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58 Biliary complications after liver transplantation
ProgramAbstracts
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BILE DUCT COMPLICATION FOLLOWING LIVER TRANSPLANTATION IN ADULTS AND CHILDREN: 1004) CONSECUTIVES PATIENTS G. Costa MD. A. Jain MD, J. Madariaga MD. J. Reyes MD, G. MazariegosMD, R. KashyapMD, John J. Fong MD,FnD. Thomas E. Starzl Transplantation Intitute. 4c Folk Clinic 3601 Fifth Ave Pitlsburgh PA 15213 USA Bile duct complication after liver transplantation has remained one major factor for postoperative morbidity including graft lost and death.Aim : Present study examines the incidence of bile duct complication, type of bile duet complication and outcome altcr the complication.Patients uud Methods : 1000 consecutive primary liver transplants under tacrulimus, performed between Aug. 1989 to Dec. 1992, were retrospectively examiucd for bile duct complications. There were 834 adults (age >18 years) and 166 children (age < 18 years). All patients were followed until Jan. 1999, mean follow up 93.4 + I I months. Resp_lts :Total 185(18.5%) bile duct complications were observed: 165(19.8%) in adults and 20 (12%) in pediatric population. Bile duct complications were further categorized as stricture, obstruction, ampullary dysfunction or leak. Frequency of different types ol'oile duct complications in adults and children is showed in the table below. Overall Adults Children Re-Tx Mortality
BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION U. Maggi, G. Rossi, E. M e l a d a , 0 . P a o n e , P. Reggiani~ M. G a l m a r i n ~ , L. R. F a s s a t i C e n t r o T r a p i a n t i F e g a t o - O s p e d a l e M a g g i o r e IRCCS Milano- Italia I n t r o d u c t i o n Biliary c o m p l i c a t i o n s r e p r e s e n t a n i m p o r t a n t s o u r c e of m o r b i d i t y a f t e r liver t r a n s p l a n t a t i o n (LT). T h e a c t u a l r a t e o f b/liary c o m p l i c a t i o n s a n d t h e i r t r e a t m e n t is u n d e r d e b a t e in t h i s s t u d y . P a t i e n t s and m e t h o d s 2 0 4 p t s a n d 2 2 1 It p e r f o r m e d f r o m 1 9 9 4 t h r o u g h 1 9 9 9 w e r e e v a l u a t e d i n c l u d i n g 139 g r a f t s t r a n s p l a n t e d in 129 a d u l t p t s ( m e a n a g e 4 4 + 1 0 y e a r s ) , a n d 82 g r a f t s in 7 5 p e d i a t r i c p t s ( m e a n a g e 5 , 3 ± 5 years}. D a t a r e l a t e d to t r e a t m e n t of bfliary c o m p l i c a t i o n s w e r e collected, a n d d e v i d e d c o n s i d e r i n g s u r g e r y a n d m i n i m a l l y invasive treatments (ERCP, PTC, PTBD, p e r c u t a n e o u s drainage}. Resulti In a d u l t s p a t i e n t s 3 2 g r a f t s (23%) u n d e r w e n t 3 8 biliary c