|
| ||
|
|
||
Biliary Strictures (biliary + stricture)
Kinds of Biliary Strictures Selected AbstractsENDOSCOPIC MANAGEMENT OF BILIARY STRICTURESDIGESTIVE ENDOSCOPY, Issue 2004Yoshitsugu Kubota ABSTRACT Endoscopic stenting, due to being less invasive, is feasible for most patients with biliary strictures; however, presumed efficacy should be balanced against the procedure-related morbidities for an individual patient. Self-expandable metallic stents have a longer patency, but are not retrievable. Therefore, the use of self-expandable metallic stents should be limited to those with unequivocal findings of unresectable malignancy. Plastic stents are indicated for strictures due to benign etiologies and equivocal malignancy. Endoscopic stenting for hilar biliary stricture is challenging. Bilateral hepatic drainage seems ideal but is often demanding to achieve with endoscopic technique, and contrast injection into undrained segments may pose a substantial risk for cholangitis and aggravate prognosis. Therefore, the extent of drainage should be balanced against the procedure-related complications. Preoperative magnetic resonance cholangiopancreatography may help determine feasibility of bilateral drainage or an ,intended and selective drainage' with a single stent and might obviate the possible morbidities. [source] Risk Factors for and Clinical Course of Non-Anastomotic Biliary Strictures After Liver TransplantationAMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2003Maureen M. J. Guichelaar Non-anastomotic biliary stricture (NAS) formation is a major complication of liver transplantation. We prospectively determined the time to development of responsiveness to treatment, and clinical outcomes following NAS formation. In addition, an extensive analysis of the association of recipient, donor, and clinical variables with NAS formation was performed. A total of 749 consecutive patients was studied in a prospective, protocol-based fashion. Seventy-two patients (9.6%) developed NAS at a mean of 23.6 ± 34.2 weeks post-transplantation. Non-anastomotic biliary stricture formation resolved in only 6% of affected patients. Although patient survival was not affected, retransplantation and graft loss rates were significantly greater in recipients who developed NAS. In contrast to previous reports, a pretransplant diagnosis of HCV was associated with a low frequency of NAS formation. The incidence of NAS was independently associated with pretransplant diagnoses of PSC and autoimmune hepatitis. Hepatic artery thrombosis, and prolonged warm and cold ischemia times were also independent risk factors for NAS formation. We conclude that NAS developed in ,10% of primary liver transplant recipients. A pretransplant diagnosis of autoimmune hepatitis has been identified as a novel independent risk factor for NAS formation. Development of NAS significantly attenuates graft but not patient survival. [source] Late surgical complications following liver transplantationLIVER TRANSPLANTATION, Issue S2 2009Paige M. Porrett Key Points 1. Biliary strictures and incisional hernias are the most common surgical complications encountered late after liver transplantation. 2. Anastomotic biliary strictures are amenable to endoscopic intervention and rarely need surgical intervention. 3. The presence of a biliary stricture mandates an evaluation of the patency of the hepatic artery. 4. Ischemic-type intrahepatic strictures are common indications for retransplantation. 5. Recipients of living related liver transplantation and donation after cardiac death allografts are at the highest risk for biliary and vascular complications late after transplantation. Liver Transpl 15:S12,S18, 2009. © 2009 AASLD. [source] Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantationLIVER TRANSPLANTATION, Issue 1 2006Thomas Zoepf Biliary strictures after liver transplantation are a therapeutic challenge for endoscopy. Anastomotic strictures occur in 10% of patients after liver transplantation, leading untreated to mortality and ultimately to graft failure. Despite of successful reports, to date, there is no defined endoscopic therapy regimen for these cases. Therefore the aim of this study was to determine the most suitable concept for endoscopic treatment of post-liver transplant anastomotic strictures (PTAS). A total of 72 patients post-liver transplantation, who