BACKGROUND Biliary atresia(BA)is the most common indication for pediatric liver transplantation,although portoenterostomy is usually performed first.However,due to the high failure rate of portoenterostomy,liver trans...BACKGROUND Biliary atresia(BA)is the most common indication for pediatric liver transplantation,although portoenterostomy is usually performed first.However,due to the high failure rate of portoenterostomy,liver transplantation has been advocated as the primary procedure for patients with BA.It is still unclear if a previous portoenterostomy has a negative impact on liver transplantation outcomes.AIM To investigate the effect of prior portoenterostomy in infants un-dergoing liver transplantation for BA.METHODS This was a retrospective cohort study of 42 pediatric patients with BA who underwent primary liver transplantation from 2013 to 2023 at a single tertiary center in Brazil.Patients with BA were divided into two groups:Those undergoing primary liver transplantation without portoenterostomy and those undergoing liver transplantation with prior portoenterostomy.Continuous variables were compared using the Student’s t-test or the Kruskal-Wallis test,and categorical variables were compared using theχ2 or Fisher’s exact test,as appropriate.Multivariable Cox regression analysis was performed to determine risk factors for portal vein thrombosis.Patient and graft survival analyses were conducted with the Kaplan–Meier product-limit estimator,and patient subgroups were compared using the two-sided log-rank test.RESULTS Forty-two patients were included in the study(25[60%]girls),23 undergoing liver transplantation without prior portoenterostomy,and 19 undergoing liver transplantation with prior portoenterostomy.Patients with prior portoenterostomy were older(12 vs 8 months;P=0.02)at the time of liver transplantation and had lower Pediatric End-Stage Liver Disease scores(13.2 vs 21.4;P=0.01).The majority of the patients(35/42,83%)underwent livingdonor liver transplantation.The group of patients without prior portoenterostomy appeared to have a higher incidence of portal vein thrombosis(39 vs 11%),but this result did not reach statistical significance.Prior portoenterostomy was not a protective factor against portal vein thrombosis in the multivariable analysis after adjusting for age at liver transplantation,graft-to-recipient weight ratio,and use of vascular grafts.Finally,the groups did not significantly differ in terms of post-transplant survival.CONCLUSION In our study,prior portoenterostomy did not significantly affect the outcomes of liver transplantation.展开更多
Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Bil...Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.展开更多
BACKGROUND: Ischemic-type biliary lesions (ITBLs) play an extremely important role in influencing the long-term survival and quality of life of recipients after orthotopic liver transplantation (OLT). Some patients ca...BACKGROUND: Ischemic-type biliary lesions (ITBLs) play an extremely important role in influencing the long-term survival and quality of life of recipients after orthotopic liver transplantation (OLT). Some patients can be cured by interventional therapies, however others lose their grafts at last and receive liver retransplantation (re-OLT). The aim of this study was to analyze the data of 66 patients who had received re-OLT at our center because of ITBL and to discuss the treatment of ITBL after OLT. METHODS: We retrospectively analyzed 66 re-OLT cases due to ITBL from September 2001 to February 2007 at our center. The Kaplan-Meier method and the Cox-Mantel test were used to identify factors associated with mortality for univariate analysis and multivariate analysis, respectively. RESULTS: Fifty-five of 66 ITBL cases underwent interventional therapies before re-OLT. The actuarial survival at I month and I year for these patients was 83% and 74%, respectively. Prognostic factors for mortality in univariate analysis were model of end-stage liver disease score (MELD) >16.5 (chi(2)=5.856, P=0.016), cold ischemia time >8 hours (chi(2)=6.539, P=0.011), infections (chi(2)=5.550, P=0.018) and complications (chi(2)=12.168, P=0.002) after re-OLT. In the multivariate analysis (Cox regression), the risk factors independently associated with mortality were MELD score >16.5 (RR: 3.140; P=0.035), cold ischemia time >8.2 hours (RR: 0.192; P=0.016) and complications (RR: 3.896, P=0.003). CONCLUSIONS: The incidence of ITBL in China is higher than in other countries. Based on our experience, MELD score, cold ischemia time and complications after re-OLT are risk factors independently associated with mortality in retransplanted ITBL patients.展开更多
AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.METHODS:...AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.METHODS: Patients who developed biliary complications were analysed in detail for the clinical information, laboratory tests, treatment offered, response to it, follow up and outcomes. The profile of liver enzymes was determined. The safety, efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed. RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be 〉 3 times (388.1 ± 70.9 U/mL vs 168.5 4± 34.2 U/L, P = 0.007) and SAP 〉 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L, P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic res in 28 (40%). Sustained success was achieved in 26 (81%) patients. CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early, non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.展开更多
BACKGROUND:Ischemia-related biliary tract complications remain high after orthotopic liver transplantation.Severe ischemic biliary complications often involve the hepatic duct bifurcation and left hepatic duct,resulti...BACKGROUND:Ischemia-related biliary tract complications remain high after orthotopic liver transplantation.Severe ischemic biliary complications often involve the hepatic duct bifurcation and left hepatic duct,resulting finally in obstructive jaundice.Prevention and management of such complications remain a challenge for transplant surgeons.METHODS:All 160 patients were followed up for at least 180 days after transplantation.One-way analysis of variance (ANOVA) and comparative univariate analysis were made using 3 groups (no complications;mild complications;severe complications),to analyze risk factors associated with biliary complications.Multiple logistic regression and linear regression analysis were used to analyze independent risk factors for severe ischemic biliary complications,after excluding other confounding factors.RESULTS:By ANOVA and comparative univariate