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Interventional ultrasound: experience in 426 orthotopic liver transplantations
Interventional Ultrasound: Experience in 426 Orthotopic Liver Transplantations A. Campatelli, G. Di Candio, L. Morelli, L. Coletti, M. De Giovanni, L. Urbani, G. Catalano, F. Filipponi, and F. Mosca ABSTRACT Background. The purpose of this study was to analyze the role of interventional ultrasound in the treatment of nonvascular complications in liver transplant recipients. Methods. Between August 1996 and May 2003, we performed 426 OLTs in 394 patients, 287 men (73%) and 107 women (27%), mean age of 50 ⫾ 9.5 years (range 17 to 68.2). A total of 2556 diagnostic ultrasound examinations were performed, resulting in a mean of 5.9 per patient (range 2 to 21). The interventional maneuvers included: echo-guided biopsies; drainage of abdominal or thoracic effusions; drainage of abdominal, intrahepatic, or splenic collections; positioning of biliary drains; and use of the “rendezvous” technique. Results. Six hundred seventy-seven echo-guided interventional maneuvers were performed in 394 OTL patients, comprising 417 (61.6%) biopsies and 260 (38.4%) therapeutic maneuvers. Eighty-one ascite drains were positioned (31.1%); in 73 cases, pleural effusions were drained (28.1%). Sixty-seven abdominal or intrahepatic collections were drained (25.8%), of which 36 (53.7%) were due to bilomas or biliary peritonitis, 15 (22.4%) hematomas, 4 (5.9%) hepatic abscesses, 11 (16.4%) infected abdominal collections, and 1 (1.5%) splenic abscess. Thirty-nine cases (15%) of biliary drainage were performed. In 33 cases (7.9%), the parenchymal biopsies were not diagnostic because of an inadequate specimen. The treatment success rate was 96.1%. No complications related to the therapeutic maneuvers were recorded, but there were 5 biopsy-related complications (1.2%). Conclusions. Echo-guided interventional maneuvers are safe, produce a high success rate, and represent an important option in the management of OLT patients.
O
RTHOTOPIC liver transplantation (OLT) represents the most important therapeutic option for treatment of end-stage liver diseases. Evolutions in surgical technique, drugs, and immunosuppressive protocols have improved both short- and long-term results. However, surgical and immunologic complications are still a major cause of morbidity and mortality. There have been many published reports concerning the successful treatment of complications by means of a percutaneous approach guided by ultrasound or computerized tomography (CT).1 The use of ultrasound has become widespread due to availability of the equipment, the rapid and simple techniques, as well as the ability to perform and monitor the entire maneuver in real time. Herein we report the results of our experience with 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.037 550
parenchymal biopsies and echo-guided percutaneous treatment of nonvascular complications of OLT. MATERIALS AND METHODS Between August 1996 and May 2003, 426 OLTs were performed in 394 recipients, including 287 men (73%) and 107 women (27%) of mean age of 50.7 ⫾ 9.5 years (range 17 to 68.2). The 2556 From the Department of General and Transplantation Surgery (A.C., G.D.C., L.M. L.C., M.D.G., F.M.) and Liver Transplant Unit (L.U., G.C., F.F.), University of Pisa, Ospedale Cisanello, Pisa, Italy. Address reprint requests to Dr Alessandro Campatelli, Department of General and Transplantation Surgery, Ospedale Cisanello, Via Paradisa 2, 56124 Pisa, Italy. E-mail: a.campatelli@ patchir.med.unipi.it © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 550⫺551 (2004)
INTERVENTIONAL ULTRASOUND diagnostic ultrasound examinations represented a mean of 5.9 per patient (range 2 to 21). The interventional maneuvers included: (1) echo-guided biopsies for the differential diagnosis of rejection, viral relapse, and hepatic toxicity; (2) drainage of abdominal, intrahepatic, or splenic collections; (3) positioning of biliary drains; and (4) use of a “rendezvous” technique in cases of failure of endoscopic retrograde cholangiopancreatography (ERCP). During the first phase of our experience (1996 to 2001), parenchymal biopsies were performed using 14G manual Tru-cut needles; since then we have used 16G or 18G automatic cutting needles. All percutaneous drainages and needle aspirations were performed under direct ultrasound guidance to monitor the passage of the needles or catheters using the freehand technique. For purposes of aspiration, we used needles with a caliber varying from 22G to 18G, whereas the drainages were performed using 18G needles, guidewires, dilators, 8 to 14-French catheters, and fixing systems. The biliary drains were positioned under combined echofluoroscopic guidance in all cases.
