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Biliary tract complications after orthotopic liver transplantation in adult patients
Biliary Tract Complications After Orthotopic Liver Transplantation in Adult Patients A. Fleck Jr., M.L. Zanotelli, M. Meine, A. Branda˜o, I. Leipnitz, E. Schlindwein, A. Cassal, T. Grezzana, C. Marroni, G.P.C. Cantisani, and R.R. Santos
O
RTHOTOPIC liver transplantation (OLT) has become the treatment of choice for many types of chronic liver disease. Biliary complications (BC) are a significant cause of morbidity (10% to 35%) and mortality (2% to 7%) following OLT.1 The aim of this study was to analyze the incidence of BC after OLT, the type of complication and timing, and the treatment performed in three different groups.
PATIENTS AND METHODS The medical reports of 157 OLTs in 150 patients who underwent liver transplantation between June 1991 and September 2000 were reviewed. The mean age was 48 years. Most of our patients were men (65%). The main indication for OLT was hepatitis C virus (HCV) cirrhosis associated with or without alcohol abuse (65%). The patients were divided into three groups of 50 cases each, according to the date of transplantation: Group 1, from June 1991 to October 1997; Group 2, from November 1997 to October 1999; Group 3, from November 1999 to September 2000. The complications were classified as early (within 30 days) and late (after 30 days).
RESULTS
A total of 23 patients (15.3%) had some type of BC (Table 1). In this group only one recipient (4%) died due to the BC. The most common early complication was biliary leak. Biliary strictures and stones appeared later. Three patients who had BC due to ischemia were not included; they underwent retransplantation. Seven of the nine patients with biliary leak were treated by surgery and two by (ERCP). All cases of biliary stones were resolved by ERCP with papillotomy. Of the seven patients who had
strictures, three were treated by surgery, two by ERCP, and one by percutaneous biliary dilatation. One patient with stricture improved with conservative treatment. DISCUSSION
Biliary complications have been reported in up to 30% of liver transplant recipients. These complications are frequently observed in the early posttransplant period. With the improvement in surgical techniques, the incidence of BC has decreased in some series.1 Given the high rate of morbidity of surgical intervention, especially within 6 months after OLT and the advances of therapeutic ERCP, this approach has increasing importance in the posttransplant patient.2 Endoscopic therapeutic interventions are less invasive than surgery and have fewer complications than do percutaneous procedures. Even when stenting does not result in permanent benefit, it provides drainage and resolution of infection, optimizing the presurgical setting. Stenting of the biliary tract has proved to be safe and effective in the long term, avoiding in most cases the need for more invasive surgical procedures.3 Endoscopic treatment was used as the first-choice strategy for the management of strictures and biliary leaks. Strictures and leaks represent the majority of BC after OLT.3–5 In our study, biliary leak was observed in From the Liver Transplant Unit, Hospital Sa˜o Francisco, Santa Casa Porto Alegre, RS, Brazil. Address reprint requests to Maria Lucia Zanotelli, Prof Annes Dias 285, Hospital Sa˜o Francisco, Santa Casa Porto Alegre, RS, Brazil.
Table 1. Incidence of Biliary Complications According to Date of Transplantation Group 2 (n ⫽ 50) (OLT 52–103)‡
Group 1 (n ⫽ 50)* (OLT 1–51)† Type of Biliary Complication
Leak (%) Stricture (%) Stones (%)
Group 3 (n ⫽ 50) (OLT 104 –157)§
Early
Late
Early
Late
Early
Late
2 (4) 2 (4) 0
1 (2) 0 5 (10)
2 (4) 0 0
1 (2) 2 (4) 2 (4)
3 (6) 1 (2) 0
0 2 (4) 0
*There were 28 initial cases with T-tube. † June 1991 to October 1997. ‡ November 1997 to October 1999. § November 1999 to September 2000.
