IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

MARTINS, Fernanda Prata; SELETI, Silvia Mansur Reimão; CONTINI, Mônica Lucia; DE PAULO, Gustavo Andrade; FERRARI, Angelo Paulo

doi:10.1590/S0004-2803.202000000-67

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ORIGINAL ARTICLE • Arq. Gastroenterol. 57 (04) • Sep-Dec 2020 • https://doi.org/10.1590/S0004-2803.202000000-67 copy

IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

Há lugar para a avaliação colangioscópica na estenose biliar anastomótica pós-transplante hepático de doador cadáver?

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND

Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment.

OBJECTIVE

On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS).

METHODS:

Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal.

RESULTS:

At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence.

CONCLUSION:

Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

HEADINGS:
Liver transplant; Self expandable metallic stents; Pathologic constriction; Biliary tract

Variable	N
N	20
Male:Female	9:11
Age (Years)
Mean (±SD)	50 (±14)
Etiology
HCV	6
Alcohol	5
Other	9
HCC	6 (30%)
MELD score
Median (range)	29 (18-39)
Cold ischemia time (hours)
Mean (±SD)	6 h (± 0.91)
Warm ischemia time (hours)
Mean (±SD)	0.77 (± 0.27)
Hepatic artery thrombosis	3 (15%)
CMV infection	7 (35%)
Time from OLT to ERCP
Mean (±SD)	411.5 (657.2)
Median (range)	159.5 (30-488)

		Pre-treatment cholangioscopy				Post-treatment cholangioscopy
Patient	OLT to ERCP (days)	Fibrotic changes	Vascular changes	Acute inflammatory changes	Suture material	Fibrotic changes	Vascular changes	Acute inflammatory changes	Suture material	Stricture resolution	FCSEMS adverse event	Stricture recurrence
1	113	Yes	No	No	No	Yes	No	No	No	No	Migration	n/a
2	154	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Migration	n/a
3	154	Yes	Yes	Yes	Yes	Yes	No	No	No	No	Migration*	n/a
4	40	Yes	Yes	Yes	Yes	Yes	No	No	No	Yes	Migration*	No
5	105	Yes	No	Yes	Yes	Yes	No	No	No	Yes	Migration*	No
6	166	Yes	No	Yes	Yes	n/a	n/a	n/a	n/a	Death	Unknown	n/a
7	215	Yes	No	No	Yes	Yes	No	No	No	No	Migration*	n/a
8	345	Yes	Yes	No	No	Yes	Yes	No	No	Yes	Migration*	Yes
9	68	Yes	Yes	No	Yes	n/a^&	n/a	n/a	n/a	No	Occlusion Cholangitis	n/a
10	260	Yes	Yes	No	No	Yes	Yes	No	No	No	Migration*	n/a
11	30	Yes	Yes	No	Yes	Yes	No	No	No	Yes	No	No
12	731	Yes	Yes	Yes	No	Yes	Yes	Yes	No	Yes	Migration*	No
13	700	Yes	No	No	No	n/a^&	n/a	n/a	n/a	No	Occlusion Cholangitis	n/a
14	165	Yes	No	No	No	Yes	No	No	No	Yes	Migration*	No
15	360	Yes	Yes	No	Yes	No	Yes	Yes	No	Yes	No	No
16	48	Yes	No	No	Yes	n/a	n/a	n/a	n/a	Death	Unknown	n/a
17	1968	Yes	No	No	No	Yes	No	No	No	No	Migration*	n/a
18	82	Yes	Yes	No	Yes	Yes	Yes	No	No	No	Migration	n/a
19	38	Yes	Yes	No	Yes	Yes	No	No	No	No	Migration Occlusion	n/a
20	2488	Yes	Yes	No	No	Yes	No	No	No	Yes	No	No

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br

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[1] Corresponding author: Fernanda Prata Martins. E-mail: fernandapbm@gmail.com