received endoscopic retrograde cholangiography (ERC) as a consequence of suspected biliary complications were retrospectively screened for the presence of PTAS. In all patients graft rejection or bile duct ischemia were excluded prior to ERC by liver biopsy or Doppler ultrasound respectively. We compared either balloon dilatation (BD) alone or dilatation plus placement of an increasing number of bile duct endoprostheses (BD + endoprostheses) in a retrospective analysis. A total of 25 of 75 patients showed PTAS. Overall, endoscopic therapy was successful in 22 of 25 patients (88%). BD was initially successful in 89% but showed recurrence in 62%. BD + endoprostheses was initially successful in 87%, and recurrence was observed only in 31%. All recurrences were successfully retreated by BD + endoprostheses. During 22 of 109 (20%) treatment sessions stone extraction was necessary. Complication rate was low with bacterial cholangitis in 8 of 109 (7.3%) sessions, mild pancreatitis in 10 of 109 (9%) sessions and minor bleeding in 2 of 25 (8%) sphincterotomies. Median follow-up after conclusion of endoscopic therapy is 6 months (range 1,43). In conclusion, our data confirm that endoscopic therapy of PTAS is highly effective and safe. As primarily successful BD shows a high rate of recurrence, we recommend a combination of BD followed by an increasing number and diameter of endoprostheses. Therapy sessions are effective at short intervals of every 2,3 months. Liver Transpl 12:88,94, 2006. © 2005 AASLD. [source] Biliary strictures following living donor liver transplantation: Even money on a tight squeezePEDIATRIC TRANSPLANTATION, Issue 3 2002Estella M. Alonso MD No abstract is available for this article. [source] ENDOSCOPIC MANAGEMENT OF BILIARY and PANCREATIC DUCTS STRICTURESDIGESTIVE ENDOSCOPY, Issue 2004Hiroyuki Maguchi ABSTRACT Endoscopic treatment is applied to a relatively large number of biliary and pancreatic duct strictures, and is a practical matter. It is essential to select the most appropriate treatment for each lesion. For instance, when treating malignant biliary stricture, accurate diagnosis of whether surgical treatment is required or not is vital; and in choosing a stent for an inoperable case, location of the stricture, with or without anticancer treatment, prognosis, and management of possible post-stenting re-stricture must be taken into consideration. For benign strictures, not only short-term results in mobility and motality, but also decades of long-term results must be cautiously questioned. Bearing these in mind, we need to accumulate the worldwide data of the treatments and establish a proper treatment guideline. [source] ENDOSCOPIC MANAGEMENT OF BILIARY STRICTURESDIGESTIVE ENDOSCOPY, Issue 2004Yoshitsugu Kubota ABSTRACT Endoscopic stenting, due to being less invasive, is feasible for most patients with biliary strictures; however, presumed efficacy should be balanced against the procedure-related morbidities for an individual patient. Self-expandable metallic stents have a longer patency, but are not retrievable. Therefore, the use of self-expandable metallic stents should be limited to those with unequivocal findings of unresectable malignancy. Plastic stents are indicated for strictures due to benign etiologies and equivocal malignancy. Endoscopic stenting for hilar biliary stricture is challenging. Bilateral hepatic drainage seems ideal but is often demanding to achieve with endoscopic technique, and contrast injection into undrained segments may pose a substantial risk for cholangitis and aggravate prognosis. Therefore, the extent of drainage should be balanced against the procedure-related complications. Preoperative magnetic resonance cholangiopancreatography may help determine feasibility of bilateral drainage or an ,intended and selective drainage' with a single stent and might obviate the possible morbidities. [source] Exercise-induced cholangitis and pancreatitisHPB, Issue 2 2005JOHN G. TOUZIOS Abstract Background. Cholangitis requires bactibilia and increased biliary pressure. Pancreatitis may be initiated by elevated intraductal pressure. The sphincter of Oddi regulates pancreatobiliary pressures and prevents reflux of duodenal contents. However, following biliary bypass or pancreatoduodenectomy, increased intra-abdominal pressure may be transmitted into the bile ducts