Endoscopic treatment of biliary stones in patients with orthotopic liver transplantation

Abstract

Objective To investigate the safety and efficacy of endoscopic retrograde cholangio-pancreatography (ERCP) in the treatment of recipients with biliary stones after liver transplantation. Methods Clinical data of 24 patients undergoing ERCP treatment for duct stones after liver transplantation in the Fuzhou General Hospital of People′s Liberation Army between January 2005 and December 2015 were analyzed retrospectively. Recipients who with biliary stones were all diagnosed with T-tube cholangiography, magnetic resonance cholangiopancreatography or ERCP. Recipients who were confirmed were all treated with balloon dilatation plus balloon dilatation placement. Diazepam was used for sedation during operation and vital signs were supervised at the same time. Indexes including types of biliary stones, narrow situation, ERCP treatment condition and liver function indexes before and after transplantation were all observed. The Wilcoxon signed-rank test was used to compare with serum TBil, ALP, GGT, ALT and AST levels before and after ERCP treatment. Results Twenty of common bile duct stones in 24 patients (including 11 patients of common bile duct stones, 9 patients of common bile duct stones and bile duct stenosis), and 4 patients of intrahepatic and extrahepatic bile duct stones. The median time from liver transplantation to bile duct stones diagnosis was (604±215) d. 19 patients developed between 12 to 66 months after liver transplantation, and the remaining 5 patients developed within 3 months after liver transplantation. Eleven patients of common bile duct stones were successfully removed with endoscopic balloon dilation combined with stenting, 9 patients of common bile duct stones complicated with bile duct stenosis were treated with endoscopic balloon dilation, stone basket stone removal, combined with stenting and internal bile duct drainage. Among them, 8 patients of nine were successfully removed; 1 patient was re-transplanted with liver transplantation due to severe biliary stricture and secondary infection. Four patients of intrahepatic and extra-biliary stones were treated with endoscopic balloon dilation, stone basket removal stone , left and right hepatic duct placement internal stent + bile duct drainage. TBil, ALP and GGT were 31, 179 and 247 mmol/L after endoscopic treatment. Both were lower than the pre-endoscopic treatment levels (43, 273, and 385 mmol/L). As of December 2017, 24 patients were followed up for 1 to 2 years, 4 patients died of primary liver cancer at 9, 5, 34 and 25 months after liver transplantation, and 1 patient had developed upper gastrointestinal bleeding and died at 34 months after liver transplantation, 1 patient underwent secondary liver transplantation due to severe biliary stenosis and died of septic shock due to liver abscess in April 2014, and 1 patient underwent septic shock after liver transplantation. No stones were found in the remaining 17 patients during the follow-up period. Conclusions Endoscopic balloon dilation plus stent placement was safe and effective for recipients with biliary stones after liver transplantation.ERCP can be used as the first-line approach for biliary stones after orthotopic liver transplantation. Key words: Orthotopic liver transplantation; Biliary complication; Biliary stone; Endoscopic retrograde cholangio-pancreatography