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Establishing a systematic endoscopic approach to the management of anastomotic biliary strictures is needed
LIVER TRANSPLANTATION WORLDWIDE Establishing a Systematic Endoscopic Approach to the Management of Anastomotic Biliary Strictures Is Needed Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Mahajani RV, Cotler SJ, Uzer F. Endoscopy 2000;32:943-949. (Reprinted with permission.) Abstract
Comments The use of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of post– orthotopic liver transplantation (OLT) biliary complications is well described.1 Types of complications that have been treated endoscopically include anastomotic ductal strictures, anastomotic ductal leaks, ductal leaks at T-tube sites, ischemic strictures, and biliary cast syndrome. The other 2 options to treat these complications are percu-
378
taneous management and surgical revision (including re-OLT).2 The study by Mahajani et al3 focuses on the endoscopic outcomes of managing a specific type of post-OLT biliary complication, the choledochocholedochal anastomotic biliary stricture. The investigators performed endoscopic balloon dilation of anastomotic strictures in 29 patients. Nine patients did not require other treatment. Of the remaining 20 patients, 10 patients required subsequent stricture dilation and 6 patients with a persistent stricture required endoscopic placement of a biliary stent. At a mean follow-up of 17.9 months (range, 0.5 to 58 months), significant improvements occurred in serum alkaline phosphatase and bilirubin levels. Surgical revision of the anastomosis was avoided in all patients. Nonfatal complications occurred after 6.5% of endoscopic procedures performed. Three patients required adjuvant percutaneous procedures to access the biliary tree. How do these results compare with those of previously published studies? Schwartz et al4 recently published results showing the efficacy of endoscopic therapy and balloon dilation for anastomotic biliary strictures in 15 patients. Balloon dilation alone was effective therapy for 47% of the patients, whereas balloon dilation followed by endoscopic stent placement was more efficacious. In this study by Mahajani et al,3 balloon dilation alone was effective in 63% of the patients. This difference may be explained by the difference in endoscopic techniques used. Schwartz et al4 used 4- and 6-mm dilating balloons, whereas Mahajani et al3 used larger caliber balloons (up to 11 mm). This difference was reflected in the larger postdilation stricture diameters achieved between the 2 studies (7.0 v 4.3 mm). Rossi et al5 described the results of endoscopic therapy for post-OLT anastomotic biliary strictures consisting of dilation using 11 F (⬃4-mm) rigid dilators as needed to allow placement of a single 10 F biliary stent. Stents remained in place across the anastomosis for 1 year.5 Of 15 patients treated, 10 patients (67%) were well 1 year after stent removal and 2 patients required endoscopic reintervention. More recently, Pfau et al6 reported their results after endoscopic management of a variety of post-OLT biliary complications. Of the 64 patients undergoing endoscopic therapy, 39 procedures were performed for obstruction, and 8 of these procedures were performed for anastomotic strictures. Of these 8 procedures, successful nonsurgical treatment using endoscopic techniques was achieved in only 4 patients (50%). Endoscopic techniques consisted of no therapy in 1 patient,
Liver Transplantation, Vol 7, No 4 (April), 2001: pp 378-379
Liver Transplantation Worldwide
biliary stent placement alone without stricture dilation in 2 patients, and combined balloon dilation (5- to 8-mm diameter) and placement of biliary stents of various diameters (1 or 2 stents, 7 F; 1 stent, 10 F) in 5 patients. With regard to the management of post-OLT anastomotic biliary strictures, what can we conclude from the endoscopic literature in light of the present study by Mahajani et al?3 I believe there are 6 major points: (1) endoscopic therapy is an effective nonsurgical option for the management of post-OLT anastomotic strictures; (2) ERCP is safer than percutaneous techniques with regard to complications, as well as more comfortable for the patient because there are no external drainage catheters using endoscopic techniques; (3) effective endoscopic therapy requires the use of either large-caliber dilating balloons (ⱖ8 mm), with stenting reserved for inadequate response to dilation (postdilation stricture diameter ⬍7 mm) or poor clinical response to dilation alone; or modest balloon dilation plus placement of large-caliber stents (ⱖ10 F); (4) the percutaneous approach should be reserved for assistance in achieving endoscopic therapy when the bile duct cannot be cannulated or the stricture cannot be traversed at ERCP (this can be achieved with a small percutaneous catheter that may be removed after repeated endoscopic therapy and also avoids the need to create a large tract through the liver or a residual external catheter; (5) percutaneous therapy should be the primary therapy for involving anastomotic strictures occurring in the setting of a choledochojejunostomy; and (6) assuming endoscopic therapy has failed and no serious procedural complications have occurred, surgical options remain unhindered. This author has approached post-OLT anastomotic strictures by using endoscopic techniques proven effective in the treatment of benign postoperative biliary strictures.7 This involves stricture dilation using an 8-mm dilating balloon and placement of either 2 stents with 10 F diameters or a combination of a 10 F and a 7 F stent, with upsizing to 2 stents of 10 F at a later date. Stents are exchanged at 3- or 4-month intervals and remain in place for up to 1 year. Using this technique, the results (T.H. Baron, unpublished data) have been nearly uniformly successful, but may be a bit of an overkill based on the results reported by Mahajani et al,3 in which aggressive balloon dilation without stent placement may suffice. These studies clearly show a need to establish a systematic endoscopic approach to the management of these strictures, as with the management of benign esophageal strictures, so that meaningful comparisons can be made and the optimal endoscopic approach may
