TY - JOUR
T1 - Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era
AU - Cortez, Alexander R.
AU - Morris, Mackenzie C.
AU - Brown, Nicholas G.
AU - Winer, Leah K.
AU - Safdar, Kamran
AU - Poreddy, Sampath
AU - Shah, Shimul A.
AU - Quillin, R. Cutler
N1 - Publisher Copyright:
© 2019, The Society for Surgery of the Alimentary Tract.
PY - 2020/7/1
Y1 - 2020/7/1
N2 - Background: Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. Methods: All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). Results: A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions—two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. Conclusions: Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.
AB - Background: Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT. Methods: All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak). Results: A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions—two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted. Conclusions: Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.
UR - http://www.scopus.com/inward/record.url?scp=85067884644&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85067884644&partnerID=8YFLogxK
U2 - 10.1007/s11605-019-04292-z
DO - 10.1007/s11605-019-04292-z
M3 - Article
C2 - 31228080
AN - SCOPUS:85067884644
VL - 24
SP - 1639
EP - 1647
JO - Journal of Gastrointestinal Surgery
JF - Journal of Gastrointestinal Surgery
SN - 1091-255X
IS - 7
ER -