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

Sang Myung Woo; Hyun Beom Kim; Kwang-Woong Lee; Woo Jin Lee; Young-Kyu Kim; Sung-Sik Han; Sang-Jae Park

doi:10.4285/jkstn.2012.26.3.188

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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

Original Article

J Korean Soc Transplant 2012;26(3):188-195.

Published online: 19 January 2012

DOI: https://doi.org/10.4285/jkstn.2012.26.3.188

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

Sang Myung Woo, M.D.¹, Hyun Beom Kim, M.D.¹, Kwang-Woong Lee, M.D.^1,^2,, Woo Jin Lee, M.D.¹, Young-Kyu Kim, M.D.¹, Sung-Sik Han, M.D.¹, Sang-Jae Park, M.D.¹

¹Center for Liver Cancer, National Cancer Center, Goyang, Korea

²Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

Correspondence：Kwang-Woong Lee, Department of Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea Tel: +82-2-760-2511, Fax: +82-2-766-3975 E-mail: kwleegs@gmail.com

Received 29 November 2011 Revised 11 August 2012 Accepted 13 August 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Bile ducts, Complication, Bile duct stent

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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.

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.

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)
No. of patient	Age (yr)	Sex	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)
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
7^a	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)
No. of patient	Success of PTBS	PTBS-related complication	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	Failure^a
3	40.3	3	8	2	Success
4	27.6	2	6	2	Failure^b
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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