analysis,the risk factors associated with biliary complications were preoperative bilirubin level (P=0.007) and T-tube stenting of the anastomosis (P=0.016).Multiple logistic regression analysis showed that the use of T-tube and preoperative serum bilirubin were not independent risk factors for severe ischemic biliary complications after orthotopic liver transplantation.Chi-square analysis indicated that in the incidence of severe ischemic biliary lesions,bile duct second warm ischemic time longer than 60 minutes was a significant risk factor.Linear regression demonstrated a negative correlation between cold preservation time and warm ischemia time.CONCLUSIONS:Preoperative serum bilirubin level and the use of T-tube stenting of the anastomosis were independent risk factors for biliary complications after liver transplantation,but not for severe ischemic biliary complications.The second warm ischemia time of bile duct longer than 60minutes and prolonged bile duct second warm ischemia time combined with cold preservation time were significant risk factors for severe ischemic biliary complications after liver transplantation with grafts from non-heart-beating donors.展开更多
AIM: To compare the value of endoscopic retrograde cholangiography (ERC) and standard T2-weighted magnetic resonance cholangiography (MRC) in the evaluation process as adult-to-adult right lobe living donor liver tran...AIM: To compare the value of endoscopic retrograde cholangiography (ERC) and standard T2-weighted magnetic resonance cholangiography (MRC) in the evaluation process as adult-to-adult right lobe living donor liver transplantation (LDLTx) demands a successful outcome, and exact knowledge of the biliary tree is implicated to avoid biliary complications, postoperatively.METHODS: After starting the LDLTx program, 18 liver transplant candidates were selected for LDLTx by a stepwise evaluation process. ERC and standard T2-weighted MRC were performed to evaluate the biliary system of the donor liver. The anatomical findings of ERC and MRC mapping were compared using the Ohkubo classification. RESULTS: ERC allowed mapping of the whole biliary system in 15/15 (100%) cases, including 14/15 (93.3%) with biliary variants while routine MRC was only accurate in 2/13 (15.4%) cases. MRC was limited in depicting the biliary system proximal of the hepatic bifurcation. Postoperative biliary complications occurred in 2 donors and 8 recipients. Biliary complications were associated with Ohkubo type C, E or G in 6/8 recipients, and 2/3 recipients with biliary leak received a graft with multiple (≥2) bile ducts. CONCLUSION: Pretransplant ERC is safe and superior over standard MRC for detection of biliary variations that occur with a high frequency. However, precise knowledge of biliary variants did not reduce the incidence of postoperative biliary complications.展开更多
Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the di...Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.展开更多
BACKGROUND Laparoscopic living donor hepatectomy(LLDH)has been successfully carried out in several transplant centers.Biliary reconstruction is key in living donor liver transplantation(LDLT).Reliable biliary reconstr...BACKGROUND Laparoscopic living donor hepatectomy(LLDH)has been successfully carried out in several transplant centers.Biliary reconstruction is key in living donor liver transplantation(LDLT).Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage.Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points,biliary variability and limitations associated with LLDH,multiple biliary tracts are often encountered during surgery,which inhibits biliary reconstruction.A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT.This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARY A 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation.Due to the scarcity of deceased donors,she was put on the waiting list for LDLT.Her father was a suitable donor;however,after a rigorous evaluation,preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract.Therefore,a laparoscopic left lateral section was performed on the donor,which met the estimated graft-to-recipient weight ratio.Under intraoperative indocyanine green cholangiography,4 biliary tracts were confirmed in the graft.It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm.A reliable cholangiojejunostomy was,therefore,utilized:Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures.At the last follow-up(1 year after surgery),the patient was complication-free.CONCLUSION Intrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.展开更多
AIM: Recently it has been reported that granulocyte colony stimulating factor (G-CSF) can induce hypercoagulability in healthy bone marrow donors. It is conceivable that the induction of a prothrombotic state in a ...AIM: Recently it has been reported that granulocyte colony stimulating factor (G-CSF) can induce hypercoagulability in healthy bone marrow donors. It is conceivable that the induction of a prothrombotic state in a recipient of an organ graft with already impaired perfusion might cause further deterioration in the transplanted organ. This study evaluated whether G-CSF treatment worsens liver perfusion following liver transplantation in the rat model. METHODS: A non-arterialized rat liver transplantation model was employed to evaluate the effect of G-CSF treatment on the liver in a syngeneic and allogeneic strain combination. Study outcomes included survival time and liver damage as investigated by liver enzymes and liver histology. Observation times were 1 d, 1 wk and 12 wk. RESULTS: Rats treated with G-CSF had increased incidence and severity of biliary damage following liver transplantation. In these animals, hepatocellular necrosis was accentuated in the centrilobular region. These lesions are indicative of impaired perfusion in G-CSF treated animals. CONCLUSION: G-CSF should be used with caution in recipients of liver transplantation, as treatment might enhance preexisting, undetected perfusion problems and ultimately lead to ischemia induced biliary complications .展开更多
