Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation

Abstract

Background: Biliary strictures are the most common complication after liver transplantation. A particular problem is ischemic-type biliary lesions (ITBLs), which are often responsible for graft failure and early retransplantation. Although some encouraging results of successful endoscopic treatment have been reported, this has not yet resulted in a standardized therapeutic approach to date.

Objective: To evaluate an optimized algorithm for the endoscopic treatment of ITBLs.

Setting and patients: All adult patients who underwent liver transplantation at the University of Essen between April 1998 and July 2006.

Design: Retrospective outcome analysis.

Main outcome measurements: Success or failure of 2 different therapeutic algorithms in terms of normalization of cholestasis parameters and graft survival.

Results: Forty-eight patients who had undergone liver transplantation and had an endoscopically determined diagnosis of ITBL were identified. The median interval between liver transplantation and first endoscopic intervention was 242.5 (range, 16-3677) days. Patients received a median of 6 treatment sessions (range 2-13) every 8 to 10 weeks. In 16 of 48 patients, a combination of balloon dilation (BD) and implantation of a plastic endoprosthesis (BD+EP) was performed; in the remaining 32 patients, BD alone was performed. Overall, endoscopic therapy was successful in 73%. BD+EP was successful in 5 of 16 (31%) and BD alone in 30 of 32 patients (91%; P = .0027). In the BD+EP group, severe cholangitis developed in 25% of patients, but only 12% of the BD group (P = .01). The median duration of therapy was 374 (range 11-808) days. Six of 48 patients underwent retransplantation because of chronic graft rejection at a median of 1288 (range 883-4204) days after the primary liver transplantation. Six of 48 patients underwent hepaticojejunostomy because of unsuccessful endoscopic therapy, and 1 patient underwent surgery because of portal vein thrombosis.

Limitations: Retrospective design.

Conclusions: An endoscopic treatment regimen for ITBLs, preferably BD alone, could prolong the time to or could completely avoid surgical revision and early retransplantation and seems to be superior to endoscopic stenting.