and/or pancreas. The aim of this analysis is to document that cholangitis or pancreatitis may be exercise-induced. Methods. The records of patients with one or more episodes of cholangitis or pancreatitis precipitated by exercise and documented to have patent hepatico- or pancreatojejunostomies were reviewed. Cholangitis was defined as fever with or without abdominal pain and transiently abnormal liver tests. Pancreatitis was defined as abdominal pain, with transient elevation of serum amylase and documented by peripancreatic inflammation on computerized tomography. Results. Twelve episodes of cholangitis occurred in six patients who had undergone hepaticojejunostomy for biliary stricture (N=3), Type I choledochal cyst (N=2), or pancreatoduodenectomy for renal cell carcinoma metastatic to the pancreas (N=1). Four episodes of pancreatitis occurred in two patients who had undergone pancreatoduodenectomy for ampullary carcinoma or chronic pancreatitis. Workup and subsequent follow-up for a median of 21 months have not documented anastomotic stricture. Each episode of cholangitis and pancreatitis was brought on by heavy exercise and avoidance of this level of exercise has prevented future episodes. Conclusion. Following biliary bypass or pancreatoduodenectomy, significant exercise may increase intra-abdominal pressure and cause cholangitis or pancreatitis. Awareness of this entity and behavior modification will avoid unnecessary procedures in these patients. [source] Post-cholecystectomy biliary strictures: Not always benignJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7pt2 2008Ajay Sharma Abstract Background:, Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge. Methods:, Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study. Results:, Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008). Conclusions:, Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy. [source] Late surgical complications following liver transplantationLIVER TRANSPLANTATION, Issue S2 2009Paige M. Porrett Key Points 1. Biliary strictures and incisional hernias are the most common surgical complications encountered late after liver transplantation. 2. Anastomotic biliary strictures are amenable to endoscopic intervention and rarely need surgical intervention. 3. The presence of a biliary stricture mandates an evaluation of the patency of the hepatic artery. 4. Ischemic-type intrahepatic strictures are common indications for retransplantation. 5. Recipients of living related liver transplantation and donation after cardiac death allografts are at the highest risk for biliary and vascular complications late after transplantation. Liver Transpl 15:S12,S18, 2009. © 2009 AASLD. [source] Biliary reconstruction for infantile living donor liver transplantation: Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy?LIVER TRANSPLANTATION, Issue 12 2008Yasumasa Shirouzu Hepaticojejunostomy is a standard biliary reconstruction method for infantile living donor liver transplantation (LDLT), but choledochocholedochostomy for infants is not generally accepted yet. Ten pediatric recipients weighing no more than 10 kg underwent duct-to-duct choledochocholedochostomy (DD) for biliary reconstruction for LDLT. Patients were followed up for a median period of 26.8 months (range: 4.0,79.0 months). The incidence of posttransplant biliary complications for DD was compared with that for Roux-en-Y hepaticojejunostomy (RY). No DD patients and 1 RY patient (5%) developed biliary leakage (P > 0.05), and biliary stricture occurred in 1 DD patient (10%) and none of the RY patients (P > 0.05); none of the DD patients and 5 RY patients (25%) suffered from uncomplicated cholangitis after LDLT (P > 0.05), and 1 DD patient (10%) and 2 RY patients (10%) died of causes unrelated to biliary complications. In conclusion, both hepaticojejunostomy and choledochocholedochostomy resulted in satisfactory outcome in terms of biliary complications, including leakage and stricture, for recipients weighing no more than 10 kg. Liver Transpl 14:1761,1765, 2008. © 2008 AASLD. [source] Anastomotic biliary strictures after liver transplantation: Causes and consequencesLIVER TRANSPLANTATION, Issue 5 2006Robert C. Verdonk We retrospectively studied the prevalence, presentation, results of treatment, and graft and patient survival of grafts developing an anastomotic biliary