- Email: [email protected]
492 ENDOSCOPIC MANAGEMENT OF POST-LIVER- TRANSPLANT BILIARY COMPLICATIONS
S184
Poster Session − Friday, April 24
with improvement of cholestasis in all but in 2/13 there was a need of retreatment due to recurrence of cholestatic hepatitis. In the RPH group SVR was reached in 43% (6/14). No statistical difference in survival (P = 0.34) was obeserved (mean followup of CFH: 35 months vs. RPH: 47 months). In CFH patients 38% (5/13) died (3: nonresponders; 2: recurrence of HCC) while 21% (3/14) in RPH (1: recurrence of HCC). Conclusion: 18 month lasting antiviral treatment offers similar survival for CFH and RPH patients and is higher than what has been previously reported for CFH. The results of this pilot study must be confirmed in larger studies.
490 SIROLIMUS IS ASSOCIATED WITH FREQUENT ADVERSE EFFECTS REQUIRING DRUG CESSATION IN LIVER TRANSPLANT RECIPIENTS I. Rowe1 , B. Gunson1 , D. Thorburn1,2 . 1 Liver Unit, University Hospital Birmingham, Birmingham, 2 Royal Free Hospital, London, UK E-mail: [email protected] Background and Aim: Sirolimus is an alternative to calcineurin inhibitors for liver transplant recipients with renal dysfunction and/or rejection. In prospective studies reported rates of discontinuation of sirolimus are 5−15%. The aim of this study was to determine the tolerability of sirolimus in clinical practice. Methods: A retrospective review of prospectively collected data regarding the use of sirolimus in a large UK liver transplant centre. All patients treated with sirolimus between 01/01/2002 and 01/12/2007 were included. Results: 109 patients have been treated with sirolimus in our centre: 71 patients as part of a renal sparing strategy, 23 patients for rejection and 15 patients due to intolerance to other immunosuppressive agents. Patients were treated a median of 2045 days (interquartile range 588 to 3986 days) after liver transplantation and the median follow-up time on sirolimus was 295 days (interquartile range 72 to 693 days). 60 patients (55.0%) remained on sirolimus at the end of the study period. The most common reasons for cessation of sirolimus were death (20 patients), mouth ulceration (4), deteriorating renal function (3), pneumonitis (2), graft hepatitis (2), neutropenia (2) and gastrointestinal upset (2). Significantly, there was one patient treated for resistant acute rejection who developed disseminated cryptococcal infection which responded to withdrawal of sirolimus and reduction in other immunosuppressive drugs. Overall 29 patients (27%) were unable to tolerate sirolimus and of these 12 patients were unable to tolerate the drug for more than one month. There was no difference in the rate of adverse effects between those started on sirolimus due to intolerance of other immunosuppressive agents and those started on sirolimus for other reasons. Conclusions: In our centre sirolimus is utilised predominantly as a renal sparing agent after liver transplantation. In contrast to prospective clinical trials, sirolimus is relatively poorly tolerated with 27% of patients in our cohort stopping treatment due to adverse effects. Patients need to be carefully counselled regarding adverse effects and the potential risks of changing treatment.
491 USEFULNESS OF NON-INVASIVE METHODS TO DIAGNOSE LIVER FIBROSIS IN LIVER TRANSPLANT PATIENTS G. Sanchez Antolin1 , F. Garcia Pajares1 , L. Julian1 , D. Pacheco2 , M.A. Vallecillo1 , R. Velicia1 , A. Caro Paton1 . 1 Gastroenterology, 2 Surgery, Rio Hortega University Hospital, Valladolid, Spain E-mail: [email protected] Many studies have reported the efficiency of transient elastography, a noninvasive, reproducible, and reliable method for predicting liver fibrosis. The current findings suggest that FibroScan and biochemical markers of liver fibrosis can be useful to predict the presence or absence of fibrosis and, therefore, to reduce the number of liver biopsies.
