Endoscopic Management of Biliary Complications After Liver Transplantation

Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for management of post-transplant biliary complications. We assess ERCP frequency and rate of early repeat ERCP and anastomotic stricture development across, living donor (LD), donation after cardiac death (DCD) and donation after brain death (DBD) liver transplant (LT) donor types.

We performed a single-center retrospective study of patients who underwent LT from January 2014 to December 2019. Proportion of patients requiring ERCP and number of ERCPs per patient were compared across donor types using analysis of variance and chi-squared methods. Logistic regression was used to assess the risk of early repeat ERCP, defined as ERCP within 28 days of preceding ERCP and anastomotic stricture development.

A total of 509 LTs, 352 (69.2%) DBD, 101 (19.8%) DCD, and 56 (11.0%) LD were performed during the study period. A greater proportion of LD (51.8%) recipients required ERCP compared with DBD (28.7%) recipients (P ≤ 0.01). LD and DCD recipients required significantly greater number of median (interquartile range [IQR]) ERCPs compared with DBD recipients (8 [4, 12] vs 3 [2, 5], P < 0.01 and 4 [2, 6] vs 3 [2, 5], P = 0.05). Risk of early repeat ERCP was significantly higher in LD (odds ratio 9.2; 95% confidence interval 4.6-18.5) and DCD (OR 2.3; 95% confidence interval 1.2-4.5) recipients compared with DBD recipients.

LD and DCD recipients experience higher ERCP frequency and greater risk of early repeat ERCP compared with DBD recipients. Our results suggest the need to tailor ERCP management protocols for post-LT biliary complications based on donor type.

Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.

Biliary strictures after orthotopic liver transplantation (OLT) are typically managed by sequential ERCP procedures, with incremental dilation of the stricture and stent exchange (IDSE) and placement of new stents. This approach resolves >80% of strictures after 12 months but requires costly, lengthy ERCPs with significant patient radiation exposure. Increasing awareness of the harmful effects of radiation, escalating healthcare costs, and decreasing reimbursement for procedures mandate maximal efficiency in performing ERCP. We compared the traditional IDSE protocol with a sequential stent addition (SSA) protocol, in which additional stents are placed across the stricture during sequential ERCPs, without stent removal/exchange or stricture dilation.

Patients undergoing ERCP for OLT-related anastomotic strictures from 2010 to 2016 were identified from a prospectively maintained endoscopy database. Procedure duration, fluoroscopy time, stricture resolution rates, adverse events, materials fees, and facility fees were analyzed for IDSE and SSA procedures.

Seventy-seven patients underwent 277 IDSE and 132 SSA procedures. Mean fluoroscopy time was 64.5% shorter (P < .0001) and mean procedure duration 41.5% lower (P < .0001) with SSA compared with IDSE. SSA procedures required fewer accessory devices, resulting in significantly lower material (63.8%, P < .0001) and facility costs (42.8%, P < .0001) compared with IDSE. Stricture resolution was >95%, and low adverse event rates did not significantly differ.

SSA results in shorter, cost-effective procedures requiring fewer accessory devices and exposing patients to less radiation. Stricture resolution rates are equivalent to IDSE, and adverse events do not differ significantly, even in this immunocompromised population.

Organ transplantation provides improved quality of life and longevity in patients with end-organ disease. These patients have significant physiological and anatomical modifications, and with new immunosuppressive agents, many of these patients will present to the emergency department with complications.

The objective was to provide emergency physicians with a review of transplant complications, including infection, rejection, medication adverse effects, and specific complications related to the transplant.

Transplant patients present significant challenges due to a large spectrum of complications that may arise. Infection is the most common complication and can be separated into different periods. The first month after transplant is associated with nosocomial and surgical infections, 1 month to 6 months after transplant with opportunistic infection, and greater than 6 months acquired infection. Rejection occurs in the hyperacute, acute, and chronic phases, with symptoms dependent on the specific organ. Medication adverse effects due to immunosuppressive agents are common and include renal dysfunction, anemia, metabolic syndrome, and gastrointestinal effects. Renal transplant dysfunction includes vascular complications, hematoma, obstruction, and lymphocele. Liver transplant complications include vascular defects, biliary tract malfunctions, and fluid collections. Heart transplant complications manifest with vasculopathy and dysrhythmia. Lung transplant complications include airway dysfunction, phrenic nerve dysfunction, and pleural fluid collections. All transplant patients in the emergency department require close communication with the transplant physician and emergency provider.

Transplant patients can present significant challenges to the emergency provider. Knowledge of these complications may improve patient care. All cases require contact with the transplant physician.