Journal List > J Korean Soc Transplant > v.26(3) > 1034374

Woo, Kim, Lee, Lee, Kim, Han, and Park: New Strategy in Cases of Failed Endoscopic Intervention of Biliary Strictures after Living Donor Liver Transplantation: Percutaneous Transhepatic Biliary Stent Insertion and Subsequent Endoscopic Treatment

Abstract

Background:

In cases of endoscopic intervention treatment for biliary stricture which fail, a percutaneous approach can be subsequently attempted. However, the quality of life is lower for those patients with percutaneous transhepatic biliary drainage (PTBD) tubes than those with endoscopic retrograde biliary drainage tubes. In this study, we report the outcome of the application of percutaneous transhepatic biliary stenting (PTBS) for use in subsequent endoscopic treatment of biliary stricture after living donor liver transplantation (LDLT).

Methods:

Of 165 patients who underwent LDLT, 40 (24.2%) were diagnosed with anastomotic biliary strictures. Of these patients, seven agreed to treatment using PTBS using a plastic stent with endoscopic follow-up instead of treatment by insertion of a PTBD tube, and were enrolled in this study.

Results:

In all seven patients, the use of this technique enabled effective advancement of a guide wire and successful placement of one or two plastic stents (7 or 10 Fr) into the PTBD tract. There were no PTBS-related complications associated with the procedure. The median duration for stent use was 40.3 weeks (range; 27.6~65.0). Upon final removal of all stents, the stricture had been resolved in four (57%) of the seven patients.

Conclusions:

Our study data suggested that, after failed use of ERCP in the treatment of biliary stricture after LDLT, the use of PTBS and ERCP may be an effective and safe treatment.

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Fig. 1.
Among 13 patients who had failure in initial endoscopic approach and received PTBD. Five pa-awho agreed with endotients scopic follow-up instead of PTBD tubes were enrolled this study; Among 6 patients for whom PTBD was done as an initial approach, btwo patients who wanted endoscopic follow-up was also enrolled in this study. Abbreviations: ERC-D, endoscopic retrograde cholangiography with dilation; PTC-D, percutaneous transhepatic cholangiography with dilation.
jkstn-26-188f1.tif
Fig. 2.
Percutaneous transhepatic biliary stent insertion. (A) The anastomotic stricture before stent insertion. (B) The placement of the guidewires and the insertion of the plastic stent at the anastomotic stricture. (C) The plastic stent left in place after treatment.
jkstn-26-188f2.tif
Table 1.
Patient characteristics
No. of patient Characteristic Indication for LDLT Time to diagnosis of strictures (wk) No. of anastomoses (donor to recipient) Cause of failure in primary endoscopic treatment Time from PTBD to PTBS (wk)
Age (yr) Sex
1 52 M Hepatocellular carcinoma 10.3 2:1 Failure of guidewire insertion 1.6
2 54 F Post-hepatitis liver cirrhosis 15.7 1:1 Failure of guidewire insertion 16.7
3 54 M Hepatocellular carcinoma 16.1 1:1 Failure of dilator insertion 2.9
4 48 M Hepatocellular carcinoma 22.0 1:1 Failure of cannulation 24.0
5 49 M Post-hepatitis liver cirrhosis 16.3 2:1 Failure of guidewire insertion 26.0
6 59 M Hepatocellular carcinoma 42.3 2:1 Failure of guidewire insertion 90.0
7a 63 M Hepatocellular carcinoma 8.6 1:1   4.6

Abbreviations: LDLT, living donor liver transplantation; PTBD, percutaneous transhepatic biliary drainage; PTBS, percutanous transhepatic biliary stenting.

a PTBD was used as initial approach for biliary stricture.

Table 2.
Outcomes of percutanous transhepatic biliary stenting (PTBS) insertion, liver chemistries in individual patients
No. of patient Success of PTBS PTBS-related complication Total bilirubin (mg/dL) Alkaline phosphatase (IU/L) Alanine aminotransferase (IU/L)
Pre Post Pre Post Pre Post
1 Yes No 1.8 1.4 750 478 45 732
2 Yes No 5.6 5.5 820 717 251 169
3 Yes No 2.1 1.0 72 63 155 9
4 Yes No 0.7 0.8 325 278 16 13
5 Yes No 0.8 0.7 95 116 15 22
6 Yes No 6.1 5.5 278 261 121 105
7 Yes No 1.8 1.4 144 332 18 12
Table 3.
Outcomes of percutanous transhepatic biliary stent insertion and subsequent endoscopic retrograde cholangiopancreatography (ERCP), balloon size, maximum number of stents in individual patients
No. of patient Stent duration (wk) Total No. of subsequent ERCP Maximum balloon size (mm) Maximum No. of stents Current state
1 64.9 5 6 2 Success
2 37.3 1 6 1 Failurea
3 40.3 3 8 2 Success
4 27.6 2 6 2 Failureb
5 65.0 3 6 1 Success
6 32.6 2 6 2 Ongoing
7 54.0 4 6 2 Success

a Failure due to guidewire insertion in subsequent ERCP;

b Failure due to invasion of recurrent hepatocellular carcinoma at common hepatic duct.

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