o m p l i c a t i o n s . T h e s e o c c u r r e d in 2 6 / 1 2 9 (20,1%) w h o l e g r a f t s - W G - , in 6 / 1 0 r e d u c e d g r a f t s - R G - {60% I. In WG, m o s t of billary c o m p l i c a t i o n s w e r e s t r i c t u r e s ( 1 7 / 3 0 t h a t is 56%) w h e r e a s in RO, l e a k a g e s ( 5 / 8 t h a t is 62,5%), S u r g e r y a l o n e w a s m o r e f r e q u e n t l y a d o p t e d in RG w i t h leakages, whereas minimally invasive treatments alone had m o r e efficacy in W G w i t h s t r i c t u r e s . I n p e d i a t r i c p a t i e n t s , 19 g r a f t s (14,6%o) h a d I S biliary c o m p l i c a t i o n s . T h e r a t e o f g r a f t s w i t h biliary c o m p l i c a t i o n s w a s 5 , 6 % in w h o l e g r a f t s , 3 1 % in all r e d u c e d g r a f t s , a n d 2 6 , 6 % in split grafts. 4 c o m p l i c a t i o n s o c c u r r e d in w h o l e g r a f t s a n d 11 in r e d u c e d g r a f t s . A m o n g t h e s e l a s t g r a f t s t h e r e w e r e 5 s t r i c t u r e s {45,4%) a n d 6 l e a k a g e s (54,50/0): 3 s t r i c t u r e s (60°/oi w e r e s u c c e s s f u l l y t r e a t e d w i t h a m i n i n v a s i v e t r e a t m e n t ; o t h e r 5 (83%) l e a k a g e s w e r e t r e a t e d s u r g i c a l l y , p r e c e e d e d o r n o t by p e r c u t a n e o u s t r e a t m e n t s : in 1 g r a f t t h e t r e a t m e n t i n c l u d e d t h e r e t r a n s p l a n t . D i s c u s s / o n and c o n c l u s i o n After liver t r a n s p l a n t a t i o n t h e r a t e of b i n a r y c o m p l i c a t i o n s w a s still high. S t r i c t u r e s a n d l e a k a g e s o c c u r r e d w i t h s i m i l a r r a t e s b u t t h e f o r m e r a r e m o r e easily s u c c e s s f u l l y m a n a g e d b y p e r c u t a n e o u s t r e a t m e n t s w h e r e a s l e a k a g e s by surgery.
Stricture Extrahepatic Intrahepatic Combined Obsg~on Intraluminal Extraluminal
Ampullary Dysf. Leak Duct to duCl Roux en Y T tube exit site
n (%) 112 (11.2) 87 23
n (%) 100 (12) 80 18
n (%7 12 (7.2) 7 5
n (*/,) 2 (1.8) 1 1
n I%) 39 (34.8) 32 7
2
2
0
0
0
21 (2.1}
14 (1.7)
7 (¢21
3 (14.3)
10 (47.6)
19 2
13 1
0 1
3 0
9 1
23 (2.3) 29 (2.9)
23 (2.7) 28 (3.3)
0 1 (0.6)
0 2 (6.7)
12 (52.2) 11 (38)
6 8
6 7
0 1
1 1
1 5
15 185 18.5)
15 165 (19.8)
0 20 112)
0 7 (3.8}
5 Overall 72 (38.0) 16 (86%) bile duct complications were associated with hepatic artery
complication; 9 (52.6%) stennsis and 7 (43.8%) thrombosis. Conclusions : Overall rate of bile duct complication was 18.5% with a mean follow up of 8 years. This was slighty higher in adults ( 19.8%7 than in children (12%). Overall mortality was 72(38.9%). Direct relationship of bile duct complication leading to retransplantantation or death needs further evaluation.