BACKGROUND Endoscopic therapy using multiple plastic stents(MPSs)is the standard therapy for postorthotopic liver transplantation(p-OLT)anastomotic biliary stricture(ABS).However,this approach demands repeated procedu...BACKGROUND Endoscopic therapy using multiple plastic stents(MPSs)is the standard therapy for postorthotopic liver transplantation(p-OLT)anastomotic biliary stricture(ABS).However,this approach demands repeated procedures.Recent studies us-ing fully covered self-expandable metallic stents(FCSEMS)have shown en-couraging results,but migration occurs in 10%to 40%of cases.The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system(Am-FCSEMS)in patients with p-OLT ABS.AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODS This study was conducted in a private tertiary care centre in S?o Paulo,Brazil and was approved by our institution's Human Research Committee.From April 2018 to October 2020,regardless of previous endoscopic treatment(MPS or FCSEMS),17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study.The exclusion criteria were pregnancy,nonanastomotic biliary or hilar stricture,hepatic artery stenosis/thrombosis,isolated biliary fistulae,a distance shorter than 2 cm from the stricture to the hepatic hilum,and patient refusal.The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that re-mained in place for a 12-mo period.Biliary sphincterotomy was performed in patients with native papilla,and an Am-FCSEMS(10 mm in final diameter and 60 or 80 mm in length)was placed(Hanarostent TM MI Tech,Co).Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTS Three patients were excluded due to loss to follow-up before stent removal.Among the 14 patients included and followed,7 were women,and the average age was 56 years(range:28-76).The average period of Am-FCSEMS placement was 362±109 d.Technical success occurred in all 14 patients(100%).There were no cases of distal stent migration.Complete resolution of the stricture occurred in 13/14 patients(92.85%).Adverse events occurred in 3/14 patients(21.42%):2 patients with mild acute pancreatitis(14.28%)and 1 patient(7.14%)with stent dysfunction(occlusion by biliary sludge and stones,which was treated endoscopically without the need for stent removal).No deaths occurred related to therapy.All stents were removed using foreign body forceps or snares without difficulty.After Am-FCSEMS removal,all 13 patients who had ABS resolution were followed-up for an average of 411±172 d,and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSION In this retrospective study,endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective,with a high stricture re-solution rate that was probably due to the absence of stent migration.展开更多
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors.Despite the remarkable advances in the surgical tec...Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors.Despite the remarkable advances in the surgical techniques and immunosuppressive therapy,the postoperative morbidity and mortality still remain high and the leading causes are biliary complications,which affect up to one quarter of recipients.The most common biliary complications are anastomotic and non-anastomotic biliary strictures,leaks,bile duct stones,sludge and casts.Despite the absence of a recommended treatment algorithm many options are available,such as surgery,percutaneous techniques and interventional endoscopy.In the last few years,endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches.Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed.Recently,new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures.Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment.Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases.This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.展开更多
Objective To observe the outcomes of living donor liver transplantation ( LDLT) for children with biliary atresia ( BA) and to summarize clinical experiences. Methods Forty - four BA patients ( 26 boys and 18 girls) u...Objective To observe the outcomes of living donor liver transplantation ( LDLT) for children with biliary atresia ( BA) and to summarize clinical experiences. Methods Forty - four BA patients ( 26 boys and 18 girls) underwent LDLT between October 2006 and December 2010. Mean ( SD) and median ( range) age展开更多
Objective To describe the technique,efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation ( OLT) . Methods From May 2004 to December 2009...Objective To describe the technique,efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation ( OLT) . Methods From May 2004 to December 2009,25 patients with anastomotic biliary stric-展开更多
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Ben...Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.展开更多
AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagn...AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagnosis of biliary complications after liver transplantation. METHODS: In 75 patients after liver transplantation, who received ERC due to suspected biliary complications, the result of the cholangiography was compared to the results of indirect imaging methods performed prior to ERC. The cholangiography showed no biliary stenosis (NoST) in 25 patients, AST in 27 and ITBL in 23 patients. RESULTS: Biliary congestion as a result of AST was detected with a sensitivity of 68.4% in US analysis (specificity 91%), of 71% in MRI (specificity 25%) and of 40% in CT (specificity 57.1%). In ITBL, biliary congestion was detected with a sensitivity of 58.8% in the US, 88.9%in MRI and of 83.3% in CT. However, as anastomotic or ischemic stenoses were the underlying cause of biliary congestion, the sensitivity of detection was very low. InMRI detected the dominant stenosis at a correct localization in 22% and CT in 10%, while US failed completely. The biochemical parameters, showed no significant difference in bilirubin (median 5.7; 4,1; 2.5 mg/dL), alkaline phosphatase (median 360; 339; 527 U/L) or gamma glutamyl transferase (median 277; 220; 239 U/L) levels between NoST, AST and ITBL.CONCLUSION: Our data confirm that indirect imaging methods to date cannot replace direct cholangiography for diagnosis of post transplant biliary stenoses. However MRI may have the potential to complement or precede imaging by cholangiography. Optimized MRCP-processing might further improve the diagnostic impact of this method.展开更多
Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults...Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.展开更多
