Endoscopic management of Post liver transplant —Biliary Complications

Dr. Randhir SudChairman

Institute of Digestive & Hepato-biliary SciencesMedanta the MedicityGurugram Haryana

Introduction

5% to 32% pts of OLT develop BC Cumulative BC rate at 1,3 and 5 yrs is

12.9% ,18.25% and 20.2% Unrelated to type of anastomosis D-D / H-J More common in LDLT

Lead to Re-transplant in 6% to 12.5% Mortality 0% to 19 Shin H - Liver transpl. 2006 Soejima Y - Liver transplant 2006

Londono M - WJG 2008, Kochhar G – WJG 2013

Incidence of biliary complications : DDLT vs LDLT

Chan C GIE 2012 : 362 pts 29 LDLT 111DDLT ( 33.3%) & 14(48.3%) LDLT needed

ERCP for biliary complications Anastomotic Strict 10% vs 27.6% p <.01 Bile leak 7.2% vs 6.9% Choledocholith. 12.6% vs 7.1%

Mean time to develop stricture same Likelihood of response to ERCP ( 63.6% vs 75%) Number of ERCPs required same ( 3.9 vs 4.7 )

Biliary complications

Bile leak (10-25%) Anastomotic Non-anastomotic

Biliary stricture (5-24%) Anastomotic Non-anastomotic

Bile duct stones, sludge, cast

POST OLT BILIARY STRICTURES

Risk factors for biliary strictures

Bile leak Local effect of the bile inducing inflammation and

subsequent fibrosis A surrogate marker of poor vascularity

Number of anastomosis? Older donor

Related to the presence of degenerative age-related changes in the microcirculation of the biliary tract

Prolonged warm / cold ischaemiaShah SA, Am J Transplant 2007

Diagnosis

USG abdomen Low sensitivity: 38-66% No good correlation between USG and

cholangiographic size MRCP

>90% sensitivity and specificity ERCP

Therapeutic

Management of biliary strictures

First line: ERCP

Second line: Percutaneous interventions

Third line: surgery

DDLT BS are easier to treat endoscopicallyPrinciples of management same as other BSSuccess rates same as post chole. BS (80-90%)FCSEMS may play increasing role in reducing the number of interventions and improving outcomes

LDLT - Anastomotic strictures

Post LDLT strictures are more difficult to treatAnastomosis is complexPeripherally locatedMultiple small caliber ductsAngulated course of ducts

Endotherapy less rewarding than DDLT (58%-76%)Very tight stricture is most common cause of failure

ERCP –Technical consideration

Principles of management same as in post-chole. Strictures MRCP is pre-requisite in LDLT Know type of anastomosis Peri procedural antibiotics Balloon dilatation + stenting better than either alone Multiple sequential stents are better Generally 3-4 sessions Proper assessment of re-modelling of stricture

Challenging LDLT biliary strict.

Type of anastomosis : Spectacle anastomosis Cystic duct anastomosis Hepatico-jejunostomy

Tight stricture Non dilated BD proximal to stricture Total separation of graft ducts from native CBD NAS

Strategies to treat difficult BS

Special guidewires Soehendra Pancreatic dilator catheter 6F Cystotome FCSEMS PTBD

Rendezvous procedures Magnetic compression therapy

Balloon assisted enteroscope ERC Surgery

SEMS in LDLT

SEMS in LDLT

FCSEMS in LDLT strictures

Only retrievable fully covered SEMS used Technically difficult to position upper end without

obstructing side branches in majority Kaffee stent with retrievable lasso used 16% migration rate No superiority over multiple plastic stents shown

Wang AY Endoscopy 2009

Difficult LDLT AS

Difficult LDLT stricture

Wire guided Cystotome facilitated stricturoplasty

Kawakami H et al 2015 22 cases with 16 BD strictures 100% success rate 2/22 developed complications

Pancreatitis inPD stricture Hemobilia in Ca GB pt

None in benign BS

Cystic duct anastomosis

Post LDLT : Non anastomotic strictures ( NAS )

NAS less frequent in LDLT than DDLT (2%-10% vs 5%-15%, )Frequently associated with casts & stonesOutcome of endotherapy poor 25% to 70%NAS takes longer to respond 185 days vs 67 days for AS Re-transplant rates of >40%

PTBD assisted rendezvous

Magnetic compression anastomosis

Magnetic compression anastomosis

Sung Ill Jang 2014 17 pts of LDLT BS treated with MCA Mean distance between magnets was 6.4mm Mean time for removal 53.3 days ( 9-181 days ) Re-stenosis occurred in 1/17 cases over median

FU of 12 months 8 bilio-enteric MCA have been done but none in

LDLT- BS

Post OLT bile leak

Post OLT -- Bile leaks

5% -25% develop bile leaks Presentation - early (<4wks) or late Early leaks treated conservatively with PCD ThethyS et al Clinical Transpl.2004 -28 bile leaks

22 treated with PCD alone – 85% healed Biliary stenting for 2 months successful in 84.6% T-tube leaks respond better 95% compared to

anastomotic leaks 43%1/3rd pts with leak develop stricture on follow up Pfau et al GIE 2000 , Tsuzino et al Am J Gast.2006

Post OLT CBD stone

Bile duct stones

Biliarys stones occur in 2%--5% after OLT* Increased lithogenicity Cyclosporin

Most stones associated with mechanical obst. ERCP outcome comparable to routine

Choledocholithiasis 90%- 100% success** *Somberg et al GIE 1993 **Gholson et al Dig.Dis.Sci.1996

Biliary cast syndrome

Single/multiple fixed hard or soft filling defects in Intra/Extra hepatic biliary tree conforming to luminal dimensions

Etiology Sloughed biliary epithelium Chronic rejection Bile stasis

Endoscopic managementBiliary cast syndrome

Tsujino T et al 2006 8/9 cleared endoscopically 4-17mm in size 1-2 in number

Endoscopic management poor if multiple intrahepatic casts 1 out of 4 successfully treated* Retransplantation may be the only option

*Pfau et al GIE 2000

Summary

BC occur in 10% to 25% cases after OLT Biliary strictures and leaks are most frequent

complications While early bile leaks respond to PCD endoscopic

stenting is very effective in other pts. Biliary strictures are managed succefully by BD +

multiple stents in >85% cases Small ducts and angulated stricture in LDLT make

ERC challenging Thermal stricturoplasty & MCA are new innovations

which help us treat more challenging pts

PULLMAN NEW DELHI AEROCITY