stricture (AS) in 531 adult liver transplantations performed between 1979 and 2003. Clinical and laboratory information was obtained from the hospital files, and radiological studies were re-evaluated. Twenty-one possible risk factors for the development of AS (variables of donor, recipient, surgical procedure, and postoperative course) were analyzed in a univariate and stepwise multivariate model. Forty-seven grafts showed an anastomotic stricture: 42 in duct-to-duct anastomoses, and 5 in hepaticojejunal Roux-en-Y anastomoses. The cumulative risk of AS after 1, 5, and 10 years was 6.6%, 10.6%, and 12.3% respectively. Postoperative bile leakage (P = 0.001), a female donor/male recipient combination (P = 0.010), and the era of transplantation (P = 0.006) were independent risk factors for the development of an AS. In 47% of cases, additional (radiologically minor) nonanastomotic strictures were diagnosed. All patients were successfully treated by 1 or more treatment modalities. As primary treatment, endoscopic retrograde cholangiopancreaticography (ERCP) was successful in 24 of 36 (67%) cases and percutaneous transhepatic cholangiodrainage in 4 of 11 (36%). In the end 15 patients (32%) were operated, all with long-term success. AS presenting more than 6 months after transplantation needed more episodes of stenting by ERCP, and more stents per episode compared to those presenting within 6 months and recurred more often. Graft and patient survival were not impaired by AS. Liver Transpl 12:726,735, 2006. © 2006 AASLD. [source] An unusual case of jaundice in secondary diabetesPRACTICAL DIABETES INTERNATIONAL (INCORPORATING CARDIABETES), Issue 5 2003RM Reynolds Specialist Registrar Abstract A 66-year-old insulin-requiring diabetic male with diabetes secondary to pancreatic damage from alcohol abuse, with well-established alcoholic liver disease and cirrhosis, developed obstructive jaundice from gall stones and later from a biliary stricture associated with gram-negative septicaemia. Death occurred from a haemorrhagic cholecystitis with ruptured gall bladder. At autopsy, a surprise finding was a non-functioning pancreatic islet cell tumour invading the ampulla of Vater. Cholestasis in this case was due to multiple factors. Copyright © 2002 John Wiley & Sons, Ltd. [source] Risk Factors for and Clinical Course of Non-Anastomotic Biliary Strictures After Liver TransplantationAMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2003Maureen M. J. Guichelaar Non-anastomotic biliary stricture (NAS) formation is a major complication of liver transplantation. We prospectively determined the time to development of responsiveness to treatment, and clinical outcomes following NAS formation. In addition, an extensive analysis of the association of recipient, donor, and clinical variables with NAS formation was performed. A total of 749 consecutive patients was studied in a prospective, protocol-based fashion. Seventy-two patients (9.6%) developed NAS at a mean of 23.6 ± 34.2 weeks post-transplantation. Non-anastomotic biliary stricture formation resolved in only 6% of affected patients. Although patient survival was not affected, retransplantation and graft loss rates were significantly greater in recipients who developed NAS. In contrast to previous reports, a pretransplant diagnosis of HCV was associated with a low frequency of NAS formation. The incidence of NAS was independently associated with pretransplant diagnoses of PSC and autoimmune hepatitis. Hepatic artery thrombosis, and prolonged warm and cold ischemia times were also independent risk factors for NAS formation. We conclude that NAS developed in ,10% of primary liver transplant recipients. A pretransplant diagnosis of autoimmune hepatitis has been identified as a novel independent risk factor for NAS formation. Development of NAS significantly attenuates graft but not patient survival. [source] Spatulated end-to-end bile duct reconstruction in orthotopic liver transplantationCLINICAL TRANSPLANTATION, Issue 1 2007Andrzej K Buczkowski Abstract:, Biliary complications continue to be a major source of morbidity following orthotopic liver transplantation. The aim of this study was to analyze the incidence and management of biliary complications related to the technique of bile duct reconstruction. The patients were stratified into two groups: group I (n = 39) had bile