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C H O L E D O C H O - C H O L E D O C H O S T O M Y STENOSIS AFTER OLT. D I A G N O S I S AND T R E A T M E N T : L O N G T E R M FOLLOW-UP M. Salizzoni, D. Reggio, F. Zamboni, A. Frachello. P. Marcbesa, P. Fonuna, G. Saraeco, E. Cerutti, D. Right Liver Transplant Center-Gastroenterology Division and Radiology Division, San Giovanni Battista Hospital, Tormo Italy The purpose of the study The stenosis of the choledocho-choledochostomy is one of the most frequent biltary complications post-OLT (3-10%),Retrospective assessment of the endoscoptc and percutancous treatment of the anastomotic stenosis post-OLT. A brief description of methods We analysed 318 liver transplant with choledochocboledochoanastomosis not accounting those patients who died within 2 months. 76 patients underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and/or Percoutaneous Cholangiography (PTC) for perststent cholestasis, recurrent cholangitis, intrahepattc biliary duct dilatation. Results The biliary ducts was damaged in 58 patients. 32 presented a stenosis of the choledocho-choledocho anastomosis, in some cases associated with sludge, lithiasis, secondary sclerosing cholangitis. 8 patients were surgically treated: 4 re-OLT and 4 bilio-dtgestive anastomosis. The remaining 24 patients were endoscoptcally or percutaneously treated (ERCP, 43: sphinterotbomy with balloon dilatauon and/or biliar2,.' plastic stent; PTC, 25: bdtoplastlc+bihary drainage). No metalhc stem was used. All the treated patients showed a temporary improvement of the clinical picture. Morbidity was 20% for ERCP and 12% for PTC. No deaths was due to the treatment. 3 patients died in the follow-up, not for biliary complication. A biliodigestive anastomosis was performed afterwards in 17 out of the remaining 21 patients (follow-up from l to 8 years) for cholestasis recurrence and/or histological signs of biliary damage. Surgical morbility was 35%: reoperation rate 23%; post-operative mortality 11%. 7 patients of the 15 surviving who under.vent surgical treatment were pereoutaneously treated for cholestasis recurrence. Conclusions The incidence of anastomotic stenosis in 318 patients was 10%. The endoscopic or pereoutaneous treatment had a low long term success rate (18%), though the temporary effect o f the method was good and without mortality. The surgical treatment had a longer lasting effect on cholestasis but a high mortality (11%). morbility and re-operation rate. Any biliary extrahepatic complication should be treated surgically as a first choice.
USE OF "I'HROMBOLYTIC BRUSH FOR BILIARY S T E N T O B S T R U C T I O N AFTER LIVER T R A N S P L A N T A T I O N V.C.Souza. M.F.A,Barros. R.A.Cury. M.G.Pessoa. C.Osawa. H.Sette Jr. Pr6-Figado - Hospital Israelita Albert Einstein/Hospital Alemfio Oswaldo Cru;,JSfio Paulo - Brazil We report on a 56-year-old white female who was submitted to a liver transplantation for cirrhosis due 1o hepatitis B virus, where a reduced-size graft (left lobe) was used. For liver preservation U.W. solution was used. total ischemia time was 20.5 hours, and liver reduction was done on the back table. Her postoperative course was somewhal complicated, and she presented two biliary auastomotic leaks, which were surgically corrected. Patient was discharged on the 32•' postoperative day. Four months post-transplantation, after rise in GGT and bilirrubin levels, she underv,'ent a percutaneous cholangiogram, which showed stcnosis of Roux-in-Y loop anastomosis and multiple intra-hepatic ducts stenosis. She was then managed by means of sequential balloon dilatatiolt procedures, and the drain was only taken out after I year. One year later she presented new biliary anastomosis stricture. and was once again submitted to pereutaneous biliary drainage. At this time a biliar'.,' stent was placed at anastomotic site. Follow up was uneventful up to li1 months, when a new episode of cholangitis occurred. Percutaneoos cholangiogram showed partially obstructed stem as well as progression of intra-hepatic ducts strictures. She was treated with antibiotics and balloon dilatation. Control cholangiogram performed 7 days later still showed a partially obstructed stent by biliary sludge. At this time it was decided to use thrombolytic brush (Caslafieda over-the-wire brush - MTI"). a device that has been used in vascular interventional radiology for mechanical thrombolysis. Control cholangiogram right after and 7 days after the procedure showed patent stent and complete absence of sludge, and the drain was then taken out. Conclusion: Biliary strictures can occur following liver transplantation. It is well known that biliary stem is prone to obstruction over time, and its management is very difficult. The thrombolytic brush, as demonstrated in this sitlgle case, can efficiently treat the stent obstruction, which would not be possible in one only procedure by any other method. Therefore, the thrombolytic brush could be a new tool for the management of biliary stent obstruction.
