Feb. 11, 2023
Anastomotic and nonanastomotic strictures of the bile duct are a well-recognized complication of liver transplantation (LT). For LT recipients with a conventional duct-to-duct anastomosis, endoscopic retrograde cholangiography (ERC) is generally regarded as the preferred approach to managing post-LT biliary strictures. However, in the subset of LT recipients who require a biliary-enteric (BE) anastomosis, choledochojejunostomy or hepaticojejunostomy, endoscopic access to manage strictures is more challenging. In these patients, percutaneous transhepatic biliary drainage (PTBD), with or without balloon-assisted cholangioplasty, has generally been regarded as the first line approach.
To date, few researchers have reported data related to the use of ERC in LT recipients with a BE anastomosis. In a study published in 2022 in the Annals of Hepato-Biliary-Pancreatic Surgery, a team of Mayo Clinic researchers and colleagues compared outcomes of ERC and PTBD as the primary therapies for biliary stricture in LT recipients with a Roux-en-Y BE anastomosis.
"Our paper details the effectiveness of these interventions in liver transplant recipients with biliary-enteric anastomosis," explains Rahul Pannala, M.D., the article's corresponding author and a gastroenterologist and hepatologist at Mayo Clinic in Arizona. "We hypothesized that ERC and PTBD would have comparable efficacy as primary therapy in this patient population."
Study methods
In this retrospective study, the researchers identified a total of 36 adult patients who underwent LT with Roux-en-Y BE anastomosis from 2001 to 2020, and had either ERC or PTBD as primary treatment for presumed biliary strictures.
Overall, the study involved 25 males and 11 females, with a mean age of 53.5 years at time of LT, most of whom underwent LT after being diagnosed with primary sclerosing cholangitis mediated chronic liver disease. The most common indications for a BE anastomosis were primary sclerosing cholangitis and duct size mismatch.
Among the 36 identified LT recipients who required biliary intervention, 29 underwent ERC and seven underwent PTBD. The researchers noted that the initial endoscope used for the ERC was a single-balloon enteroscope in 16 patients, a double-balloon enteroscope in seven patients, a pediatric colonoscope in five patients and a conventional reusable duodenoscope in one patient.
Results
According to Dr. Pannala and co-authors, the study data demonstrate that in LT recipients with a Roux-en-Y BE anastamosis who require biliary intervention, ERC performed with a balloon-assisted enteroscope is a safe option. And the success rate associated with ERC is comparable to the rate achieved with PTBD.
- Technical success was defined as the ability to cannulate the bile duct and was achieved in 24 of the 29 patients (82.8%) who underwent post-LT ERC versus six of the seven patients (85.7%) who underwent post-LT PTBD.
- Clinical success was defined as the ability to perform cholangiography and therapeutic interventions. This was achieved in 22 of the 29 patients (75.9%) who underwent post-LT ERC versus six of the seven patients (85.7%) who underwent post-LT PTBD.
"Our study shows both endoscopic and percutaneous interventions are clinically and technically successful in the majority of patients with biliary-enteric anastomoses post-transplant," explains Dr. Pannala. The data suggest that in settings where expertise is available, endoscopic treatment of biliary strictures in this population is effective, as is percutaneous drainage. In some complex patients, a combination of endoscopic and percutaneous approaches may be required. And the availability of specific endoscopes, such as single- and double-balloon enteroscopes, facilitates successful device-assisted therapeutic ERC in these patients with altered anatomy."
Next steps
Dr. Pannala notes that additional research is needed to answer some key questions and provide additional valuable information to guide treatment in these patients.
"The current study was limited to patients treated at Mayo Clinic in Arizona and was retrospective. It would be important to study the effectiveness of these interventions in a multicenter approach. Further studies are also required to understand the impact of surgical variables such as the length of the biliary limb and the nature of the anastomosis. For example, it would be helpful to examine the impact of choledochoduodenostomy versus choledochojejunostomy or hepaticojejunostomy on the success of the endoscopic interventions."
For more information
Kohli DR, et al. Outcomes of endoscopic retrograde cholangiography and percutaneous transhepatic biliary drainage in liver transplant recipients with a Roux-en-Y biliary-enteric anastomosis. Annals of Hepato-Biliary-Pancreatic Surgery. In press.
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