AIM To summarize and compare the clinical characteristics of drug-induced liver injury(DILI) and primary biliary cirrhosis(PBC).METHODS A total of 124 patients with DILI and 116 patients with PBC treated at Shengjing ...AIM To summarize and compare the clinical characteristics of drug-induced liver injury(DILI) and primary biliary cirrhosis(PBC).METHODS A total of 124 patients with DILI and 116 patients with PBC treated at Shengjing Hospital Affiliated to China Medical University from 2005 to 2013 were included. Demographic data(sex and age),biochemical indexes(total protein,albumin,alanine aminotransferase,aspartate aminotransferase,total bilirubin,direct bilirubin,indirect bilirubin,alkaline phosphatase,and gamma glutamyltransferase),immunological indexes [immunoglobulin(Ig) A,Ig G,Ig M,antinuclear antibody,anti-smooth muscle antibody,anti-mitochondrial antibody,and anti-mitochondrial antibodies] and pathological findings were compared in PBC patients,untyped DILI patients and patients with different types of DILI(hepatocellular type,cholestatic type and mixed type). RESULTS There were significant differences in age and gender distribution between DILI patients and PBC patients. Biochemical indexes(except ALB),immunological indexes,positive rates of autoantibodies(except SMA),and number of cases of patients with different ANA titers(except the group at a titer of 1:10000)significantly differed between DILI patients and PBC patients. Biochemical indexes,immunological indexes,and positive rate of autoantibodies were not quite similar in different types of DILI. PBC was histologically characterized mainly by edematous degeneration of hepatocytes(n = 30),inflammatory cell infiltration around bile ducts(n = 29),and atypical hyperplasia of small bile ducts(n = 28). DILI manifested mainly as fatty degeneration of hepatocytes(n = 15) and spotty necrosis or loss of hepatocytes(n = 14).CONCLUSION Although DILI and PBC share some similar laboratory tests(biochemical and immunological indexes) and pathological findings,they also show some distinct characteristics,which are helpful to the differential diagnosis of the two diseases.展开更多
Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these ...Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings makes the diagnosis challenging. Moreover, direct cholangiographic procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography present an inadmissible rate of adverse events to be utilized in clinically low suspected patients. Magnetic resonance (MR) maging with MR cholangiopancreatography is crucial in assessing abnormalities in the biliary system after liver surgery, including liver transplant. MR cholangiopancreatography is a safe, rapid, non-invasive, and effective diagnostic procedure for the evaluation of biliary adverse events after liver transplantation, since it plays an increasingly important role in the diagnosis and management of these events. On the basis of a recent systematic review of the literature the summary estimates of sensitivity and specificity of MR cholangiopancreatography for diagnosis of biliary adverse events following OLT were 0.95 and 0.92, respectively. It can provide a non-invasive method of imaging surgical reconstruction of the biliary anastomoses as well as adverse events including anastomotic and non-anastomotic strictures, biliary lithiasis and sphincter of Oddi dysfunction in liver transplant recipients. Nevertheless, conventional T2-weighted MR cholangiography can be implemented with T1-weighted contrast-enhanced MR cholangiography using hepatobiliary contrast agents (in particular using Gd-EOB-DTPA) in order to improve the diagnostic accuracy in the adverse events’ detection such as bile leakage and strictures, especially in selected patients with biliary-enteric anastomosis.展开更多
AIM: To summarize our single-center experience with liver transplantation(LT) for biliary atresia(BA).METHODS: From October 2006 to December 2012, 188 children with BA were analyzed retrospectively. The stage?Ⅰ?group...AIM: To summarize our single-center experience with liver transplantation(LT) for biliary atresia(BA).METHODS: From October 2006 to December 2012, 188 children with BA were analyzed retrospectively. The stage?Ⅰ?group(from October 2006 to December 2010) comprised the first 74 patients, and the stage Ⅱ group(from January 2011 to December 2012) comprised the remaining 114 patients. Finally, 123 liver transplants were performed in 122(64.9%) patients, whereas 66 patients did not undergo LT due to denial by their parents or lack of suitable liver grafts. The selection of graft types depended on the patients' clinical status and whether a suitable living donor was available. The characteristics of patients in stages?Ⅰ?and Ⅱ were described, and the surgical outcomes of LT recipients were compared between the two stages. The KaplanMeier method was used to estimate the cumulative patient and graft survival rates, and the equality of survival distributions was evaluated using the log-rank test.RESULTS: The 188 children consisted of 102 boysand 86 girls. Their ages ranged from 3 to 144 mo with a median of 8 mo. One hundred and fifteen(61.2%) patients were born in rural areas. Comparing stage?Ⅰ?and stage Ⅱ patients, the proportion of patients referred by pediatricians(43.2% vs 71.1%, respectively; P < 0.001) and the proportion of patients who previously received a Kasai procedure(KP)(32.4% vs 44.7%, respectively; P = 0.092) obviously increased, and significantly more parents were willing to treat their children with LT(73% vs 86%, respectively; P = 0.027). Grafts from living donors(102/122, 83.6%) were the most commonly used graft type. Surgical complications(16/25, 64.0%) were the main reason for posttransplant mortality. Among the living donor liver transplantation recipients(n = 102), the incidence of surgical complications was significantly reduced(34.1% vs 15.5%, respectively; P = 0.029) and survival rates of patients and grafts were greatly improved(81.8% vs 89.7%, respectively, at 1 year; 75.0% vs 87.8%, respectively, at 3 years; P = 0.107) from stage?Ⅰ?to stage Ⅱ.CONCLUSION: The status of surgical treatments for BA has been changing in China's Mainland. Favorable midterm outcomes after LT were achieved as centers gained greater technical experience.展开更多
AIM: To evaluate the risk factors for ischemic-type biliary lesion(ITBL) after ABO-incompatible(ABO-I) adult living donor liver transplantation(ALDLT).METHODS: Among 141 ALDLTs performed in our hospital between 2008 a...AIM: To evaluate the risk factors for ischemic-type biliary lesion(ITBL) after ABO-incompatible(ABO-I) adult living donor liver transplantation(ALDLT).METHODS: Among 141 ALDLTs performed in our hospital between 2008 and 2014, 27(19%) were ABO-I ALDLT and 114 were ABO-identical/compatible ALDLT. In this study, we extensively analyzed the clinico-pathological data of the 27 ABO-I recipients to determine the risk factors for ITBL after ABO-I ALDLT. All ABO-I ALDLT recipients underwent an identical B-cell depletion protocol with preoperative rituximab, plasma exchange(PE), and operative splenectomy. The median follow-up period after transplantation was 26 mo. The clinical outcomes of the 27 ABO-I ALDLT recipients were compared with those of 114 ABO-identical/compatible ALDLT