Single-operator cholangioscopy for biliary complications in liver transplant recipients

Abstract

AIMTo evaluate cholangioscopy in addition to endoscopic retrograde cholangiopancreatography (ERCP) for management of biliary complications after liver transplantation (LT).METHODSTwenty-six LT recipients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between April and December 2016 at the university hospital of Muenster were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis and bile was collected during the intervention for microbial analysis and for antibiotic susceptibility testing.RESULTSThirty-three biliary complications were found in a total of 22 patients, whereas four patients showed normal bile ducts. Anastomotic strictures were evident in 14 (53.8%) patients, non-anastomotic strictures in seven (26.9%), biliary cast in three (11.5%), and stones in six (23.1%). A benefit of cholangioscopy was seen in 12 (46.2%) patients. In four of them, cholangioscopy was crucial for selective guidewire placement prior to planned intervention. In six patients, biliary cast and/or stones failed to be diagnosed by ERCP and were only detectable through cholangioscopy. In one case, a bile duct ulcer due to fungal infection was diagnosed by cholangioscopy. In another case, signs of bile duct inflammation caused by acute cholangitis were evident. One patient developed post-interventional cholangitis. No further procedure-related complications occurred. Thirty-seven isolates were found in bile. Sixteen of these were gram-positive (43.2%), 12 (32.4%) were gram-negative bacteria, and Candida species accounted for 24.3% of all isolated microorganisms. Interestingly, only 48.6% of specimens were sensitive to prophylactic antibiotics.CONCLUSIONSingle-operator cholangioscopy can provide important diagnostic information, helping endoscopists to plan and perform interventional procedures in LT-related biliary complications.

Biliary interventions using single‐operator cholangioscopy

“…Ducts were completely cleared (technical success) in 97.3% of patients and cleared in a single session in 77.4% of patients . The results corroborate previously published studies on D‐SOC in the management of difficult‐to‐treat bile duct stones . The overall success rate of stone removal with D‐SOC appears to be over 95%.…”

“…7 A prospective study in liver transplant patients evaluated the usefulness of D-SOC for detection of stones as compared with ERCP for retained stones. 33 D-SOC was superior to standard ERCP for stone detection in three patients. Therefore, SOC seems to be useful for identification and extraction of residual stones missed by fluoroscopy.…”

“…Cholangioscopy can be used to detect small stones not visualized by ERCP and other imaging modalities . A prospective study in liver transplant patients evaluated the usefulness of D‐SOC for detection of stones as compared with ERCP for retained stones . D‐SOC was superior to standard ERCP for stone detection in three patients.…”

“…Single‐operator cholangioscopy facilitates selective guidewire placement into the complicated bile duct stricture or opening of a cystic duct that is difficult to access conventional ERCP . A prospective study in liver transplant patients evaluated the usefulness of SOC for successful guidewire placement that had failed standard ERCP and found that it was helpful in four patients …”

“…36 The results corroborate previously published studies on D-SOC in the management of difficult-to-treat bile duct stones. 6,22,33,[36][37][38][39][40][41] The overall success rate of stone removal with D-SOC appears to be over 95%.…”