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Endoscopic management of Post liver transplant - Bilary Complications
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Transcript of Endoscopic management of Post liver transplant - Bilary Complications
Endoscopic management of Post liver transplant —Biliary Complications
Dr. Randhir SudChairman
Institute of Digestive & Hepato-biliary SciencesMedanta the MedicityGurugram Haryana
Introduction
5% to 32% pts of OLT develop BC Cumulative BC rate at 1,3 and 5 yrs is
12.9% ,18.25% and 20.2% Unrelated to type of anastomosis D-D / H-J More common in LDLT
Lead to Re-transplant in 6% to 12.5% Mortality 0% to 19 Shin H - Liver transpl. 2006 Soejima Y - Liver transplant 2006
Londono M - WJG 2008, Kochhar G – WJG 2013
Incidence of biliary complications : DDLT vs LDLT
Chan C GIE 2012 : 362 pts 29 LDLT 111DDLT ( 33.3%) & 14(48.3%) LDLT needed
ERCP for biliary complications Anastomotic Strict 10% vs 27.6% p <.01 Bile leak 7.2% vs 6.9% Choledocholith. 12.6% vs 7.1%
Mean time to develop stricture same Likelihood of response to ERCP ( 63.6% vs 75%) Number of ERCPs required same ( 3.9 vs 4.7 )
Biliary complications
Bile leak (10-25%) Anastomotic Non-anastomotic
Biliary stricture (5-24%) Anastomotic Non-anastomotic
Bile duct stones, sludge, cast
POST OLT BILIARY STRICTURES
Risk factors for biliary strictures
Bile leak Local effect of the bile inducing inflammation and
subsequent fibrosis A surrogate marker of poor vascularity
Number of anastomosis? Older donor
Related to the presence of degenerative age-related changes in the microcirculation of the biliary tract
Prolonged warm / cold ischaemiaShah SA, Am J Transplant 2007
Diagnosis
USG abdomen Low sensitivity: 38-66% No good correlation between USG and
cholangiographic size MRCP
>90% sensitivity and specificity ERCP
Therapeutic
Management of biliary strictures
First line: ERCP
Second line: Percutaneous interventions
Third line: surgery
DDLT BS are easier to treat endoscopicallyPrinciples of management same as other BSSuccess rates same as post chole. BS (80-90%)FCSEMS may play increasing role in reducing the number of interventions and improving outcomes
LDLT - Anastomotic strictures
Post LDLT strictures are more difficult to treatAnastomosis is complexPeripherally locatedMultiple small caliber ductsAngulated course of ducts
Endotherapy less rewarding than DDLT (58%-76%)Very tight stricture is most common cause of failure
ERCP –Technical consideration
Principles of management same as in post-chole. Strictures MRCP is pre-requisite in LDLT Know type of anastomosis Peri procedural antibiotics Balloon dilatation + stenting better than either alone Multiple sequential stents are better Generally 3-4 sessions Proper assessment of re-modelling of stricture
Challenging LDLT biliary strict.
Type of anastomosis : Spectacle anastomosis Cystic duct anastomosis Hepatico-jejunostomy
Tight stricture Non dilated BD proximal to stricture Total separation of graft ducts from native CBD NAS
Strategies to treat difficult BS
Special guidewires Soehendra Pancreatic dilator catheter 6F Cystotome FCSEMS PTBD
Rendezvous procedures Magnetic compression therapy
Balloon assisted enteroscope ERC Surgery
SEMS in LDLT
SEMS in LDLT
FCSEMS in LDLT strictures
Only retrievable fully covered SEMS used Technically difficult to position upper end without
obstructing side branches in majority Kaffee stent with retrievable lasso used 16% migration rate No superiority over multiple plastic stents shown
Wang AY Endoscopy 2009
Difficult LDLT AS
Difficult LDLT stricture
Wire guided Cystotome facilitated stricturoplasty
Kawakami H et al 2015 22 cases with 16 BD strictures 100% success rate 2/22 developed complications
Pancreatitis inPD stricture Hemobilia in Ca GB pt
None in benign BS
Cystic duct anastomosis
Post LDLT : Non anastomotic strictures ( NAS )
NAS less frequent in LDLT than DDLT (2%-10% vs 5%-15%, )Frequently associated with casts & stonesOutcome of endotherapy poor 25% to 70%NAS takes longer to respond 185 days vs 67 days for AS Re-transplant rates of >40%
PTBD assisted rendezvous
Magnetic compression anastomosis
Magnetic compression anastomosis
Sung Ill Jang 2014 17 pts of LDLT BS treated with MCA Mean distance between magnets was 6.4mm Mean time for removal 53.3 days ( 9-181 days ) Re-stenosis occurred in 1/17 cases over median
FU of 12 months 8 bilio-enteric MCA have been done but none in
LDLT- BS
Post OLT bile leak
Post OLT -- Bile leaks
5% -25% develop bile leaks Presentation - early (<4wks) or late Early leaks treated conservatively with PCD ThethyS et al Clinical Transpl.2004 -28 bile leaks
22 treated with PCD alone – 85% healed Biliary stenting for 2 months successful in 84.6% T-tube leaks respond better 95% compared to
anastomotic leaks 43%1/3rd pts with leak develop stricture on follow up Pfau et al GIE 2000 , Tsuzino et al Am J Gast.2006
Post OLT CBD stone
Bile duct stones
Biliarys stones occur in 2%--5% after OLT* Increased lithogenicity Cyclosporin
Most stones associated with mechanical obst. ERCP outcome comparable to routine
Choledocholithiasis 90%- 100% success** *Somberg et al GIE 1993 **Gholson et al Dig.Dis.Sci.1996
Biliary cast syndrome
Single/multiple fixed hard or soft filling defects in Intra/Extra hepatic biliary tree conforming to luminal dimensions
Etiology Sloughed biliary epithelium Chronic rejection Bile stasis
Endoscopic managementBiliary cast syndrome
Tsujino T et al 2006 8/9 cleared endoscopically 4-17mm in size 1-2 in number
Endoscopic management poor if multiple intrahepatic casts 1 out of 4 successfully treated* Retransplantation may be the only option
*Pfau et al GIE 2000
Summary
BC occur in 10% to 25% cases after OLT Biliary strictures and leaks are most frequent
complications While early bile leaks respond to PCD endoscopic
stenting is very effective in other pts. Biliary strictures are managed succefully by BD +
multiple stents in >85% cases Small ducts and angulated stricture in LDLT make
ERC challenging Thermal stricturoplasty & MCA are new innovations
which help us treat more challenging pts
PULLMAN NEW DELHI AEROCITY