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BILE DUCT COMPLICATION FOLLOWING LIVER TRANSPLANTATION IN ADULTS AND CHILDREN: 1004) CONSECUTIVES PATIENTS G. Costa MD. A. Jain MD, J. Madariaga MD. J. Reyes MD, G. MazariegosMD, R. KashyapMD, John J. Fong MD,FnD. Thomas E. Starzl Transplantation Intitute. 4c Folk Clinic 3601 Fifth Ave Pitlsburgh PA 15213 USA Bile duct complication after liver transplantation has remained one major factor for postoperative morbidity including graft lost and death.Aim : Present study examines the incidence of bile duct complication, type of bile duet complication and outcome altcr the complication.Patients uud Methods : 1000 consecutive primary liver transplants under tacrulimus, performed between Aug. 1989 to Dec. 1992, were retrospectively examiucd for bile duct complications. There were 834 adults (age >18 years) and 166 children (age < 18 years). All patients were followed until Jan. 1999, mean follow up 93.4 + I I months. Resp_lts :Total 185(18.5%) bile duct complications were observed: 165(19.8%) in adults and 20 (12%) in pediatric population. Bile duct complications were further categorized as stricture, obstruction, ampullary dysfunction or leak. Frequency of different types ol'oile duct complications in adults and children is showed in the table below. Overall Adults Children Re-Tx Mortality
BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION U. Maggi, G. Rossi, E. M e l a d a , 0 . P a o n e , P. Reggiani~ M. G a l m a r i n ~ , L. R. F a s s a t i C e n t r o T r a p i a n t i F e g a t o - O s p e d a l e M a g g i o r e IRCCS Milano- Italia I n t r o d u c t i o n Biliary c o m p l i c a t i o n s r e p r e s e n t a n i m p o r t a n t s o u r c e of m o r b i d i t y a f t e r liver t r a n s p l a n t a t i o n (LT). T h e a c t u a l r a t e o f b/liary c o m p l i c a t i o n s a n d t h e i r t r e a t m e n t is u n d e r d e b a t e in t h i s s t u d y . P a t i e n t s and m e t h o d s 2 0 4 p t s a n d 2 2 1 It p e r f o r m e d f r o m 1 9 9 4 t h r o u g h 1 9 9 9 w e r e e v a l u a t e d i n c l u d i n g 139 g r a f t s t r a n s p l a n t e d in 129 a d u l t p t s ( m e a n a g e 4 4 + 1 0 y e a r s ) , a n d 82 g r a f t s in 7 5 p e d i a t r i c p t s ( m e a n a g e 5 , 3 ± 5 years}. D a t a r e l a t e d to t r e a t m e n t of bfliary c o m p l i c a t i o n s w e r e collected, a n d d e v i d e d c o n s i d e r i n g s u r g e r y a n d m i n i m a l l y invasive treatments (ERCP, PTC, PTBD, p e r c u t a n e o u s drainage}. Resulti In a d u l t s p a t i e n t s 3 2 g r a f t s (23%) u n d e r w e n t 3 8 biliary c o m p l i c a t i o n s . T h e s e o c c u r r e d in 2 6 / 1 