Single-operator cholangioscopy for biliary complications in liver transplant recipients

AIM To evaluate cholangioscopy in addition to endoscopic retrograde cholangiopancreatography(ERCP) for management of biliary complications after liver transplantation(LT).METHODS Twenty-six LT recipients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between April and December2016 at the university hospital of Muenster were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy s y s t e m(S py G la s s D S ?) wa s pe r fo r me d dur ing the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis and bile was collected during the intervention for microbial analysis and for antibiotic susceptibility testing.RESULTS Thirty-three biliary complications were found in a total of 22 patients, whereas four patients showed normal bile ducts. Anastomotic strictures were evident in 14(53.8%) patients, non-anastomotic strictures in seven(26.9%), biliary cast in three(11.5%), and stones in six(23.1%). A benefit of cholangioscopy was seen in 12(46.2%) patients. In four of them, cholangioscopy was crucial for selective guidewire placement prior to planned intervention. In six patients, biliary cast and/or stones failed to be diagnosed by ERCP and were only detectable through cholangioscopy. In one case, a bile duct ulcer due to fungal infection was diagnosed by cholangioscopy. In another case, signs of bile duct inflammation caused by acute cholangitis were evident. One patient developed post-interventional cholangitis. No further procedure-related complications occurred. Thirty-seven isolates were found in bile. Sixteen of these were gram-positive(43.2%), 12(32.4%) were gram-negative bacteria, and Candida species accounted for 24.3% of all isolated microorganisms. Interestingly, only 48.6% of specimens were sensitive to prophylactic antibiotics.CONCLUSION Single-operator cholangioscopy can provide important diagnostic information, helping endoscopists to plan and perform interventional procedures in LT-related biliary complications.

Paclitaxel-eluting balloon dilation of biliary anastomotic stricture after liver transplantation

AIM:To investigate the safety and effectiveness of endoscopic therapy with a paclitaxel-eluting balloon(PEB) for biliary anastomotic stricture(AS) after liver transplantation(LT).METHODS:This prospective pilot study enrolled 13 consecutive eligible patients treated for symptomatic AS after LT at the University Hospital of Münster between January 2011 and March 2014.The patients were treated by endoscopic therapy with a PEB and followed up every 8 wk by endoscopic retrograde cholangiopancreatography(ERCP).In cases of re-stenosis,further balloon dilation with a PEB was performed.Follow-up was continued until 24 mo after the last intervention.RESULTS:Initial technical feasibility,defined as successful balloon dilation with a PEB during the initial ERCP procedure,was achieved in 100% of cases.Long-term clinical success(LTCS),defined as no need for further endoscopic intervention for at least 24 mo,was achieved in 12 of the 13 patients(92.3%).The mean number of endoscopic interventions required to achieve LTCS was only 1.7 ± 1.1.Treatment failure,defined as the need for definitive alternative treatment,occurred in only one patient,who developed recurrent stenosis with increasing bile duct dilatation that required stent placement.CONCLUSION:Endoscopic therapy with a PEB is very effective for the treatment of AS after LT,and seems to significantly shorten the overall duration of endoscopic treatment by reducing the number of interventions needed to achieve LTCS.