duct reconstruction performed by an end-to-end single interrupted suture choledochocholedochostomy (EE-CDCD) and group II (n = 38) had a spatulated end-to-end CDCD (spEE-CDCD) reconstruction; both groups had an intraductal stent. The groups were similar in age, gender, liver transplant indications and Pugh score. Ten biliary complications (26%), including five bile leaks (13%) and five biliary strictures (13%), were observed in the EE-CDCD group, while one biliary stricture (2.6%) occurred in the spEE-CDCD group (p < 0.05). Subsequent imaging studies and endoscopic retrograde cholangiopancreatography were performed less often in patients undergoing spEE-CDCD reconstruction (p < 0.05). The technique of a spatulated end-to-end bile duct reconstruction provides a significant improvement in lowering biliary complication rates in liver transplant patients. Despite the modest number of cases in this study this technique shows promise and has become the technique of choice in our institution. [source] BILIARY STENTING FOR MALIGNANT BILIARY OBSTRUCTIONDIGESTIVE ENDOSCOPY, Issue 1 2006Toshio Tsuyuguchi Management of patients with malignant biliary obstruction remains controversial. We reviewed our current status of biliary stenting for malignancy. The initial step in our management is endoscopic nasobiliary drainage, which is used not only for preoperative drainage but also to decide whether or not surgery is appropriate treatment. Although a metal stent has a longer patency time than a plastic stent, it costs up to thirty-fold more than the latter in Japan. Therefore, stent selection, metal or plastic, should be dependent on the expected prognosis of each patient with malignant biliary strictures. In the present paper, we also discuss the efficacy of the covered metal stent and stenting for malignant hilar obstruction. [source] ENDOSCOPIC MANAGEMENT OF BILIARY STRICTURESDIGESTIVE ENDOSCOPY, Issue 2004Yoshitsugu Kubota ABSTRACT Endoscopic stenting, due to being less invasive, is feasible for most patients with biliary strictures; however, presumed efficacy should be balanced against the procedure-related morbidities for an individual patient. Self-expandable metallic stents have a longer patency, but are not retrievable. Therefore, the use of self-expandable metallic stents should be limited to those with unequivocal findings of unresectable malignancy. Plastic stents are indicated for strictures due to benign etiologies and equivocal malignancy. Endoscopic stenting for hilar biliary stricture is challenging. Bilateral hepatic drainage seems ideal but is often demanding to achieve with endoscopic technique, and contrast injection into undrained segments may pose a substantial risk for cholangitis and aggravate prognosis. Therefore, the extent of drainage should be balanced against the procedure-related complications. Preoperative magnetic resonance cholangiopancreatography may help determine feasibility of bilateral drainage or an ,intended and selective drainage' with a single stent and might obviate the possible morbidities. [source] Endoscopic removal of a dislocated covered wallstent using a wire-loop techniqueDIGESTIVE ENDOSCOPY, Issue 4 2003Takao Itoi Background:, Self-expandable metallic stents (SEMS) and covered-SEMS (cSEMS) are used for patients with unresectable malignant biliary strictures. Occasionally, there are cases where stent migration can easily occur. Methods and Results:, We experienced a dislocated distal cSEMS that was unable to be removed by previously described techniques. However, we could successfully remove cSEMS with a wire-loop technique using a polypectomy snare and guidewire. Conclusion:, This technique may provide hope for the removal of severely dislocated cSEMS. [source] Recurrence of primary biliary cirrhosis and primary sclerosing cholangitis after liver transplantation in JapanHEPATOLOGY RESEARCH, Issue 2007Satoshi Yamagiwa Although there was some initial controversy, there is now a consensus that primary biliary cirrhosis (PBC) does indeed recur in both cadaveric and living donated allografts. Recurrence rate after deceased donor liver transplantation (LT) was reported to be 10.9,23% at 5 years. In the present study, we reviewed 221 PBC patients who underwent living-donor liver transplantation (LDLT) in Japan. The 5-year overall survival rate was 79%, and the rate of recurrence