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 519–520 (2002)
0041-1345/0⫺2000/$–see front matter PII S0041-1345(02)02615-5 519
520
39.1% of BC. Also, it was the most frequent early complication. Two cases of leak were successfully treated by ERCP. Initial cases were treated by surgery with no deaths related to the procedure. No statistical difference was found in the incidence of BC between the first 28 cases using T-tube and the other cases. Biliary stones were the most common late complication and were treated by ERCP with papillotomy. Biliary strictures can be anastomotic (related to the surgical technique) and nonanastomotic (result of hepatic artery thrombosis),1 the latter requiring surgical correction or retransplantation. In our study there were three cases of early stricture and four cases of late stricture. Surgery was performed in three patients, ERCP in two, and one patient was treated by percutaneous biliary dilatation (ERCP failed). One case of late stricture displayed improved serum liver enzyme levels with ursodeoxycholic acid. Cholangitis is probably the most frequent complication of ERCP for choledocholithiasis, leak or stricture. Clogging may occur at any time after placement of stents for strictures. For this reason we have used ursodeoxycholic acid in all patients and removed the endoprosthesis after 4 to 5 months. In our series we had an 11.7% incidence of cholangitis, all of them successfully treated with antibiotics, and 11.7% of pancreatitis, namely a total complication rate
FLECK, ZANOTELLI, MEINE ET AL
of 23.5%. No deaths related to the procedure were observed. Elevation of serum liver enzyme levels is often the first manifestation of a biliary complication. The clinical presentation may be indistinguishable from other complications such as rejection, hepatic artery occlusion, primary graft dysfunction, and viral infections. Imaging studies capable of detecting a biliary tract abnormality are therefore carried out in these cases. We perform ultrasound, CT, MRI, and ERCP in cases of biliary dilatation or stones. The incidence of BC and mortality in this study was similar to literature data. The incidence of BC was the same in all groups, except the incidence of biliary stones, which was more frequent in those transplanted before October 1997. REFERENCES 1. Catalano MF, Van Dam J, Sivak MV Jr: Endoscopy 27:584, 1995 2. Sossenheimer A, Slivka A, Carr-Locke D: Endoscopy 28:565, 1996 3. Bourgeois N, Devie´re J, Yeaton P, et al: Gastrointest Endosc 42:527, 1995 4. Rossi AF, Grosso C, Zanasi G, et al: Endoscopy 30:360, 1998 5. Greif F, Bronsther OL, Van Thiel DH, et al: Ann Surg 219:40, 1994
O
RTHOTOPIC liver transplantation (OLT) has become the treatment of choice for many types of chronic liver disease. Biliary complications (BC) are a significant cause of morbidity (10% to 35%) and mortality (2% to 7%) following OLT.1 The aim of this study was to analyze the incidence of BC after OLT, the type of complication and timing, and the treatment performed in three different groups.
PATIENTS AND METHODS The medical reports of 157 OLTs in 150 patients who underwent liver transplantation between June 1991 and September 2000 were reviewed. The mean age was 48 years. Most of our patients were men (65%). The main indication for OLT was hepatitis C virus (HCV) cirrhosis associated with or without alcohol abuse (65%). The patients were divided into three groups of 50 cases each, according to the date of transplantation: Group 1, from June 1991 to October 1997; Group 2, from November 1997 to October 1999; Group 3, from November 1999 to September 2000. The complications were classified as early (within 30 days) and late (after 30 days).
RESULTS
A total of 23 patients (15.3%) had some type of BC (Table 1). In this group only one recipient (4%) died due to the BC. The most common early complication was biliary leak. Biliary strictures and stones appeared later. Three patients who had BC due to ischemia were not included; they underwent retransplantation. Seven of the nine patients with biliary leak were treated by surgery and two by (ERCP). All cases of biliary stones were resolved by ERCP with papillotomy. Of the seven patients who had
strictures, three were treated by surgery, two by ERCP, and one by percutaneous biliary dilatation. One patient with stricture improved with conservative treatment. DISCUSSION
Biliary complications have been reported in up to 30% of liver transplant recipients. These complications are frequently observed in the early posttransplant period. With the improvement in surgical techniques, the incidence of BC has decreased in some series.1 Given the high rate of morbidity of surgical intervention, especially within 6 months after OLT and the advances of therapeutic ERCP, this approach has increasing importance in the posttransplant patient.2 Endoscopic therapeutic interventions are less invasive than surgery and have fewer complications than do percutaneous procedures. Even when stenting does not result in permanent benefit, it provides drainage and resolution of infection, optimizing the presurgical setting. Stenting of the biliary tract has proved to be safe and effective in the long term, avoiding in most cases the need for more invasive surgical procedures.3 Endoscopic treatment was used as the first-choice strategy for the management of strictures and biliary leaks. Strictures and leaks represent the majority of BC after OLT.3–5 In our study, biliary leak was observed in From the Liver Transplant Unit, Hospital Sa˜o Francisco, Santa Casa Porto Alegre, RS, Brazil. Address reprint requests to Maria Lucia Zanotelli, Prof Annes Dias 285, Hospital Sa˜o Francisco, Santa Casa Porto Alegre, RS, Brazil.