RESULTS
A total of 677 echo-guided interventional maneuvers were performed in 394 OTL patients including 417 (61.6%) biopsies and 260 (38.4%) therapeutic maneuvers. Of the 417 biopsies, 379 (90.8%) were performed manually using 14G manual cutting needles, and 38 were performed automatically: 36 (11.4%) with 16G needles and 2 (0.6%) with 18G needles. The biopsy material was insufficient in 33 cases (7.9%). Five maneuver-related complications occurred (1.2%): one patient developed a hemothorax, and one each of intraparenchymal arterovenous fistula, hemoperitoneum, intraparenchymal hematoma, and choleperitoneum. All complications occurred after the use of manual 14G needles; they were conservatively treated with the aid of percutaneous maneuvers. Eighty-one peritoneal drains were positioned because of development of ascites (31.1%). There were 73 cases of pleural effusion drainage (28.1%). Sixty-seven abdominal or parenchymal collections were drained (25.8%), of which 36 (53.7%) were due to bilomas or biliary peritonitis, 15 (22.4%) to hematomas, 4 (5.9%) to hepatic abscesses, 11 (16.4%) to infected abdominal collections, and 1 (1.5%) to splenic abscess. Thirty-nine cases (15%) of biliary drainage were performed to treat biliary stenoses, of which 29 (74.3%) were external biliary drainages and 10 (25.7%) internal– external. In 2 cases (5.1%), biliary drainage was useful for endoscopic positioning of a stent (rendezvous technique). The success rate of the interventional echo-guided maneuvers was 96.1%. No complications related to the therapeutic maneuvers were recorded. No patient died as a result of these procedures.
551
DISCUSSION
Echo-guided biopsy is a fundamental option for the diagnosis of post-OLT liver dysfunction. The incidence of complications in our patient series was comparable to that described in the literature (1.2% vs 1.6%), and low in relation to the timely diagnosis essential for saving the organ.2 Positioning of drainage devices for treatment of fluid collections, abscesses, or bilomas shows a success rate of ⬎90%, thus reducing the need for repeat laparotomies.3 Fluid collections are frequent after liver transplantation and, although most are not infected and resolve spontaneously, infected collections are associated with high morbidity and mortality rates. Successful treatment can be undertaken by means of percutaneously positioned drains. Post-OLT biliary complications are one of the main sources of morbidity and mortality, and have an incidence rate of 13% to 35%.4 In our experience, the treatment of choice for biliary collections is echo-guided positioning of abdominal drains. A valid alternative in the case of high daily drainage levels is positioning of a nasobiliary probe or an endoprosthesis by means of ERCP. The other main biliary complication is obstruction, which is usually evaluated and treated endoscopically or percutaneously, although some investigators consider ERCP to be the treatment of first choice.4 We believe that interventional echotomography is useful when the stenoses are impenetrable endoscopically. We have found that, in such cases, the positioning of a biliary drain is useful to rebalance patients awaiting surgery or for the placement of a stent using the “rendezvous” technique. We conclude that the low incidence of complications and high success rate of interventional maneuvers performed under ultrasound guidance make them a fundamental diagnostic and therapeutic option for the management of OLT patients. These techniques have been successful in most clinical situations, thus obviating the need for further surgical interventions or retransplantations. REFERENCES 1. Cheng YF, Chen YS, Huang TL, et al: Interventional radiologic procedures in liver transplantation. Transplant Int 14:223, 2001 2. Perez RF, Banares R, Clemente G, et al: Severe complications of percutaneous hepatic biopsy in patients with orthotopic liver transplantation. Gastroenterol Hepatol 18:410, 1995 3. Civardi G, Di Candio G, Giorgio A, et al: Abdominal percutaneous drainage of abdominal abscess in the hands of a clinician: a multicenter Italian study. Eur J Ultrasound 8:91, 1998 4. Rerknimitr R, Sherman S, Fogel EL, et al: Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 55:224, 2002
O
RTHOTOPIC liver transplantation (OLT) represents the most important therapeutic option for treatment of end-stage liver diseases. Evolutions in surgical technique, drugs, and immunosuppressive protocols have improved both short- and long-term results. However, surgical and immunologic complications are still a major cause of morbidity and mortality. There have been many published reports concerning the successful treatment of complications by means of a percutaneous approach guided by ultrasound or computerized tomography (CT).1 The use of ultrasound has become widespread due to availability of the equipment, the rapid and simple techniques, as well as the ability to perform and monitor the entire maneuver in real time. Herein we report the results of our experience with 0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.02.037 550
parenchymal biopsies and echo-guided percutaneous treatment of nonvascular complications of OLT. MATERIALS AND METHODS Between August 1996 and May 2003, 426 OLTs were performed in 394 recipients, including 287 men (73%) and 107 women (27%) of mean age of 50.7 ⫾ 9.5 years (range 17 to 68.2). The 2556 From the Department of General and Transplantation Surgery (A.C., G.D.C., L.M. L.C., M.D.G., F.M.) and Liver Transplant Unit (L.U., G.C., F.F.), University of Pisa, Ospedale Cisanello, Pisa, Italy. Address reprint requests to Dr Alessandro Campatelli, Department of General and Transplantation Surgery, Ospedale Cisanello, Via Paradisa 2, 56124 Pisa, Italy. E-mail: a.campatelli@ patchir.med.unipi.it © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 36, 550⫺551 (2004)
INTERVENTIONAL ULTRASOUND diagnostic ultrasound examinations represented a mean of 5.9 per patient (range 2 to 21). The interventional maneuvers included: (1) echo-guided biopsies for the differential diagnosis of rejection, viral relapse, and hepatic toxicity; (2) drainage of abdominal, intrahepatic, or splenic collections; (3) positioning of biliary drains; and (4) use of a “rendezvous” technique in cases of failure of endoscopic retrograde cholangiopancreatography (ERCP). During the first phase of our experience (1996 to 2001), parenchymal biopsies were performed using 14G manual Tru-cut needles; since then we have used 16G or 18G automatic cutting needles. All percutaneous drainages and needle aspirations were performed under direct ultrasound guidance to monitor the passage of the needles or catheters using the freehand technique. For purposes of aspiration, we used needles with a caliber varying from 22G to 18G, whereas the drainages were performed using 18G needles, guidewires, dilators, 8 to 14-French catheters, and fixing systems. The biliary drains were positioned under combined echofluoroscopic guidance in all cases.