2 9 (20,1%) w h o l e g r a f t s - W G - , in 6 / 1 0 r e d u c e d g r a f t s - R G - {60% I. In WG, m o s t of billary c o m p l i c a t i o n s w e r e s t r i c t u r e s ( 1 7 / 3 0 t h a t is 56%) w h e r e a s in RO, l e a k a g e s ( 5 / 8 t h a t is 62,5%), S u r g e r y a l o n e w a s m o r e f r e q u e n t l y a d o p t e d in RG w i t h leakages, whereas minimally invasive treatments alone had m o r e efficacy in W G w i t h s t r i c t u r e s . I n p e d i a t r i c p a t i e n t s , 19 g r a f t s (14,6%o) h a d I S biliary c o m p l i c a t i o n s . T h e r a t e o f g r a f t s w i t h biliary c o m p l i c a t i o n s w a s 5 , 6 % in w h o l e g r a f t s , 3 1 % in all r e d u c e d g r a f t s , a n d 2 6 , 6 % in split grafts. 4 c o m p l i c a t i o n s o c c u r r e d in w h o l e g r a f t s a n d 11 in r e d u c e d g r a f t s . A m o n g t h e s e l a s t g r a f t s t h e r e w e r e 5 s t r i c t u r e s {45,4%) a n d 6 l e a k a g e s (54,50/0): 3 s t r i c t u r e s (60°/oi w e r e s u c c e s s f u l l y t r e a t e d w i t h a m i n i n v a s i v e t r e a t m e n t ; o t h e r 5 (83%) l e a k a g e s w e r e t r e a t e d s u r g i c a l l y , p r e c e e d e d o r n o t by p e r c u t a n e o u s t r e a t m e n t s : in 1 g r a f t t h e t r e a t m e n t i n c l u d e d t h e r e t r a n s p l a n t . D i s c u s s / o n and c o n c l u s i o n After liver t r a n s p l a n t a t i o n t h e r a t e of b i n a r y c o m p l i c a t i o n s w a s still high. S t r i c t u r e s a n d l e a k a g e s o c c u r r e d w i t h s i m i l a r r a t e s b u t t h e f o r m e r a r e m o r e easily s u c c e s s f u l l y m a n a g e d b y p e r c u t a n e o u s t r e a t m e n t s w h e r e a s l e a k a g e s by surgery.
Stricture Extrahepatic Intrahepatic Combined Obsg~on Intraluminal Extraluminal
Ampullary Dysf. Leak Duct to duCl Roux en Y T tube exit site
n (%) 112 (11.2) 87 23
n (%) 100 (12) 80 18
n (%7 12 (7.2) 7 5
n (*/,) 2 (1.8) 1 1
n I%) 39 (34.8) 32 7
2
2
0
0
0
21 (2.1}
14 (1.7)
7 (¢21
3 (14.3)
10 (47.6)
19 2
13 1
0 1
3 0
9 1
23 (2.3) 29 (2.9)
23 (2.7) 28 (3.3)
0 1 (0.6)
0 2 (6.7)
12 (52.2) 11 (38)
6 8
6 7
0 1
1 1
1 5
15 185 18.5)
15 165 (19.8)
0 20 112)
0 7 (3.8}
5 Overall 72 (38.0) 16 (86%) bile duct complications were associated with hepatic artery
complication; 9 (52.6%) stennsis and 7 (43.8%) thrombosis. Conclusions : Overall rate of bile duct complication was 18.5% with a mean follow up of 8 years. This was slighty higher in adults ( 19.8%7 than in children (12%). Overall mortality was 72(38.9%). Direct relationship of bile duct complication leading to retransplantantation or death needs further evaluation.