based on histological findings was 10% (7/70) after a median time of 36 months. Primary immunosuppression, withdrawal of corticosteroids and human leukocyte antigen matches were not associated with the recurrence. Recurrent PBC appears to have little impact on graft function and survival, but this may become a greater problem with longer follow up. It is noteworthy that the 10-year survival of primary sclerosing cholangitis (PSC) patients who underwent LDLT wasfound to be only 39.1% in Japan, whereas that of PBC was 72.9%. Factors associated with the poor prognosis include biliary strictures, hepatobiliary and colorectal malignancies, and recurrence of PSC. In our study, we reviewed 66 patients with PSC who underwent LDLT in Japan. The 5-year survival rate was 72%, and the rate of recurrence diagnosed on histological and cholangiographic findings was 25% (11/44). Well-defined diagnostic criteria and longer studies are required to characterize the nature of recurrent PSC and its impact on graft survival in more detail. [source] Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central HospitalHPB, Issue 3 2002A Elhamel Background Laparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed. Method A total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient, who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations. Conclusions It is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed. [source] Post-cholecystectomy biliary strictures: Not always benignJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7pt2 2008Ajay Sharma Abstract Background:, Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge. Methods:, Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study. Results:, Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008). Conclusions:, Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy. [source] Role of radiology in the treatment of malignant hilar biliary strictures 1: Review of the literatureJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 1 2004Michael WJ Hii SUMMARY Malignant strictures of the biliary tree are an uncommon cause of obstructive jaundice. There are a number of pathological subtypes, but tumours in this region tend to have similar clinical and diagnostic features and therapeutic and prognostic implications. We review the published literature on this topic discussing diagnostic modalities and treatment options with a focus on radiological intervention. Diagnosis currently is best achieved using a range of procedures. Direct cholangiography remains the gold standard in delineating anatomy, but the invasiveness of this procedure limits its use as a purely diagnostic tool. Magnetic resonance technology, in particular magnetic resonance cholangiopancreatography, has an increasing role as accessibility is improved. Treatment of these tumours is difficult. Surgical resection and palliative biliary enteric bypass are the most common methods used with endoscopic and percutaneous therapies reserved for palliating patients not fit for surgery. There is little firm evidence to suggest that any one palliative modality is superior. Interventional radiology is particularly suitable for palliative management of difficult and expansive lesions as the anatomy can preclude easy access by surgical or endoscopic techniques. Good palliative results with minimal mortality and morbidity can be achieved with percutaneous stenting . [source] Long-term outcomes in pediatric liver transplantationLIVER TRANSPLANTATION, Issue S2 2009John Bucuvalas Key Points 1. Critical clinical outcomes for pediatric liver transplantation (LT) recipients include (1) patient and graft survival, (2) complications (immune and nonimmune) of chronic immunosuppressive medications, and (3) long-term graft function. 2. Recurrence of malignancy, sepsis, and posttransplant lymphoproliferative disorder account for more than 65% of deaths occurring more than 1 year after LT. 3. Chronic rejection, late hepatic artery thrombosis, and biliary strictures account for 70% of graft loss occurring more than 1 year after LT. 4. Late histological changes in the allograft are emerging as a common problem in patients more than 5 years after LT. The pathogenesis of these findings and the impact on graft survival remain to be determined. Liver Transpl 15:S6,S11, 2009. © 2009 AASLD. [source] Late surgical complications following liver transplantationLIVER TRANSPLANTATION, Issue S2 2009Paige M. Porrett Key Points 1. Biliary strictures and incisional hernias are the most common surgical complications encountered late after liver transplantation. 