Response to endoscopic therapy for biliary anastomotic strictures in deceased versus living donor liver transplantation

BACKGROUND:Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation(DDLT) and living donor liver transplantation(LDLT).LDLT is thought to be associated with higher rates of biliary complications,but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups.This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT.METHODS:This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) after liver transplantation.The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT.The response of anastomotic stricture to endoscopic therapy was also analyzed.RESULTS:A total of 362 patients underwent liver transplantation between 2003 and 2011,with 125 requiring ERCP to manage biliary complications.Thirty-three(9.9%) cases of DDLT and 8(27.6%) of LDLT(P=0.01) were found to have anastomotic stricture.When comparing DDLT and LDLT,there was no difference in the mean time to the development of anastomotic strictures(98±17 vs 172±65 days,P=0.11),likelihood of response to ERCP [22(66.7%) vs 6(75.0%),P=0.69],mean time to the resolution of anastomotic strictures(268±77 vs 125±37 days,P=0.34),and the number of ERCPs required to achieve resolution(3.9±0.4 vs 4.7±0.9,P=0.38).CONCLUSIONS:Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation.Anastomotic strictures occur more frequently in LDLT compared with DDLT,with equivalent endoscopic treatment response and outcomes for both groups.

Biliary tract reconstruction using jejunal tube:an experimental study in dogs

BACKGROUND:To physiologically reconstruct the biliary tract,Crema et al suggested the application of the Monti principle to the biliary tract,already used in humans for the urinary tract.With this technique,a jejunal segment is transversely retubularized.This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs.METHODS:Thirteen dogs underwent a laparoscopic common bile duct ligature,followed by a biliodigestive connection by jejunal tube interposition after one week.The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases,total bilirubins,alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia,which was performed 6 weeks after biliodigestive connection.RESULTS:Data on 9 dogs were analyzed statistically.The dogs presented with obstructive jaundice after common bile duct ligature,as confirmed by biochemical examination.They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment.CONCLUSION:A statistically significant reduction was seen in total bilirubin and canalicular enzymes(alkaline phosphatase and gamma-glutamyltransferase)in the 9 dogs 6 weeks after biliodigestive connetion by jejunal tube interposition.

Clinical features and treatment of sump syndrome following hepaticojejunostomy

BACKGROUND:Cholangitis after Roux-en-Y hepaticojejunostomy is usually caused by anastomotic stricture.A small number of cases present without evidence of obstruction and are ascribed to reflux of gastro-intestinal content into the biliary tree above the anastomosis (sump syndrome).Despite prophylactic rotating antibiotic therapy,the cholangitic episode may be severe and life-threatening.METHODS:From 2001 to 2006,six patients who had undergone an end-to-side hepaticojejunostomy presented to our institution with recurrent episodes of biliary sepsis.Anastomotic stricture was excluded by liver MRI/MRCP and percutaneous transhepatic cholangiogram (PTC).Barium meal showed reflux of contrast into the biliary tree in all patients.Three patients had a short jejunal Roux limb (less than 50 cm) on pre-operative imaging.RESULTS:Five patients underwent surgery and two of them had two operations.One patient had a Tsuchida antireflux valve and subsequently underwent lengthening of the Roux loop.Three patients had lengthening of the Roux loop;one underwent re-do hepaticojejunostomy and one had concomitant revision of the hepaticojejunostomy and lengthening of the Roux loop.The latter underwent further lengthening of the Roux loop.Three patients are cholangitis-free 6,36 and 60 months after surgery;two still experience mild episodes of cholangitis.CONCLUSIONS:An adequate length of the Roux loop is important to prevent reflux.However,Roux loop lengthening to 70 cm or more does not always resolve the problem and cholangitis,although generally less frequent and severe,may recur despite appropriate reconstructive or antireflux surgery.In these cases,life-long rotating antibiotics is the only available measure.