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C H O L E D O C H O - C H O L E D O C H O S T O M Y STENOSIS AFTER OLT. D I A G N O S I S AND T R E A T M E N T : L O N G T E R M FOLLOW-UP M. Salizzoni, D. Reggio, F. Zamboni, A. Frachello. P. Marcbesa, P. Fonuna, G. Saraeco, E. Cerutti, D. Right Liver Transplant Center-Gastroenterology Division and Radiology Division, San Giovanni Battista Hospital, Tormo Italy The purpose of the study The stenosis of the choledocho-choledochostomy is one of the most frequent biltary complications post-OLT (3-10%),Retrospective assessment of the endoscoptc and percutancous treatment of the anastomotic stenosis post-OLT. A brief description of methods We analysed 318 liver transplant with choledochocboledochoanastomosis not accounting those patients who died within 2 months. 76 patients underwent an Endoscopic Retrograde CholangioPancreatography (ERCP) and/or Percoutaneous Cholangiography (PTC) for perststent cholestasis, recurrent cholangitis, intrahepattc biliary duct dilatation. Results The biliary ducts was damaged in 58 patients. 32 presented a stenosis of the choledocho-choledocho anastomosis, in some cases associated with sludge, lithiasis, secondary sclerosing cholangitis. 8 patients were surgically treated: 4 re-OLT and 4 bilio-dtgestive anastomosis. The remaining 24 patients were endoscoptcally or percutaneously treated (ERCP, 43: sphinterotbomy with balloon dilatauon and/or biliar2,.' plastic stent; PTC, 25: bdtoplastlc+bihary drainage). No metalhc stem was used. All the treated patients showed a temporary improvement of the clinical picture. Morbidity was 20% for ERCP and 12% for PTC. No deaths was due to the treatment. 3 patients died in the follow-up, not for biliary complication. A biliodigestive anastomosis was performed afterwards in 17 out of the remaining 21 patients (follow-up from l to 8 years) for cholestasis recurrence and/or histological signs of biliary damage. Surgical morbility was 35%: reoperation rate 23%; post-operative mortality 11%. 7 patients of the 15 surviving who under.vent surgical treatment were pereoutaneously treated for cholestasis recurrence. Conclusions The incidence of anastomotic stenosis in 318 patients was 10%. The endoscopic or pereoutaneous treatment had a low long term success rate (18%), though the temporary effect o f the method was good and without mortality. The surgical treatment had a longer lasting effect on cholestasis but a high mortality (11%). morbility and re-operation rate. Any biliary extrahepatic complication should be treated surgically as a first choice.
USE OF "I'HROMBOLYTIC BRUSH FOR BILIARY S T E N T O B S T R U C T I O N AFTER LIVER T R A N S P L A N T A T I O N V.C.Souza. M.F.A,Barros. R.A.Cury. M.G.Pessoa. C.Osawa. H.Sette Jr. Pr6-Figado - Hospital Israelita Albert Einstein/Hospital Alemfio Oswaldo Cru;,JSfio Paulo - Brazil We report on a 56-year-old white female who was submitted to a liver transplantation for cirrhosis due 1o hepatitis B virus, where a reduced-size graft (left lobe) was used. For liver preservation U.W. solution was used. total ischemia time was 20.5 hours, and liver reduction was done on the back table. Her postoperative course was somewhal complicated, and she presented two biliary auastomotic leaks, which were surgically corrected. Patient was discharged on the 32•' postoperative day. Four months post-transplantation, after rise in GGT and bilirrubin levels, she underv,'ent a percutaneous cholangiogram, which showed stcnosis of Roux-in-Y loop anastomosis and multiple intra-hepatic ducts stenosis. She was then managed by means of sequential balloon dilatatiolt procedures, and the drain was only taken out after I year. One year later she presented new biliary anastomosis stricture. and was once again submitted to pereutaneous biliary drainage. At this time a biliar'.,' stent was placed at anastomotic site. Follow up was uneventful up to li1 months, when a new episode of cholangitis occurred. Percutaneoos cholangiogram showed partially obstructed stem as well as progression of intra-hepatic ducts strictures. She was treated with antibiotics and balloon dilatation. Control cholangiogram performed 7 days later still showed a partially obstructed stent by biliary sludge. At this time it was decided to use thrombolytic brush (Caslafieda over-the-wire brush - MTI"). a device that has been used in vascular interventional radiology for mechanical thrombolysis. Control cholangiogram right after and 7 days after the procedure showed patent stent and complete absence of sludge, and the drain was then taken out. Conclusion: Biliary strictures can occur following liver transplantation. It is well known that biliary stem is prone to obstruction over time, and its management is very difficult. The thrombolytic brush, as demonstrated in this sitlgle case, can efficiently treat the stent obstruction, which would not be possible in one only procedure by any other method. Therefore, the thrombolytic brush could be a new tool for the management of biliary stent obstruction.