2. Anastomotic biliary strictures are amenable to endoscopic intervention and rarely need surgical intervention. 3. The presence of a biliary stricture mandates an evaluation of the patency of the hepatic artery. 4. Ischemic-type intrahepatic strictures are common indications for retransplantation. 5. Recipients of living related liver transplantation and donation after cardiac death allografts are at the highest risk for biliary and vascular complications late after transplantation. Liver Transpl 15:S12,S18, 2009. © 2009 AASLD. [source] Anastomotic biliary strictures after liver transplantation: Causes and consequencesLIVER TRANSPLANTATION, Issue 5 2006Robert C. Verdonk We retrospectively studied the prevalence, presentation, results of treatment, and graft and patient survival of grafts developing an anastomotic biliary stricture (AS) in 531 adult liver transplantations performed between 1979 and 2003. Clinical and laboratory information was obtained from the hospital files, and radiological studies were re-evaluated. Twenty-one possible risk factors for the development of AS (variables of donor, recipient, surgical procedure, and postoperative course) were analyzed in a univariate and stepwise multivariate model. Forty-seven grafts showed an anastomotic stricture: 42 in duct-to-duct anastomoses, and 5 in hepaticojejunal Roux-en-Y anastomoses. The cumulative risk of AS after 1, 5, and 10 years was 6.6%, 10.6%, and 12.3% respectively. Postoperative bile leakage (P = 0.001), a female donor/male recipient combination (P = 0.010), and the era of transplantation (P = 0.006) were independent risk factors for the development of an AS. In 47% of cases, additional (radiologically minor) nonanastomotic strictures were diagnosed. All patients were successfully treated by 1 or more treatment modalities. As primary treatment, endoscopic retrograde cholangiopancreaticography (ERCP) was successful in 24 of 36 (67%) cases and percutaneous transhepatic cholangiodrainage in 4 of 11 (36%). In the end 15 patients (32%) were operated, all with long-term success. AS presenting more than 6 months after transplantation needed more episodes of stenting by ERCP, and more stents per episode compared to those presenting within 6 months and recurred more often. Graft and patient survival were not impaired by AS. Liver Transpl 12:726,735, 2006. © 2006 AASLD. [source] Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantationLIVER TRANSPLANTATION, Issue 1 2006Thomas Zoepf Biliary strictures after liver transplantation are a therapeutic challenge for endoscopy. Anastomotic strictures occur in 10% of patients after liver transplantation, leading untreated to mortality and ultimately to graft failure. Despite of successful reports, to date, there is no defined endoscopic therapy regimen for these cases. Therefore the aim of this study was to determine the most suitable concept for endoscopic treatment of post-liver transplant anastomotic strictures (PTAS). A total of 72 patients post-liver transplantation, who received endoscopic retrograde cholangiography (ERC) as a consequence of suspected biliary complications were retrospectively screened for the presence of PTAS. In all patients graft rejection or bile duct ischemia were excluded prior to ERC by liver biopsy or Doppler ultrasound respectively. We compared either balloon dilatation (BD) alone or dilatation plus placement of an increasing number of bile duct endoprostheses (BD + endoprostheses) in a retrospective analysis. A total of 25 of 75 patients showed PTAS. Overall, endoscopic therapy was successful in 22 of 25 patients (88%). BD was initially successful in 89% but showed recurrence in 62%. BD + endoprostheses was initially successful in 87%, and recurrence was observed only in 31%. All recurrences were successfully retreated by BD + endoprostheses. During 22 of 109 (20%) treatment sessions stone extraction was necessary. Complication rate was low with bacterial cholangitis in 8 of 109 (7.3%) sessions, mild pancreatitis in 10 of 109 (9%) sessions and minor bleeding in 2 of 25 (8%) sphincterotomies. Median follow-up after conclusion of endoscopic therapy is 