Accepted:
August 30,
2012
Received:
February 23,
2012
Footnotes
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
See CME section; p. 108.
Identification
Copyright
© 2013 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
