Long-term Outcome of Endoscopic and Percutaneous Transhepatic Approaches for Biliary Complications in Liver Transplant Recipients

Abstract

BackgroundBiliary complications occur in 6% to 34% of liver transplant recipients, for which endoscopic retrograde cholangiopancreatography has become widely accepted as the first-line therapy. We evaluated long-term outcome of biliary complications in patients liver transplanted between 2004 and 2014 at Karolinska University Hospital, Stockholm.MethodsData were retrospectively collected, radiological images were analyzed for type of biliary complication, and graft and patient survivals were calculated.ResultsIn 110 (18.5%) of 596 transplantations, there were a total of 153 cases of biliary complications: 68 (44.4%) anastomotic strictures, 43 (28.1%) nonanastomotic strictures, 24 (15.7%) bile leaks, 11 (7.2%) cases of stone- and/or sludge-related problems, and 7 (4.6%) cases of mixed biliary complications. Treatment success rates for each complication were 90%, 73%, 100%, 82% and 80%, respectively. When the endoscopic approach was unsatisfactory or failed, percutaneous transhepatic cholangiography or a combination of treatments was often successful (in 18 of 24 cases). No procedure-related mortality was observed. Procedure-related complications were reported in 7.7% of endoscopic retrograde cholangiopancreatography and 3.8% of percutaneous transhepatic cholangiography procedures. Patient survival rates, 1, 3, 5, and 10 years posttransplant in patients with biliary complications were 92.7%, 80%, 74.7%, and 54.1%, respectively, compared with 92%, 86.6%, 83.7%, and 72.8% in patients free from biliary complications (P < 0.01). Similarly, long-term graft survival was lower in the group experiencing biliary complications (P < 0.0001).ConclusionsEndoscopic and percutaneous approaches for treating biliary complications are safe and efficient and should be considered complementing techniques. Despite a high treatment success rate of biliary complications, their occurrence still has a significant negative impact on patient and graft long-term survivals.

The real incidence of biliary tract complications after adult liver transplantation: the role of the prospective routine use of cholangiography during post‐transplant follow‐up

“…Despite their invasive nature, PTC and ERC remain the gold standard for BTC diagnosis [19,43–47]. The observations made by Kohli et al in relation to the diagnostic accuracy of liver tests and noninvasive imaging in the detection of post‐LT biliary strictures and those made by Ginat et al and Rönning et al in relation to safety of these procedures are in line with our choice of direct visualization of the biliary tree [14,48,49]. The advantages of the ultrasound‐guided percutaneous access to the biliary tree around the 3rd to 6th post‐LT month are fivefold: (i) the chosen time periods correspond with the highest probability of BTC formation; (ii) both cholangiography and liver biopsy can be realized in one single session; (iii) the visualization of the peripheral bile ducts is better and can be done using less contrast medium compared to ERC; (iv) the ‘bilio‐dynamic’ consequence of a lesion permits immediate evaluation of the evacuation of the contrast medium thereby allowing withholding of any treatment despite the presence of BTCs (‘wait‐and‐see’ strategy and finally (v) if treatment is judged to be necessary a first step (e.g.…”

Biliary Complications Following Orthotopic Liver Transplantation: the Place of Surgical Reconstruction in the Minimally-Invasive Era

“…MRI with cholangiography is the most effective non-invasive imaging modality for the assessment of BC after LT, with a sensitivity and specificity for the diagnosis ≥ 90% (28,35,42). 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).…”

“…However, complications involving the biliary tract continue to be a frequent problem after transplanta-Biliary Complications Following Orthotopic Liver Transplantation: the Place of Surgical Reconstruction in the Minimally-Invasive Era tion. The most common biliary complications (BC) are biliary strictures (BS) and biliary leaks (BL), and the estimated incidence ranges between 6 to 35% (1,2,3,4). These complications often result in surgical reinterventions, hospital readmissions, higher costs, and contribute to significant morbidity and mortality rates.…”

Biliary Strictures Are Associated With Both Early and Late Hepatic Artery Stenosis

“… 17 , 18 The average number of times the procedure needs repeating is four and a successful outcome is achieved in 46%–90% of cases. 19 , 20 In situations where endoscopic access via the ampulla no longer exists, such as duct-to-bowel anastomoses, dilation and stenting can be performed percutaneously. Five patients in our study required biliary reconstruction due to unsuccessful endoscopic or percutaneous intervention.…”