recipients.RESULTS: ITBL occurred in four recipients(14.8%) between 45 and 112 d after ABO-I ALDLT. The overall survival rates were not different between ABO-I ALDLT and ABO-identical/compatible ALDLT(P = 0.303). Among the ABO-I ALDLT recipients, there was no difference between patients with ITBL and those without ITBL in terms of B-cell and T-cell count, serum isoagglutinin titers, number of PEs, operative time and transfusion, use of graft infusion therapy, or number of remnant B-cell follicles and plasma cells in the spleen. However, the perioperative NK cell counts in the blood of patients with ITBL were significantly higher than those in the patients without ITBL(P < 0.05). Preoperative NK cell count > 150/μL and postoperative NK cell count > 120/μL were associated with greater relative risks(RR) for development of ITBL(RR = 20 and 14.3, respectively, P < 0.05). CONCLUSION: High NK cell counts in a transplant recipient's blood are associated with ITBL after ABO-I ALDLT. Further research is needed to elucidate the molecular mechanism of NK cell involvement in the development of ITBL.展开更多
文摘BACKGROUND Biliary atresia(BA)is the most common indication for pediatric liver transplantation,although portoenterostomy is usually performed first.However,due to the high failure rate of portoenterostomy,liver transplantation has been advocated as the primary procedure for patients with BA.It is still unclear if a previous portoenterostomy has a negative impact on liver transplantation outcomes.AIM To investigate the effect of prior portoenterostomy in infants un-dergoing liver transplantation for BA.METHODS This was a retrospective cohort study of 42 pediatric patients with BA who underwent primary liver transplantation from 2013 to 2023 at a single tertiary center in Brazil.Patients with BA were divided into two groups:Those undergoing primary liver transplantation without portoenterostomy and those undergoing liver transplantation with prior portoenterostomy.Continuous variables were compared using the Student’s t-test or the Kruskal-Wallis test,and categorical variables were compared using theχ2 or Fisher’s exact test,as appropriate.Multivariable Cox regression analysis was performed to determine risk factors for portal vein thrombosis.Patient and graft survival analyses were conducted with the Kaplan–Meier product-limit estimator,and patient subgroups were compared using the two-sided log-rank test.RESULTS Forty-two patients were included in the study(25[60%]girls),23 undergoing liver transplantation without prior portoenterostomy,and 19 undergoing liver transplantation with prior portoenterostomy.Patients with prior portoenterostomy were older(12 vs 8 months;P=0.02)at the time of liver transplantation and had lower Pediatric End-Stage Liver Disease scores(13.2 vs 21.4;P=0.01).The majority of the patients(35/42,83%)underwent livingdonor liver transplantation.The group of patients without prior portoenterostomy appeared to have a higher incidence of portal vein thrombosis(39 vs 11%),but this result did not reach statistical significance.Prior portoenterostomy was not a protective factor against portal vein thrombosis in the multivariable analysis after adjusting for age at liver transplantation,graft-to-recipient weight ratio,and use of vascular grafts.Finally,the groups did not significantly differ in terms of post-transplant survival.CONCLUSION In our study,prior portoenterostomy did not significantly affect the outcomes of liver transplantation.
文摘Biliary complications are still the main complications for liver transplantation recipients. Biliary strictures comprise the major part of all biliary complications after deceased-donor liver transplantation (LT). Biliary strictures following LT are divided into anastomotic strictures (AS) and non-anastomotic strictures (NAS). A Limitation of current published researches is that most studies aren’t based on clinical practice. The aim of this review is to summarize risk factors, clinical presentation, diagnosis and management in post-LT biliary strictures.
基金a grant from the China Medical Board in New York(No.06837).
文摘BACKGROUND: Ischemic-type biliary lesions (ITBLs) play an extremely important role in influencing the long-term survival and quality of life of recipients after orthotopic liver transplantation (OLT). Some patients can be cured by interventional therapies, however others lose their grafts at last and receive liver retransplantation (re-OLT). The aim of this study was to analyze the data of 66 patients who had received re-OLT at our center because of ITBL and to discuss the treatment of ITBL after OLT. METHODS: We retrospectively analyzed 66 re-OLT cases due to ITBL from September 2001 to February 2007 at our center. The Kaplan-Meier method and the Cox-Mantel test were used to identify factors associated with mortality for univariate analysis and multivariate analysis, respectively. RESULTS: Fifty-five of 66 ITBL cases underwent interventional therapies before re-OLT. The actuarial survival at I month and I year for these patients was 83% and 74%, respectively. Prognostic factors for mortality in univariate analysis were model of end-stage liver disease score (MELD) >16.5 (chi(2)=5.856, P=0.016), cold ischemia time >8 hours (chi(2)=6.539, P=0.011), infections (chi(2)=5.550, P=0.018) and complications (chi(2)=12.168, P=0.002) after re-OLT. In the multivariate analysis (Cox regression), the risk factors independently associated with mortality were MELD score >16.5 (RR: 3.140; P=0.035), cold ischemia time >8.2 hours (RR: 0.192; P=0.016) and complications (RR: 3.896, P=0.003). CONCLUSIONS: The incidence of ITBL in China is higher than in other countries. Based on our experience, MELD score, cold ischemia time and complications after re-OLT are risk factors independently associated with mortality in retransplanted ITBL patients.
文摘AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.METHODS: Patients who developed biliary complications were analysed in detail for the clinical information, laboratory tests, treatment offered, response to it, follow up and outcomes. The profile of liver enzymes was determined. The safety, efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed. RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be 〉 3 times (388.1 ± 70.9 U/mL vs 168.5 4± 34.2 U/L, P = 0.007) and SAP 〉 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L, P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic res in 28 (40%). Sustained success was achieved in 26 (81%) patients. CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early, non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.