6 months (range 1,43). In conclusion, our data confirm that endoscopic therapy of PTAS is highly effective and safe. As primarily successful BD shows a high rate of recurrence, we recommend a combination of BD followed by an increasing number and diameter of endoprostheses. Therapy sessions are effective at short intervals of every 2,3 months. Liver Transpl 12:88,94, 2006. © 2005 AASLD. [source] Intrahepatic cholestasis after liver transplantationLIVER TRANSPLANTATION, Issue 10 2003Ziv Ben-Ari Cholestasis is a common sequela of liver transplantation. Although the majority of cases remain subclinical, severe cholestasis may be associated with irreversible liver damage, requiring retransplantation. Therefore, it is essential that clinicians be able to identify and treat the syndromes associated with cholestasis. In this review, we consider causes of intrahepatic cholestasis. These may be categorized by time of occurrence, namely, within 6 months of liver transplantation (early) and thereafter (late), although there may be an overlap in their causes. The causes of intrahepatic cholestasis include ischemia/reperfusion injury, bacterial infection, acute cellular rejection, cytomegalovirus infection, small-for-size graft, drugs for hepatotoxicity, intrahepatic biliary strictures, chronic rejection, hepatic artery thrombosis, ABO blood group incompatibility, and recurrent disease. The mechanisms of cholestasis in each category and the clinical presentation, diagnosis, treatment, and outcome are discussed in detail. [source] Recurrence of primary sclerosing cholangitis after liver transplantationLIVER TRANSPLANTATION, Issue 7 2002Ivo W. Graziadei MD Orthotopic liver transplantation (OLT) has become the only effective therapeutic option for patients with end-stage liver disease caused by primary sclerosing cholangitis (PSC). Excellent long-term outcome has been reported, with 5-year patient survival rates of approximately 80%. In the last few years, increasing evidence has emerged that PSC recurs after OLT. The diagnosis of PSC is based on well-defined cholangiographic features combined with biochemical and histological findings. However, none of these features is specific for PSC, particularly after OLT, because biliary strictures in the liver allograft can occur from a variety of causes other than recurrence. Therefore, PSC recurrence remains a controversial issue, especially because of a lack of a gold standard for diagnosis and well-established diagnostic criteria. Some reports provided cholangiographic evidence that post-OLT biliary strictures occurred more frequently in patients with PSC than in those who underwent OLT for other liver diseases (including patients with a Roux-en-Y biliary reconstruction). Because no other possible cause of biliary strictures could be invoked to explain the greater prevalence of these strictures, recurrent disease has been implicated. There also is histological evidence suggesting that PSC recurs after OLT. Histological findings suggestive of PSC were found more often in PSC allografts compared with a control group. Furthermore, histological features typical for PSC (fibro-obliterative lesions) were seen exclusively in liver biopsy specimens from patients with PSC. Recurrence of PSC was defined in a recent study from the Mayo Clinic by means of strict cholangiographic and histological criteria in a large cohort of patients with PSC in whom other causes of biliary strictures were excluded. PSC recurrence was found in 20% of patients. No risk factor for PSC recurrence could be found, and recurrent disease did not influence patient or graft survival after a mean follow-up of 4.5 years. In conclusion, several studies provided convincing evidence that PSC recurs after OLT, with an incidence of 5% to 20% and an interval to diagnosis of at least 1 year after OLT. To date, patient and graft survival do not appear to be negatively affected by disease recurrence in the intermediate term of follow-up. (Liver Transpl 2002;8:575-581.) [source] Establishing a systematic endoscopic approach to the management of anastomotic biliary strictures is neededLIVER TRANSPLANTATION, Issue 4 2001Todd H. Baron MD [source] Incidence and management of biliary strictures in living-related donor graftPEDIATRIC TRANSPLANTATION, Issue 6 2002Koichi Tanaka Professor MD First page of article [source] | ||||||||||