379
be determined. The differences in published outcomes after endoscopic dilation of post-OLT anastomotic biliary strictures can be explained by differences in endoscopic methods. Whether dilation is performed and to what degree and whether biliary stents are placed, as well as their diameter, affect the outcome after endoscopic therapy. As with most controversial issues in medicine, final recommendations regarding therapy for post-OLT anastomotic strictures will require a randomized controlled trial, likely a multicenter trial, to achieve a sufficient sample size. Although the ultimate comparative study would randomize patients to undergo the 3 different treatment options of endoscopic therapy, percutaneous therapy, and surgical therapy for treatment of anastomotic strictures, it is highly unlikely this will (or could) be done. Until then, I believe an endoscopic approach for the management of post-OLT anastomotic strictures is the best first option. However, a multidisciplinary approach involving the transplant surgeon, transplant hepatologist, and interventionalists (endoscopic and radiological) is needed to manage an individual patient with a post-OLT anastomotic stricture in context with the strengths and weaknesses of each discipline within an institution. Todd H. Baron, MD, FACP Department of Gastroenterology and Hepatology Mayo Medical Center 200 First St SW, Eisenberg 8A Rochester, MN 55905
References 1. Sherman S, Jamidar P, Shaked A, Kendall BJ, Goldstein LI, Busuttil RW. Biliary tract complications after orthotopic liver transplantation. Endoscopic approach to diagnosis and therapy. Transplantation 1995;60:467-470. 2. Jeffrey GP, Brind AM, Ormonde DG, Frazer CK, Ferguson J, Bell R, et al. Management of biliary tract complications following liver transplantation. Aust N Z J Surg 1999;69:717-722. 3. Mahajani RV, Cotler SJ, Uzer F. Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 2000;32:943-949. 4. Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 2000;51:169-174. 5. Rossi AF, Grosso C, Zanasi G, Gambitta P, Bini M, De Carlis L, 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. 6. Pfau PR, Kochman ML, Lewis JD, Long WB, Lucey MR, Olthoff K, et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000;52:55-63. 7. Davids PH, Tanka AK, Rauws EA, van Gulik TM, van Leeuwen DJ, de Wit LT, et al. Benign biliary strictures. Surgery or endoscopy? Ann Surg 1993;217:237-243.
Comments The use of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of post– orthotopic liver transplantation (OLT) biliary complications is well described.1 Types of complications that have been treated endoscopically include anastomotic ductal strictures, anastomotic ductal leaks, ductal leaks at T-tube sites, ischemic strictures, and biliary cast syndrome. The other 2 options to treat these complications are percu-
378
taneous management and surgical revision (including re-OLT).2 The study by Mahajani et al3 focuses on the endoscopic outcomes of managing a specific type of post-OLT biliary complication, the choledochocholedochal anastomotic biliary stricture. The investigators performed endoscopic balloon dilation of anastomotic strictures in 29 patients. Nine patients did not require other treatment. Of the remaining 20 patients, 10 patients required subsequent stricture dilation and 6 patients with a persistent stricture required endoscopic placement of a biliary stent. At a mean follow-up of 17.9 months (range, 0.5 to 58 months), significant improvements occurred in serum alkaline phosphatase and bilirubin levels. Surgical revision of the anastomosis was avoided in all patients. Nonfatal complications occurred after 6.5% of endoscopic procedures performed. Three patients required adjuvant percutaneous procedures to access the biliary tree. How do these results compare with those of previously published studies? Schwartz et al4 recently published results showing the efficacy of endoscopic therapy and balloon dilation for anastomotic biliary strictures in 15 patients. Balloon dilation alone was effective therapy for 47% of the patients, whereas balloon dilation followed by endoscopic stent placement was more efficacious. In this study by Mahajani et al,3 balloon dilation alone was effective in 63% of the patients. This difference may be explained by the difference in endoscopic techniques used. Schwartz et al4 used 4- and 6-mm dilating balloons, whereas Mahajani et al3 used larger caliber balloons (up to 11 mm). This difference was reflected in the larger postdilation stricture diameters achieved between the 2 studies (7.0 v 4.3 mm). Rossi et al5 described the results of endoscopic therapy for post-OLT anastomotic biliary strictures consisting of dilation using 11 F (⬃4-mm) rigid dilators as needed to allow placement of a single 10 F biliary stent. Stents remained in place across the anastomosis for 1 year.5 Of 15 patients treated, 10 patients (67%) were well 1 year after stent removal and 2 patients required endoscopic reintervention. More recently, Pfau et al6 reported their results after endoscopic management of a variety of post-OLT biliary complications. Of the 64 patients undergoing endoscopic therapy, 39 procedures were performed for obstruction, and 8 of these procedures were performed for anastomotic strictures. Of these 8 procedures, successful nonsurgical treatment using endoscopic techniques was achieved in only 4 patients (50%). Endoscopic techniques consisted of no therapy in 1 patient,