Aim: To asses the correlation between non invasive test to measure the liver fibrosis in liver transplant patients: Fibroscan, the aspartate transaminase to platelets ratio index [APRI]) and Forns index. Methods: We assessed the accuracy of liver stiffness measurement using Fibroscan, and compared these values with those of APRI and Forns index to diagnose liver fibrosis in 43 liver transplant patients in our institution. The cut-off for significative fibrosis in most of studies is >7.2 for Fibroscan, >1.5 for APRI and >6.9 for the Forns Index. Results: The Pearson correlation between Fibroscan and Apri was 0.79, but with the Forns Index it was 0.44, perhaps because of the small number of patiens in each group. Conclusions: At the moment, the non invasive fibrosis test does not seem to be able to assess liver fibrosis in liver transplant patients avoiding liver biopsy. The correlation between Fibroscan and Forns Index wasn’t very good. Perhaps APRI test and Fibroscan can give better results in combination. More studies are needed to assess the usefulness of noninvasive fibrosis test. This study has been supported with a Research Grant Gerencia SACYL 2008. 492 ENDOSCOPIC MANAGEMENT OF POST-LIVERTRANSPLANT BILIARY COMPLICATIONS C. Sanna1 , C. Giordanino1 , C. Barletti1 , D. Reggio2 , A. Repici3 , M. Salizzoni2 , A. Ricchiuti2 , I. Giono2 , M. Rizzetto1 , G. Saracco1 . 1 Department of Gastrohepatology, San Giovanni Battista − Molinette Hospital of Turin, 2 Liver Transplantation Center, University of Turin, Turin, 3 Gastroenterology and Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy E-mail: [email protected] Background: ERCP is the standard approach for management of biliary complications in the posttransplant setting; however, its long-term impact on morbidity and mortality rates has not been fully established as well as safety. Aim: To evaluate the long-term outcome of transplanted patients with biliary complications treated by ERCP and the safety of such procedure. Methods: Case report forms of 1585 liver transplanted patients between October 1990 and December 2007 were reviewed and patients who underwent at least one ERCP were identified. Indications, findings, interventions and complications were noted for each ERCP report and compared with those of 6189 ERCPs performed in non-transplanted patients (NTP) in the same years by the same endoscopists. Results: Since 1990, 94 of 1585 (5.8%) liver transplant patients (LTP) (mean age 52±9.6, M = 72, F = 22) underwent 150 ERCP after orthotopic liver transplantation (OLT). Anastomotic stricture was present in 45 pts (48%), biliary stones in 24 (25%), biliary fistula in 6 (6%), the remaining 19 patients showed no significant alteration of the biliary tract. An ERCP success rate of 92% was achieved, biliary stenting with endoscopic sphincterotomy led to resolution of bile leak in 6/6 pts, biliary stones were removed by Dormia basket after papillotomy in 23/24 pts; due to the surgeon’s decision, only 25 of 45 pts with anastomotic stricture underwent endoscopic dilation with or without stenting. We obtained a complete resolution in 19/25 pts (76%). After a mean follow-up of 8.2 years (SD±4.8), 72 pts (75%) are still alive; causes of death in the remaining 22 pts are not related to biliary complications. Post-ERCP pancreatitis rate was 4.7% in LTP vs 9.6% in NTP (p = 0.04, RR=1.05, CI 95% 1.01−1.09), post-ERCP bleeding rate was 5.3% in LTP vs 1.3% in NTP (p = 0.0001, RR = 0.95, CI 95% 0.92−0.99) but sphincterotomy was performed in 78% of LTP compared with 51% of NTP (p = 0.0002); ERCP-related mortality rate was 0% in LTP vs 0.1% in NTP (p = 0.65). Conclusions: ERCP is safe and effective in the management of post-OLT biliary complications. Its therapeutic effect is durable with a surprisingly low rate of post-procedure pancreatitis.
Poster Session − Friday, April 24
with improvement of cholestasis in all but in 2/13 there was a need of retreatment due to recurrence of cholestatic hepatitis. In the RPH group SVR was reached in 43% (6/14). No statistical difference in survival (P = 0.34) was obeserved (mean followup of CFH: 35 months vs. RPH: 47 months). In CFH patients 38% (5/13) died (3: nonresponders; 2: recurrence of HCC) while 21% (3/14) in RPH (1: recurrence of HCC). Conclusion: 18 month lasting antiviral treatment offers similar survival for CFH and RPH patients and is higher than what has been previously reported for CFH. The results of this pilot study must be confirmed in larger studies.
490 SIROLIMUS IS ASSOCIATED WITH FREQUENT ADVERSE EFFECTS REQUIRING DRUG CESSATION IN LIVER TRANSPLANT RECIPIENTS I. Rowe1 , B. Gunson1 , D. Thorburn1,2 . 1 Liver Unit, University Hospital Birmingham, Birmingham, 2 Royal Free Hospital, London, UK E-mail: [email protected] Background and Aim: Sirolimus is an alternative to calcineurin inhibitors for liver transplant recipients with renal dysfunction and/or rejection. In prospective studies reported rates of discontinuation of sirolimus are 5−15%. The aim of this study was to determine the tolerability of sirolimus in clinical practice. Methods: A retrospective review of prospectively collected data regarding the use of sirolimus in a large UK liver transplant centre. All patients treated with sirolimus between 01/01/2002 and 01/12/2007 were included. Results: 109 patients have been treated with sirolimus in our centre: 71 patients as part of a renal sparing strategy, 23 patients for rejection and 15 patients due to intolerance to other immunosuppressive agents. Patients were treated a median of 2045 days (interquartile range 588 to 3986 days) after liver transplantation and the median follow-up time on sirolimus was 295 days (interquartile range 72 to 693 days). 60 patients (55.0%) remained on sirolimus at the end of the study period. The most common reasons for cessation of sirolimus were death (20 patients), mouth ulceration (4), deteriorating renal function (3), pneumonitis (2), graft hepatitis (2), neutropenia (2) and gastrointestinal upset (2). Significantly, there was one patient treated for resistant acute rejection who developed disseminated cryptococcal infection which responded to withdrawal of sirolimus and reduction in other immunosuppressive drugs. Overall 29 patients (27%) were unable to tolerate sirolimus and of these 12 patients were unable to tolerate the drug for more than one month. There was no difference in the rate of adverse effects between those started on sirolimus due to intolerance of other immunosuppressive agents and those started on sirolimus for other reasons. Conclusions: In our centre sirolimus is utilised predominantly as a renal sparing agent after liver transplantation. In contrast to prospective clinical trials, sirolimus is relatively poorly tolerated with 27% of patients in our cohort stopping treatment due to adverse effects. Patients need to be carefully counselled regarding adverse effects and the potential risks of changing treatment.
