ABSTRACT
In recent years, with the development of organ preservation, surgical techniques, perioperative management and immunosuppression regimens, the success rate of liver transplantation and survival rate of the recipients have been significantly enhanced. Liver transplantation has become the optimal treatment for patients with end-stage liver disease. However, biliary complications still commonly occur after liver transplantation, especially biliary anastomotic stricture. Severe biliary anastomotic stricture will not only increase the cost of treatment, but also lead to graft loss and even affect the survival rate of recipients. Therefore, timely diagnosis and treatment of biliary anastomotic stricture play a significant role in improving the survival rate of liver transplant recipients. In this article, the risk factors, clinical symptoms, diagnosis and treatment of biliary anastomotic stricture after liver transplantation were reviewed, aiming to provide novel ideas for the research, diagnosis and treatment of biliary anastomotic stricture after liver transplantation, and further enhance clinical efficacy of liver transplantation and the quality of life of recipients.
ABSTRACT
Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.
ABSTRACT
Objective To study the safety and efficacy of magnetic compression anastomosis (MCA) in treatment of biliary anastomotic stricture after orthotopic liver transplantation (LT).Methods Five patients who were treated unsuccessfully by ERCP were admitted to The First Affiliated Hospital of Xi'an Jiaotong University from 2012 January to 2018 May to undergo MCA.The treatment results were analyzed retrospectively.Results In four patients,the treatment was successful while in one patient it failed.For the four successful patients,the biliary stricture length was 2～4 mm.Re-canalization was achieved within 7～12 days and these patients were discharged home without any adverse events.Multiple plastic stents (in 2 patients) or full-covered self-expansion mental stents (in 2 patients) were inserted into the new fistulae after re-canalization.In two patients whose stents were removed,there was no recurrence of biliary strictures after follow-up for 64 months and 59 months,respectively.Conclusion The MCA technique is a revolutionary and effective method of performing interventional choledochocholedochostomy in patients with biliary anastomotic stricture after LT for whom the conventional endoscopic procedures were not successful.
ABSTRACT
OBJECTIVE: To evaluate the effect of temporary stent graft placement in the treatment of benign anastomotic biliary strictures. MATERIALS AND METHODS: Nine patients, five women and four men, 22-64 years old (mean, 47.5 years), with chronic benign biliary anastomotic strictures, refractory to repeated balloon dilations, were treated by prolonged, temporary placement of stent-grafts. Four patients had strictures following a liver transplantation; three of them in bilio-enteric anastomoses and one in a choledocho-choledochostomy. Four of the other five patients had strictures at bilio-enteric anastomoses, which developed after complications following laparoscopic cholecystectomies and in one after a Whipple procedure for duodenal carcinoma. In eight patients, balloon-expandable stent-grafts were placed and one patient was treated by insertion of a self-expanding stent-graft. RESULTS: In the transplant group, treatment of patients with bilio-enteric anastomoses was unsuccessful (mean stent duration, 30 days). The patient treated for stenosis in the choledocho-choledochostomy responded well to consecutive self-expanding stent-graft placement (total placement duration, 112 days). All patients with bilio-enteric anastomoses in the non-transplant group were treated successfully with stent-grafts (mean placement duration, 37 days). CONCLUSION: Treatment of benign biliary strictures with temporary placement of stent-grafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant.