Efficacy of Endoscopic Management of Anastomotic Biliary Strictures after Hepatic Transplantation

Background and Study Aims: Anastomotic biliary strictures are the most common cause of biliary obstruction following liver transplantation. We studied the efficacy and safety of endoscopic management of anastomotic strictures retrospectively.

Patients and Methods: A stricture at choledocho-choledochal anastomosis was identified in 30 of 354 sequential adult liver-transplant recipients at our institution. Balloon dilation was performed in 29 patients and a stent was inserted across the anastomotic stricture in one patient at initial endoscopy. A total of nine patients did not require further treatment; ten had repeated dilation (median 2). A stent was placed for persistent anastomotic stricture in six patients and for other indications in four patients. Outcomes studied were improvement in cholestasis, stricture diameter, and need for surgical treatment. Safety of therapy was assessed with nature and number of procedural complications.

Results: The median serum bilirubin level decreased from 3.25 mg/dl to 1.1 mg/dl (P < 0.001) and median alkaline phosphatase decreased from 451.5 IU/l to 125 IU/l (P = 0.001) following endoscopic therapy. Cholestasis improved in 26 of 30 patients with therapy. Of the remainder, three of three patients with concurrent nonanastomotic strictures and one patient with anastomotic stricture and histologic evidence of rejection showed worsening cholestasis at follow-up. Stricture diameter improved from a median of 2.5 mm to 7 mm (P < 0.001). Median follow-up was 17.9 months from the last therapeutic endoscopy. Five treatable, nonlethal complications occurred after 77 procedures. None of the patients required surgery for anastomotic stricture during a follow-up period up to 58 months.

Conclusions: Endoscopic management offers effective and safe treatment for posttransplantation anastomotic biliary strictures and avoids the need for surgical intervention.