文摘BACKGROUND:Ischemia-related biliary tract complications remain high after orthotopic liver transplantation.Severe ischemic biliary complications often involve the hepatic duct bifurcation and left hepatic duct,resulting finally in obstructive jaundice.Prevention and management of such complications remain a challenge for transplant surgeons.METHODS:All 160 patients were followed up for at least 180 days after transplantation.One-way analysis of variance (ANOVA) and comparative univariate analysis were made using 3 groups (no complications;mild complications;severe complications),to analyze risk factors associated with biliary complications.Multiple logistic regression and linear regression analysis were used to analyze independent risk factors for severe ischemic biliary complications,after excluding other confounding factors.RESULTS:By ANOVA and comparative univariate analysis,the risk factors associated with biliary complications were preoperative bilirubin level (P=0.007) and T-tube stenting of the anastomosis (P=0.016).Multiple logistic regression analysis showed that the use of T-tube and preoperative serum bilirubin were not independent risk factors for severe ischemic biliary complications after orthotopic liver transplantation.Chi-square analysis indicated that in the incidence of severe ischemic biliary lesions,bile duct second warm ischemic time longer than 60 minutes was a significant risk factor.Linear regression demonstrated a negative correlation between cold preservation time and warm ischemia time.CONCLUSIONS:Preoperative serum bilirubin level and the use of T-tube stenting of the anastomosis were independent risk factors for biliary complications after liver transplantation,but not for severe ischemic biliary complications.The second warm ischemia time of bile duct longer than 60minutes and prolonged bile duct second warm ischemia time combined with cold preservation time were significant risk factors for severe ischemic biliary complications after liver transplantation with grafts from non-heart-beating donors.
文摘AIM: To compare the value of endoscopic retrograde cholangiography (ERC) and standard T2-weighted magnetic resonance cholangiography (MRC) in the evaluation process as adult-to-adult right lobe living donor liver transplantation (LDLTx) demands a successful outcome, and exact knowledge of the biliary tree is implicated to avoid biliary complications, postoperatively.METHODS: After starting the LDLTx program, 18 liver transplant candidates were selected for LDLTx by a stepwise evaluation process. ERC and standard T2-weighted MRC were performed to evaluate the biliary system of the donor liver. The anatomical findings of ERC and MRC mapping were compared using the Ohkubo classification. RESULTS: ERC allowed mapping of the whole biliary system in 15/15 (100%) cases, including 14/15 (93.3%) with biliary variants while routine MRC was only accurate in 2/13 (15.4%) cases. MRC was limited in depicting the biliary system proximal of the hepatic bifurcation. Postoperative biliary complications occurred in 2 donors and 8 recipients. Biliary complications were associated with Ohkubo type C, E or G in 6/8 recipients, and 2/3 recipients with biliary leak received a graft with multiple (≥2) bile ducts. CONCLUSION: Pretransplant ERC is safe and superior over standard MRC for detection of biliary variations that occur with a high frequency. However, precise knowledge of biliary variants did not reduce the incidence of postoperative biliary complications.
文摘Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation.While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction,our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors,in particular,our surgical protocols.We present herein,the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts.Over this period of transition,our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0%to 10.2%.
基金Capital's Funds for Health Improvement and Research,No.2020-1-2024.
文摘BACKGROUND Laparoscopic living donor hepatectomy(LLDH)has been successfully carried out in several transplant centers.Biliary reconstruction is key in living donor liver transplantation(LDLT).Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage.Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points,biliary variability and limitations associated with LLDH,multiple biliary tracts are often encountered during surgery,which inhibits biliary reconstruction.A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT.This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARY A 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation.Due to the scarcity of deceased donors,she was put on the waiting list for LDLT.Her father was a suitable donor;however,after a rigorous evaluation,preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract.Therefore,a laparoscopic left lateral section was performed on the donor,which met the estimated graft-to-recipient weight ratio.Under intraoperative indocyanine green cholangiography,4 biliary tracts were confirmed in the graft.It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm.A reliable cholangiojejunostomy was,therefore,utilized:Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures.At the last follow-up(1 year after surgery),the patient was complication-free.CONCLUSION Intrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.
基金Supported by the Deutsche Forschungsgemeinschaft (KFO 117/1) and the IFORES Research Program, University Hospital Essen
文摘AIM: Recently it has been reported that granulocyte colony stimulating factor (G-CSF) can induce hypercoagulability in healthy bone marrow donors. It is conceivable that the induction of a prothrombotic state in a recipient of an organ graft with already impaired perfusion might cause further deterioration in the transplanted organ. This study evaluated whether G-CSF treatment worsens liver perfusion following liver transplantation in the rat model. METHODS: A non-arterialized rat liver transplantation model was employed to evaluate the effect of G-CSF treatment on the liver in a syngeneic and allogeneic strain combination. Study outcomes included survival time and liver damage as investigated by liver enzymes and liver histology. Observation times were 1 d, 1 wk and 12 wk. RESULTS: Rats treated with G-CSF had increased incidence and severity of biliary damage following liver transplantation. In these animals, hepatocellular necrosis was accentuated in the centrilobular region. These lesions are indicative of impaired perfusion in G-CSF treated animals. CONCLUSION: G-CSF should be used with caution in recipients of liver transplantation, as treatment might enhance preexisting, undetected perfusion problems and ultimately lead to ischemia induced biliary complications .
