Sa1303 IS THERE A PLACE FOR SPYGLASSTM EVALUATION OF POST LIVER TRANSPLANT BILIARY ANASTOMOTIC STRICTURE?

Abstract

Cholangioscopy allows bile duct visualization, tissue sampling and therapeutic interventions. The aims of this study were to evaluate the usefulness of SpyGlassTM in post orthotopic liver transplant (OLT) biliary anastomotic strictures (BAS) and eventually identify endoscopic predictors of treatment result. This is a prospective observational cohort study conducted at a tertiary center in Brazil. Institutional review board approval and informed consent were obtained. Consecutive eligible patients with suspected post OLT biliary complications referred to ERCP were considered to SpyGlassTM. Exclusion criteria were previous endoscopic therapy, pregnancy, age under 18 years old, and inability to provide informed consent. Once a stricture was confirmed, patients were submitted to SpyGlassTM cholangioscopy followed by deployment of a fully covered self-expandable metal stent (CSEMS). Stent removal was scheduled at 12 months, when SpyGlassTM evaluation was repeated. Primary outcome measures were cholangioscopy success rate and biliary ductal changes in post-OLT BAS before and after CSEMS treatment. Secondary outcome measure was description of adverse events. Between March/16 and June/17, a total of 42 patients with post-OLT biliary complications were assessed for eligibility, and 20 were enrolled (results are summarized in Table 1). Cholangioscopy was successfully performed in all patients and showed the stricture orifice and a pale scar area in all of them. Remarkable findings were the presence of surgical sutures visualized in 10 and debris in 5 patients. All 20 patients had a previous abdominal ultrasound and stones had been described in 5 (25%). However, only 1 was confirmed by cholangioscopy and the remaining 4 ended up being sutures and debris misinterpreted as stones. Cholangioscopy-assisted guide wire placement was necessary in 5 (25%) patients. Other cholangioscopic findings are in Table 1. Two patients died with the stent in place and were excluded. Five patients still have the stent in place. Acute pancreatitis was the most common procedure complication (6.6%). Distal CSEMS migration occurred in 55.5% (10/18) and proximal in 5.5% (1/18) of patients. CSEMS occlusion was found in 16.6% (3/18). So far, with median follow-up of 412 days, stricture resolution was achieved in 30.8%. In best-case scenario, the success rate reaches 50%. No cholangioscopic finding was statistically related to treatment outcome. There were no recurrences. The most interesting finding of cholangioscopic evaluation after stent removal or migration was sutures’ disappearance. The presence of sutures and debris at the anastomotic site in post-OLT patients was remarkable. SpyGlassTM was useful to transverse the stricture in severe cases. The role of diagnostic cholangioscopy in post-OLT patients remains to be defined.Tabled 1Summary of resultsN20Female : Male9:11Age (years)Average (range)50 (19 – 68)Median (±SD)54 (±14)Time from OLT to ERCP (days)Average (range)411.5 (30 - 2488)Median (±SD)159.5 (±657.2)BAS treatmentSuccess4/18 (22.2%)Failure9/18 (50%)In treatment5/18 (27.8%)Stent treatment duration (days)Average (range)180 (14 – 403)Median (±SD)136 (±156)Adverse eventsAbdominal pain with hospitalization2/33 (6.6%)Acute pancreatitis2/33 (6.6%)Distal migration10/18 (55.5%)Proximal migration1/18 (5.5%)Occlusion3/18 (16.6%) Open table in a new tab Table 2SpyGlassTM evaluation in in post orthotopic liver transplantation (OLT) biliary anastomotic strictures.SpyGlassTM findingsBefore CSEMSAfter CSEMSStricture orifice20 (100%)5 (55.5%)Pale scar area20 (100%)1 (11.1%)Granular surface10 (50%)7 (77.8%)Sutures10 (50%)-Prominent small caliber vessels6 (30%)4 (44.4%)Debris5 (25%)-Convergence of folds4 (20%)-Prominent enlarged vessels3 (15%)1 (11.1%)Ulceration2 (10%)-Friability2 (10%)-Mucosal projections1 (5%)-Necrotic tissue1 (5%)1 (11.1%) Open table in a new tab