RESULTS
A total of 677 echo-guided interventional maneuvers were performed in 394 OTL patients including 417 (61.6%) biopsies and 260 (38.4%) therapeutic maneuvers. Of the 417 biopsies, 379 (90.8%) were performed manually using 14G manual cutting needles, and 38 were performed automatically: 36 (11.4%) with 16G needles and 2 (0.6%) with 18G needles. The biopsy material was insufficient in 33 cases (7.9%). Five maneuver-related complications occurred (1.2%): one patient developed a hemothorax, and one each of intraparenchymal arterovenous fistula, hemoperitoneum, intraparenchymal hematoma, and choleperitoneum. All complications occurred after the use of manual 14G needles; they were conservatively treated with the aid of percutaneous maneuvers. Eighty-one peritoneal drains were positioned because of development of ascites (31.1%). There were 73 cases of pleural effusion drainage (28.1%). Sixty-seven abdominal or parenchymal collections were drained (25.8%), of which 36 (53.7%) were due to bilomas or biliary peritonitis, 15 (22.4%) to hematomas, 4 (5.9%) to hepatic abscesses, 11 (16.4%) to infected abdominal collections, and 1 (1.5%) to splenic abscess. Thirty-nine cases (15%) of biliary drainage were performed to treat biliary stenoses, of which 29 (74.3%) were external biliary drainages and 10 (25.7%) internal– external. In 2 cases (5.1%), biliary drainage was useful for endoscopic positioning of a stent (rendezvous technique). The success rate of the interventional echo-guided maneuvers was 96.1%. No complications related to the therapeutic maneuvers were recorded. No patient died as a result of these procedures.
551
DISCUSSION
Echo-guided biopsy is a fundamental option for the diagnosis of post-OLT liver dysfunction. The incidence of complications in our patient series was comparable to that described in the literature (1.2% vs 1.6%), and low in relation to the timely diagnosis essential for saving the organ.2 Positioning of drainage devices for treatment of fluid collections, abscesses, or bilomas shows a success rate of ⬎90%, thus reducing the need for repeat laparotomies.3 Fluid collections are frequent after liver transplantation and, although most are not infected and resolve spontaneously, infected collections are associated with high morbidity and mortality rates. Successful treatment can be undertaken by means of percutaneously positioned drains. Post-OLT biliary complications are one of the main sources of morbidity and mortality, and have an incidence rate of 13% to 35%.4 In our experience, the treatment of choice for biliary collections is echo-guided positioning of abdominal drains. A valid alternative in the case of high daily drainage levels is positioning of a nasobiliary probe or an endoprosthesis by means of ERCP. The other main biliary complication is obstruction, which is usually evaluated and treated endoscopically or percutaneously, although some investigators consider ERCP to be the treatment of first choice.4 We believe that interventional echotomography is useful when the stenoses are impenetrable endoscopically. We have found that, in such cases, the positioning of a biliary drain is useful to rebalance patients awaiting surgery or for the placement of a stent using the “rendezvous” technique. We conclude that the low incidence of complications and high success rate of interventional maneuvers performed under ultrasound guidance make them a fundamental diagnostic and therapeutic option for the management of OLT patients. These techniques have been successful in most clinical situations, thus obviating the need for further surgical interventions or retransplantations. REFERENCES 1. Cheng YF, Chen YS, Huang TL, et al: Interventional radiologic procedures in liver transplantation. Transplant Int 14:223, 2001 2. Perez RF, Banares R, Clemente G, et al: Severe complications of percutaneous hepatic biopsy in patients with orthotopic liver transplantation. Gastroenterol Hepatol 18:410, 1995 3. Civardi G, Di Candio G, Giorgio A, et al: Abdominal percutaneous drainage of abdominal abscess in the hands of a clinician: a multicenter Italian study. Eur J Ultrasound 8:91, 1998 4. Rerknimitr R, Sherman S, Fogel EL, et al: Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 55:224, 2002