Table 1. Incidence of Biliary Complications According to Date of Transplantation Group 2 (n ⫽ 50) (OLT 52–103)‡
Group 1 (n ⫽ 50)* (OLT 1–51)† Type of Biliary Complication
Leak (%) Stricture (%) Stones (%)
Group 3 (n ⫽ 50) (OLT 104 –157)§
Early
Late
Early
Late
Early
Late
2 (4) 2 (4) 0
1 (2) 0 5 (10)
2 (4) 0 0
1 (2) 2 (4) 2 (4)
3 (6) 1 (2) 0
0 2 (4) 0
*There were 28 initial cases with T-tube. † June 1991 to October 1997. ‡ November 1997 to October 1999. § November 1999 to September 2000.
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 519–520 (2002)
0041-1345/0⫺2000/$–see front matter PII S0041-1345(02)02615-5 519
520
39.1% of BC. Also, it was the most frequent early complication. Two cases of leak were successfully treated by ERCP. Initial cases were treated by surgery with no deaths related to the procedure. No statistical difference was found in the incidence of BC between the first 28 cases using T-tube and the other cases. Biliary stones were the most common late complication and were treated by ERCP with papillotomy. Biliary strictures can be anastomotic (related to the surgical technique) and nonanastomotic (result of hepatic artery thrombosis),1 the latter requiring surgical correction or retransplantation. In our study there were three cases of early stricture and four cases of late stricture. Surgery was performed in three patients, ERCP in two, and one patient was treated by percutaneous biliary dilatation (ERCP failed). One case of late stricture displayed improved serum liver enzyme levels with ursodeoxycholic acid. Cholangitis is probably the most frequent complication of ERCP for choledocholithiasis, leak or stricture. Clogging may occur at any time after placement of stents for strictures. For this reason we have used ursodeoxycholic acid in all patients and removed the endoprosthesis after 4 to 5 months. In our series we had an 11.7% incidence of cholangitis, all of them successfully treated with antibiotics, and 11.7% of pancreatitis, namely a total complication rate
FLECK, ZANOTELLI, MEINE ET AL
of 23.5%. No deaths related to the procedure were observed. Elevation of serum liver enzyme levels is often the first manifestation of a biliary complication. The clinical presentation may be indistinguishable from other complications such as rejection, hepatic artery occlusion, primary graft dysfunction, and viral infections. Imaging studies capable of detecting a biliary tract abnormality are therefore carried out in these cases. We perform ultrasound, CT, MRI, and ERCP in cases of biliary dilatation or stones. The incidence of BC and mortality in this study was similar to literature data. The incidence of BC was the same in all groups, except the incidence of biliary stones, which was more frequent in those transplanted before October 1997. REFERENCES 1. Catalano MF, Van Dam J, Sivak MV Jr: Endoscopy 27:584, 1995 2. Sossenheimer A, Slivka A, Carr-Locke D: Endoscopy 28:565, 1996 3. Bourgeois N, Devie´re J, Yeaton P, et al: Gastrointest Endosc 42:527, 1995 4. Rossi AF, Grosso C, Zanasi G, et al: Endoscopy 30:360, 1998 5. Greif F, Bronsther OL, Van Thiel DH, et al: Ann Surg 219:40, 1994