491 USEFULNESS OF NON-INVASIVE METHODS TO DIAGNOSE LIVER FIBROSIS IN LIVER TRANSPLANT PATIENTS G. Sanchez Antolin1 , F. Garcia Pajares1 , L. Julian1 , D. Pacheco2 , M.A. Vallecillo1 , R. Velicia1 , A. Caro Paton1 . 1 Gastroenterology, 2 Surgery, Rio Hortega University Hospital, Valladolid, Spain E-mail: [email protected] Many studies have reported the efficiency of transient elastography, a noninvasive, reproducible, and reliable method for predicting liver fibrosis. The current findings suggest that FibroScan and biochemical markers of liver fibrosis can be useful to predict the presence or absence of fibrosis and, therefore, to reduce the number of liver biopsies.
Aim: To asses the correlation between non invasive test to measure the liver fibrosis in liver transplant patients: Fibroscan, the aspartate transaminase to platelets ratio index [APRI]) and Forns index. Methods: We assessed the accuracy of liver stiffness measurement using Fibroscan, and compared these values with those of APRI and Forns index to diagnose liver fibrosis in 43 liver transplant patients in our institution. The cut-off for significative fibrosis in most of studies is >7.2 for Fibroscan, >1.5 for APRI and >6.9 for the Forns Index. Results: The Pearson correlation between Fibroscan and Apri was 0.79, but with the Forns Index it was 0.44, perhaps because of the small number of patiens in each group. Conclusions: At the moment, the non invasive fibrosis test does not seem to be able to assess liver fibrosis in liver transplant patients avoiding liver biopsy. The correlation between Fibroscan and Forns Index wasn’t very good. Perhaps APRI test and Fibroscan can give better results in combination. More studies are needed to assess the usefulness of noninvasive fibrosis test. This study has been supported with a Research Grant Gerencia SACYL 2008. 492 ENDOSCOPIC MANAGEMENT OF POST-LIVERTRANSPLANT BILIARY COMPLICATIONS C. Sanna1 , C. Giordanino1 , C. Barletti1 , D. Reggio2 , A. Repici3 , M. Salizzoni2 , A. Ricchiuti2 , I. Giono2 , M. Rizzetto1 , G. Saracco1 . 1 Department of Gastrohepatology, San Giovanni Battista − Molinette Hospital of Turin, 2 Liver Transplantation Center, University of Turin, Turin, 3 Gastroenterology and Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy E-mail: [email protected] Background: ERCP is the standard approach for management of biliary complications in the posttransplant setting; however, its long-term impact on morbidity and mortality rates has not been fully established as well as safety. Aim: To evaluate the long-term outcome of transplanted patients with biliary complications treated by ERCP and the safety of such procedure. Methods: Case report forms of 1585 liver transplanted patients between October 1990 and December 2007 were reviewed and patients who underwent at least one ERCP were identified. Indications, findings, interventions and complications were noted for each ERCP report and compared with those of 6189 ERCPs performed in non-transplanted patients (NTP) in the same years by the same endoscopists. Results: Since 1990, 94 of 1585 (5.8%) liver transplant patients (LTP) (mean age 52±9.6, M = 72, F = 22) underwent 150 ERCP after orthotopic liver transplantation (OLT). Anastomotic stricture was present in 45 pts (48%), biliary stones in 24 (25%), biliary fistula in 6 (6%), the remaining 19 patients showed no significant alteration of the biliary tract. An ERCP success rate of 92% was achieved, biliary stenting with endoscopic sphincterotomy led to resolution of bile leak in 6/6 pts, biliary stones were removed by Dormia basket after papillotomy in 23/24 pts; due to the surgeon’s decision, only 25 of 45 pts with anastomotic stricture underwent endoscopic dilation with or without stenting. We obtained a complete resolution in 19/25 pts (76%). After a mean follow-up of 8.2 years (SD±4.8), 72 pts (75%) are still alive; causes of death in the remaining 22 pts are not related to biliary complications. Post-ERCP pancreatitis rate was 4.7% in LTP vs 9.6% in NTP (p = 0.04, RR=1.05, CI 95% 1.01−1.09), post-ERCP bleeding rate was 5.3% in LTP vs 1.3% in NTP (p = 0.0001, RR = 0.95, CI 95% 0.92−0.99) but sphincterotomy was performed in 78% of LTP compared with 51% of NTP (p = 0.0002); ERCP-related mortality rate was 0% in LTP vs 0.1% in NTP (p = 0.65). Conclusions: ERCP is safe and effective in the management of post-OLT biliary complications. Its therapeutic effect is durable with a surprisingly low rate of post-procedure pancreatitis.