References

• 1 Iwatsuki S, Shaw B W, Starzl T E. Biliary tract complications in liver transplantation under cyclosporin-steroid therapy.  Transplantation. 1983;  17 1289-1291
• 2 Lerut J, Gordon R D, Iwatsuki S, et al. Biliary tract complications in human orthotopic liver transplantation.  Transplantation. 1987;  43 47-51
• 3 Colonna II J O, Shaked A, Gomes A S, et al. Biliary strictures complicating liver transplantation. Incidence, pathogenesis, management and outcome.  Ann Surg. 1992;  216 344-350
• 4 Rossi G, Lucianetti A, Gridelli B, et al. Biliary tract complications in 224 orthotopic liver transplantations.  Transplant Proc. 1994;  26 3626-3628
• 5 Stratta R J, Wood R P, Langnas A N, et al. Diagnosis and treatment of biliary tract complications of orthotopic liver transplantation.  Surgery. 1989;  106 675-683
• 6 Greif F, Bronsther O L, Van Thiel D H, et al. The incidence, timing and management of biliary tract complications after orthotopic liver transplantation.  Ann Surg. 1994;  219 40-45
• 7 Popescu I, Sheiner P, Mor E, et al. Biliary complications in 400 cases of liver transplantation.  Mt Sinai J Med. 1994;  61 57-62
• 8 Gholson C, Zibari G, McDonald J C. Endoscopic diagnosis and management of biliary complications following liver transplantation.  Dig Dis Sci. 1996;  41 1045-1053
• 9 Porayko M K, Kondo M, Steers J L. Liver transplantation: late complications of the biliary tract and their management.  Semin Liver Dis. 1995;  15 139-155
• 10 Vallera R, Cotton P, Clavien P. Biliary reconstruction for liver transplantation and management of biliary complications: overview and survey of current practices in the United States.  Liver Transplant Surg. 1995;  1 143-152
• 11 Krom R AF, Kingma L M, Haagsma E B, et al. Choledocho-choledochostomy: a relatively safe procedure in orthotopic liver transplantation.  Surgery. 1985;  97 522-526
• 12 Hiatt R, Quinones-Baldrich J, Ramming K, et al. Operations upon the biliary tract during transplantation of the liver.  Surg Gynecol Obstet. 1987;  165 89-93
• 13 Miller W J, Campbell W L, Zajko A B, et al. Obstructive dilation of extrahepatic recipient and donor bile ducts complicating orthotopic liver transplantation: imaging and laboratory findings.  Am J Roentgenol. 1981;  157 29-32
• 14 Donovan J. Nonsurgical management of biliary tract disease after liver transplantation.  Gastroenterol Clin N Am. 1993;  22 317-336
• 15 O'Connor T, Lewis D, Jenkins R. Biliary tract complications after liver transplantation.  Arch Surg. 1995;  130 312-317
• 16 O'Connor H J, Vickers C R, Buckels J A, et al. Role of endoscopic retrograde cholangiopancreatography after orthotopic liver transplantation.  Gut. 1991;  32 419-423
• 17 Thielmann L, Kuppers B, Kadmon M, et al. Biliary tract strictures after liver transplantation: diagnosis and management.  Endoscopy. 1994;  26 517-522
• 18 Sherman S, Jamidar P, Shaked A, et al. Biliary tract complications after orthotopic liver transplantation. Endoscopic approach to diagnosis and therapy.  Transplantation. 1995;  60 467-470
• 19 Zajko A B, Sheng R, Zetti G M, et al. Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience.  J Vasc Interv Radiol. 1995;  6 79-83
• 20 Ward E M, Kiely M J, Maus T P, et al. Hilar biliary strictures after liver transplantation: cholangiography and percutaneous treatment.  Radiology. 1990;  177 259-263
• 21 Zajko A B, Campbell W L, Bron K M, et al. Cholangiography and interventional biliary radiology in adult liver transplantation.  Am J Roentgenol. 1985;  144 127-133
• 22 Klein A, Savader S, Burdick J, et al. Reduction in morbidity and mortality from biliary complications after liver transplantation.  Hepatology. 1991;  14 818-823
• 23 Osorio R W, Freise C E, Stock P G, et al. Non-operative management of biliary leaks after liver transplantation.  Transplantation. 1993;  55 1074-1077
• 24 Sossenheimer M, Slivka A, Carr-Locke D. Management of extrahepatic biliary disease after orthotopic liver transplantation: review of literature and results of a multicenter survey.  Endoscopy. 1996;  28 565-571
• 25 Kuo P C, Lewis W D, Stokes K, et al. A comparison of operation, endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation.  J Am Coll Surg. 1994;  179 177-181
• 26 Rossi A, Grosso C, Zanasi G, et al. Endoscopic treatment of anastomotic biliary stenosis in patients with orthotopic liver transplantation.  Diagn Ther Endosc. 1995;  2 93-97
• 27 Feller R B, Vaugh R C, Selby W S, et al. Biliary strictures after liver transplantation: clinical picture, correlates and outcomes.  J Gastroenterol Hepatol. 1996;  11 21-25
• 28 Rossi A F, Grosso C, Zanasi G, et al. Long term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation.  Endoscopy. 1998;  30 360-366
• 29 Rizk R S, McVicar J P, Emond M J, et al. Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival.  Gastrointest Endosc. 1998;  47 128-135
• 30 Schwartz D A, Petersen B T, Poterucha J J, et al. Endoscopic therapy of anastomotic bile duct strictures after liver transplantation.  Gastrointest Endosc. 2000;  51 169-174
• 31 Sanchez Urdazpal L, Gores G J, Ward E M, et al. Diagnostic features and clinical outcome of ischemic-type biliary complications after liver transplantation.  Hepatology. 1993;  17 605-609
• 32 Belzer F, D'Alessandro A, Hoffman R, et al. Management of the common duct in extended preservation of the liver.  Transplantation. 1992;  53 1166-1168
• 33 Catalano M F, Van Dam J, Sivak M V. Endoscopic retrograde cholangiopancreatography in the orthotopic liver transplant patient.  Endoscopy. 1995;  27 584-588
• 34 Bourgeois N, Deviere J, Yeaton P, et al. Diagnostic and therapeutic endoscopic retrograde cholangiography after liver transplantation.  Gastrointest Endosc. 1995;  42 572-574
• 35 Zemel G, Zajko A, Skolnick M L, et al. The role of sonography and transhepatic cholangiography in the diagnosis of biliary complications after liver transplantation.  Am J Roentgenol. 1988;  151 943-946
• 36 Adamek H E, Albert J, Weitz M, et al. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction.  Gut. 1998;  43 (5) 680-683