文摘BACKGROUND Endoscopic therapy using multiple plastic stents(MPSs)is the standard therapy for postorthotopic liver transplantation(p-OLT)anastomotic biliary stricture(ABS).However,this approach demands repeated procedures.Recent studies us-ing fully covered self-expandable metallic stents(FCSEMS)have shown en-couraging results,but migration occurs in 10%to 40%of cases.The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system(Am-FCSEMS)in patients with p-OLT ABS.AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODS This study was conducted in a private tertiary care centre in S?o Paulo,Brazil and was approved by our institution's Human Research Committee.From April 2018 to October 2020,regardless of previous endoscopic treatment(MPS or FCSEMS),17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study.The exclusion criteria were pregnancy,nonanastomotic biliary or hilar stricture,hepatic artery stenosis/thrombosis,isolated biliary fistulae,a distance shorter than 2 cm from the stricture to the hepatic hilum,and patient refusal.The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that re-mained in place for a 12-mo period.Biliary sphincterotomy was performed in patients with native papilla,and an Am-FCSEMS(10 mm in final diameter and 60 or 80 mm in length)was placed(Hanarostent TM MI Tech,Co).Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTS Three patients were excluded due to loss to follow-up before stent removal.Among the 14 patients included and followed,7 were women,and the average age was 56 years(range:28-76).The average period of Am-FCSEMS placement was 362±109 d.Technical success occurred in all 14 patients(100%).There were no cases of distal stent migration.Complete resolution of the stricture occurred in 13/14 patients(92.85%).Adverse events occurred in 3/14 patients(21.42%):2 patients with mild acute pancreatitis(14.28%)and 1 patient(7.14%)with stent dysfunction(occlusion by biliary sludge and stones,which was treated endoscopically without the need for stent removal).No deaths occurred related to therapy.All stents were removed using foreign body forceps or snares without difficulty.After Am-FCSEMS removal,all 13 patients who had ABS resolution were followed-up for an average of 411±172 d,and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSION In this retrospective study,endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective,with a high stricture re-solution rate that was probably due to the absence of stent migration.
文摘Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors.Despite the remarkable advances in the surgical techniques and immunosuppressive therapy,the postoperative morbidity and mortality still remain high and the leading causes are biliary complications,which affect up to one quarter of recipients.The most common biliary complications are anastomotic and non-anastomotic biliary strictures,leaks,bile duct stones,sludge and casts.Despite the absence of a recommended treatment algorithm many options are available,such as surgery,percutaneous techniques and interventional endoscopy.In the last few years,endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches.Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed.Recently,new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures.Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment.Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases.This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
文摘Objective To observe the outcomes of living donor liver transplantation ( LDLT) for children with biliary atresia ( BA) and to summarize clinical experiences. Methods Forty - four BA patients ( 26 boys and 18 girls) underwent LDLT between October 2006 and December 2010. Mean ( SD) and median ( range) age
文摘Objective To describe the technique,efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation ( OLT) . Methods From May 2004 to December 2009,25 patients with anastomotic biliary stric-
文摘Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation(LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
文摘AIM: To evaluate the diagnostic value of different indirect methods like biochemical parameters, ultrasound (US) analysis, CT-scan and MRI/MRCP in comparison with endoscopic retrograde cholangiography (ERC), for diagnosis of biliary complications after liver transplantation. METHODS: In 75 patients after liver transplantation, who received ERC due to suspected biliary complications, the result of the cholangiography was compared to the results of indirect imaging methods performed prior to ERC. The cholangiography showed no biliary stenosis (NoST) in 25 patients, AST in 27 and ITBL in 23 patients. RESULTS: Biliary congestion as a result of AST was detected with a sensitivity of 68.4% in US analysis (specificity 91%), of 71% in MRI (specificity 25%) and of 40% in CT (specificity 57.1%). In ITBL, biliary congestion was detected with a sensitivity of 58.8% in the US, 88.9%in MRI and of 83.3% in CT. However, as anastomotic or ischemic stenoses were the underlying cause of biliary congestion, the sensitivity of detection was very low. InMRI detected the dominant stenosis at a correct localization in 22% and CT in 10%, while US failed completely. The biochemical parameters, showed no significant difference in bilirubin (median 5.7; 4,1; 2.5 mg/dL), alkaline phosphatase (median 360; 339; 527 U/L) or gamma glutamyl transferase (median 277; 220; 239 U/L) levels between NoST, AST and ITBL.CONCLUSION: Our data confirm that indirect imaging methods to date cannot replace direct cholangiography for diagnosis of post transplant biliary stenoses. However MRI may have the potential to complement or precede imaging by cholangiography. Optimized MRCP-processing might further improve the diagnostic impact of this method.
文摘Biliary tract diseases are the most common complications following liver transplantation(LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents(FCSEMSs) has not been demonstrated to be superior(except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
文摘AIM To summarize and compare the clinical characteristics of drug-induced liver injury(DILI) and primary biliary cirrhosis(PBC).METHODS A total of 124 patients with DILI and 116 patients with PBC treated at Shengjing Hospital Affiliated to China Medical University from 2005 to 2013 were included. Demographic data(sex and age),biochemical indexes(total protein,albumin,alanine aminotransferase,aspartate aminotransferase,total bilirubin,direct bilirubin,indirect bilirubin,alkaline phosphatase,and gamma glutamyltransferase),immunological indexes [immunoglobulin(Ig) A,Ig G,Ig M,antinuclear antibody,anti-smooth muscle antibody,anti-mitochondrial antibody,and anti-mitochondrial antibodies] and pathological findings were compared in PBC patients,untyped DILI patients and patients with different types of DILI(hepatocellular type,cholestatic type and mixed type). RESULTS There were significant differences in age and gender distribution between DILI patients and PBC patients. Biochemical indexes(except ALB),immunological indexes,positive rates of autoantibodies(except SMA),and number of cases of patients with different ANA titers(except the group at a titer of 1:10000)significantly differed between DILI patients and PBC patients. Biochemical indexes,immunological indexes,and positive rate of autoantibodies were not quite similar in different types of DILI. PBC was histologically characterized mainly by edematous degeneration of hepatocytes(n = 30),inflammatory cell infiltration around bile ducts(n = 29),and atypical hyperplasia of small bile ducts(n = 28). DILI manifested mainly as fatty degeneration of hepatocytes(n = 15) and spotty necrosis or loss of hepatocytes(n = 14).CONCLUSION Although DILI and PBC share some similar laboratory tests(biochemical and immunological indexes) and pathological findings,they also show some distinct characteristics,which are helpful to the differential diagnosis of the two diseases.