Liver Transplantation, Vol 7, No 4 (April), 2001: pp 378-379
Liver Transplantation Worldwide
biliary stent placement alone without stricture dilation in 2 patients, and combined balloon dilation (5- to 8-mm diameter) and placement of biliary stents of various diameters (1 or 2 stents, 7 F; 1 stent, 10 F) in 5 patients. With regard to the management of post-OLT anastomotic biliary strictures, what can we conclude from the endoscopic literature in light of the present study by Mahajani et al?3 I believe there are 6 major points: (1) endoscopic therapy is an effective nonsurgical option for the management of post-OLT anastomotic strictures; (2) ERCP is safer than percutaneous techniques with regard to complications, as well as more comfortable for the patient because there are no external drainage catheters using endoscopic techniques; (3) effective endoscopic therapy requires the use of either large-caliber dilating balloons (ⱖ8 mm), with stenting reserved for inadequate response to dilation (postdilation stricture diameter ⬍7 mm) or poor clinical response to dilation alone; or modest balloon dilation plus placement of large-caliber stents (ⱖ10 F); (4) the percutaneous approach should be reserved for assistance in achieving endoscopic therapy when the bile duct cannot be cannulated or the stricture cannot be traversed at ERCP (this can be achieved with a small percutaneous catheter that may be removed after repeated endoscopic therapy and also avoids the need to create a large tract through the liver or a residual external catheter; (5) percutaneous therapy should be the primary therapy for involving anastomotic strictures occurring in the setting of a choledochojejunostomy; and (6) assuming endoscopic therapy has failed and no serious procedural complications have occurred, surgical options remain unhindered. This author has approached post-OLT anastomotic strictures by using endoscopic techniques proven effective in the treatment of benign postoperative biliary strictures.7 This involves stricture dilation using an 8-mm dilating balloon and placement of either 2 stents with 10 F diameters or a combination of a 10 F and a 7 F stent, with upsizing to 2 stents of 10 F at a later date. Stents are exchanged at 3- or 4-month intervals and remain in place for up to 1 year. Using this technique, the results (T.H. Baron, unpublished data) have been nearly uniformly successful, but may be a bit of an overkill based on the results reported by Mahajani et al,3 in which aggressive balloon dilation without stent placement may suffice. These studies clearly show a need to establish a systematic endoscopic approach to the management of these strictures, as with the management of benign esophageal strictures, so that meaningful comparisons can be made and the optimal endoscopic approach may
379
be determined. The differences in published outcomes after endoscopic dilation of post-OLT anastomotic biliary strictures can be explained by differences in endoscopic methods. Whether dilation is performed and to what degree and whether biliary stents are placed, as well as their diameter, affect the outcome after endoscopic therapy. As with most controversial issues in medicine, final recommendations regarding therapy for post-OLT anastomotic strictures will require a randomized controlled trial, likely a multicenter trial, to achieve a sufficient sample size. Although the ultimate comparative study would randomize patients to undergo the 3 different treatment options of endoscopic therapy, percutaneous therapy, and surgical therapy for treatment of anastomotic strictures, it is highly unlikely this will (or could) be done. Until then, I believe an endoscopic approach for the management of post-OLT anastomotic strictures is the best first option. However, a multidisciplinary approach involving the transplant surgeon, transplant hepatologist, and interventionalists (endoscopic and radiological) is needed to manage an individual patient with a post-OLT anastomotic stricture in context with the strengths and weaknesses of each discipline within an institution. Todd H. Baron, MD, FACP Department of Gastroenterology and Hepatology Mayo Medical Center 200 First St SW, Eisenberg 8A Rochester, MN 55905
References 1. Sherman S, Jamidar P, Shaked A, Kendall BJ, Goldstein LI, Busuttil RW. Biliary tract complications after orthotopic liver transplantation. Endoscopic approach to diagnosis and therapy. Transplantation 1995;60:467-470. 2. Jeffrey GP, Brind AM, Ormonde DG, Frazer CK, Ferguson J, Bell R, et al. Management of biliary tract complications following liver transplantation. Aust N Z J Surg 1999;69:717-722. 3. Mahajani RV, Cotler SJ, Uzer F. Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 2000;32:943-949. 4. Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 2000;51:169-174. 5. Rossi AF, Grosso C, Zanasi G, Gambitta P, Bini M, De Carlis L, 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. 6. Pfau PR, Kochman ML, Lewis JD, Long WB, Lucey MR, Olthoff K, et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000;52:55-63. 7. Davids PH, Tanka AK, Rauws EA, van Gulik TM, van Leeuwen DJ, de Wit LT, et al. Benign biliary strictures. Surgery or endoscopy? Ann Surg 1993;217:237-243.