文摘Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings makes the diagnosis challenging. Moreover, direct cholangiographic procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography present an inadmissible rate of adverse events to be utilized in clinically low suspected patients. Magnetic resonance (MR) maging with MR cholangiopancreatography is crucial in assessing abnormalities in the biliary system after liver surgery, including liver transplant. MR cholangiopancreatography is a safe, rapid, non-invasive, and effective diagnostic procedure for the evaluation of biliary adverse events after liver transplantation, since it plays an increasingly important role in the diagnosis and management of these events. On the basis of a recent systematic review of the literature the summary estimates of sensitivity and specificity of MR cholangiopancreatography for diagnosis of biliary adverse events following OLT were 0.95 and 0.92, respectively. It can provide a non-invasive method of imaging surgical reconstruction of the biliary anastomoses as well as adverse events including anastomotic and non-anastomotic strictures, biliary lithiasis and sphincter of Oddi dysfunction in liver transplant recipients. Nevertheless, conventional T2-weighted MR cholangiography can be implemented with T1-weighted contrast-enhanced MR cholangiography using hepatobiliary contrast agents (in particular using Gd-EOB-DTPA) in order to improve the diagnostic accuracy in the adverse events’ detection such as bile leakage and strictures, especially in selected patients with biliary-enteric anastomosis.
基金Supported by Key Joint Research Program of Shanghai Health Bureau,No.2013ZYJB0001a subtopic of Scientific and Technological Innovation and Action Project of Shanghai Science and Technology Commission,No.14411950404
文摘AIM: To summarize our single-center experience with liver transplantation(LT) for biliary atresia(BA).METHODS: From October 2006 to December 2012, 188 children with BA were analyzed retrospectively. The stage?Ⅰ?group(from October 2006 to December 2010) comprised the first 74 patients, and the stage Ⅱ group(from January 2011 to December 2012) comprised the remaining 114 patients. Finally, 123 liver transplants were performed in 122(64.9%) patients, whereas 66 patients did not undergo LT due to denial by their parents or lack of suitable liver grafts. The selection of graft types depended on the patients' clinical status and whether a suitable living donor was available. The characteristics of patients in stages?Ⅰ?and Ⅱ were described, and the surgical outcomes of LT recipients were compared between the two stages. The KaplanMeier method was used to estimate the cumulative patient and graft survival rates, and the equality of survival distributions was evaluated using the log-rank test.RESULTS: The 188 children consisted of 102 boysand 86 girls. Their ages ranged from 3 to 144 mo with a median of 8 mo. One hundred and fifteen(61.2%) patients were born in rural areas. Comparing stage?Ⅰ?and stage Ⅱ patients, the proportion of patients referred by pediatricians(43.2% vs 71.1%, respectively; P < 0.001) and the proportion of patients who previously received a Kasai procedure(KP)(32.4% vs 44.7%, respectively; P = 0.092) obviously increased, and significantly more parents were willing to treat their children with LT(73% vs 86%, respectively; P = 0.027). Grafts from living donors(102/122, 83.6%) were the most commonly used graft type. Surgical complications(16/25, 64.0%) were the main reason for posttransplant mortality. Among the living donor liver transplantation recipients(n = 102), the incidence of surgical complications was significantly reduced(34.1% vs 15.5%, respectively; P = 0.029) and survival rates of patients and grafts were greatly improved(81.8% vs 89.7%, respectively, at 1 year; 75.0% vs 87.8%, respectively, at 3 years; P = 0.107) from stage?Ⅰ?to stage Ⅱ.CONCLUSION: The status of surgical treatments for BA has been changing in China's Mainland. Favorable midterm outcomes after LT were achieved as centers gained greater technical experience.
基金Supported by An Academic-Grant for Scientific Research from Astellas Pharma Korea,Inc
文摘AIM: To evaluate the risk factors for ischemic-type biliary lesion(ITBL) after ABO-incompatible(ABO-I) adult living donor liver transplantation(ALDLT).METHODS: Among 141 ALDLTs performed in our hospital between 2008 and 2014, 27(19%) were ABO-I ALDLT and 114 were ABO-identical/compatible ALDLT. In this study, we extensively analyzed the clinico-pathological data of the 27 ABO-I recipients to determine the risk factors for ITBL after ABO-I ALDLT. All ABO-I ALDLT recipients underwent an identical B-cell depletion protocol with preoperative rituximab, plasma exchange(PE), and operative splenectomy. The median follow-up period after transplantation was 26 mo. The clinical outcomes of the 27 ABO-I ALDLT recipients were compared with those of 114 ABO-identical/compatible ALDLT recipients.RESULTS: ITBL occurred in four recipients(14.8%) between 45 and 112 d after ABO-I ALDLT. The overall survival rates were not different between ABO-I ALDLT and ABO-identical/compatible ALDLT(P = 0.303). Among the ABO-I ALDLT recipients, there was no difference between patients with ITBL and those without ITBL in terms of B-cell and T-cell count, serum isoagglutinin titers, number of PEs, operative time and transfusion, use of graft infusion therapy, or number of remnant B-cell follicles and plasma cells in the spleen. However, the perioperative NK cell counts in the blood of patients with ITBL were significantly higher than those in the patients without ITBL(P < 0.05). Preoperative NK cell count > 150/μL and postoperative NK cell count > 120/μL were associated with greater relative risks(RR) for development of ITBL(RR = 20 and 14.3, respectively, P < 0.05). CONCLUSION: High NK cell counts in a transplant recipient's blood are associated with ITBL after ABO-I ALDLT. Further research is needed to elucidate the molecular mechanism of NK cell involvement in the development of ITBL.