Evaluation Of Biliary Complications Research Articles

Evaluation of biliary complications on magnetic resonance cholangiopancreatography and comparison with direct cholangiography after living-donor liver transplantation

To evaluate the imaging characteristics of biliary complications following liver transplantation on magnetic resonance cholangiopancreatography (MRCP) and its diagnostic accuracy in comparison with direct cholangiography. In this prospective study, 34 patients being evaluated for possible biliary complications after living-donor liver transplantation (LDLT) with abnormal MRCP findings were followed up for information regarding direct cholangiography either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) within 7 days of MRCP. Twenty-nine patients underwent ERCP and five patients underwent PTC. Compared to findings at direct cholangiography, MRCP presented 96.9% sensitivity, 96.9% positive predictive value, and 94.1% accuracy for the detection of biliary complications. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detection of anastomotic strictures, biliary leak, and biliary stone or sludge on MRCP was found to be 100%, 84.6%, 91.3%, 100% and 94.1%; 72.7%, 95.7%, 88.9%, 88% and 88.2%; 80%, 100%, 100%, 96.7% and 97.1%, respectively. MRCP is a reliable non-invasive technique to evaluate the biliary complications following LDLT. MRCP should be the imaging method of choice for diagnosis in this setting and direct cholangiography should be reserved for cases that need therapeutic interventions.

Biliary complications following orthotopic liver transplantation: May contrast-enhanced MR Cholangiography provide additional information?

PurposeTo assess whether contrast-enhanced T1-weighted MR Cholangiography may provide additional information in the evaluation of biliary complications in orthotopic liver transplant recipients. Material and methodsEighty liver transplant patients with suspicion of biliary adverse events underwent MR imaging at 1.5T scanner. After acquisition of axial T1-/T2-weighted images and conventional T2-weighted MR Cholangiography (image set 1), 3D gradient-echo T1-weighted fat-suppressed LAVA (Liver Acquisition with Volume Acceleration) sequences were obtained about 30min after intravenous infusion of mangafodipir trisodium (Mn-DPDP,Teslascan®) (image set 2). The diagnostic value of mangafodipir trisodium-enhanced MR Cholangiography in the detection of biliary complications was tested by separate analysis results of image set 1 alone and image set 1 and 2 together. MRI results were correlated with direct cholangiography in 46 patients, surgery in 14 and/or clinical-radiological follow-up in the remaining 20 cases. ResultsThe level of confidence in the assessment of biliary adverse events was significantly increased by the administration of mangafodipir trisodium (p<0.05). Particularly, contrast-enhanced T1-weighted LAVA sequences tended to out-perform conventional T2-weighted MR Cholangiography in the delineation of anastomotic and non-anastomotic biliary strictures and in the diagnosis of biliary leak. ConclusionsContrast-enhanced T1-weighted MR Cholangiography may improve the level of diagnostic confidence provided by conventional T2-weighted MR Cholangiography in the evaluation of biliary complications after orthotopic liver transplantation.

A Clinical Algorithm to Guide the Need for ERCP for Evaluation of Early Post Liver Transplant Cholestasis.

Introduction: Severe cholestasis after liver transplant can be due to delayed graft dysfunction, reperfusion injury or biliary complications. ERCP in the immediate post-transplant period has significant risks and limitations. Our aim was to develop a criteria using a combination of HIDA and clinical information to further guide biliary intervention in these patients. Methods: Among 806 liver transplants, 62 patients required further evaluation of biliary complications within 30 days of transplant by HIDA scan. 57 patients (5 excluded as they had bile leak), were included in the study. Serum total bilirubin levels within 48 hours of ERCP were used to determine the success of ERCP intervention. If there was a > 50% reduction in bilirubin levels within 48 hours of ERCP intervention, biliary duct obstruction was established and ERCP was considered successful. Results: 25 patients had normal HIDA, 32 patients had delayed uptake suggesting hepatocellular dysfunction. Among the 25 patients with normal HIDA, 12 had ERCP, 6 required stent. Among the 6 patients with stent only 2 had >50% decrease in serum bilirubin within 48 hours (true biliary duct obstruction =8%). Out of 32 patients with delayed uptake on HIDA scan, 22 had ERCP, and 14 required stents. 4 patients had >50% decrease in bilirubin within 48 hours ( true biliary obstruction =12.5%). 3 patients had >50% decrease in bilirubin 48 hours after ERCP even when no stent was placed. Hence, among the 57 patients with severe hyperbilirubinemia in the immediate post-operative period, only 11% had large duct obstruction as the etiology of the hyperbilirubinemia. More importantly, of the 34 ERCPs performed only 17% had biliary obstruction. The peak AST among patients with biliary obstruction was lower at 1005±364 IU/L (vs. 2522±3177 IU/L p value 0.035) and the peak bilirubin among patients with biliary obstruction was 24±11mg/ (vs. 18±10 mg/dl p value 0.02). On multivariate analysis, we found that patients having both AST < 1500 IU/L, a bilirubin >15 mg/dl have an odds ratio of 25.1 (p value 0.002, 95% CI 6-37) in predicting biliary obstruction and benefiting from ERCP. Conclusion: Normal HIDA scan along with combination of peak AST and peak bilirubin levels offer a valuable tool in identifying patients who will NOT benefit from ERCP. By using these parameters large number of ERCPs could be avoided in the immediate post-transplant period.

Prospective Evaluation of Single-Operator Peroral Cholangioscopy in Liver Transplant Recipients Requiring an Evaluation of the Biliary Tract

In this descriptive study, we examined the role of single-operator cholangioscopy (SOC) in the evaluation of biliary complications after liver transplantation (LT). We prospectively included adult recipients of deceased donor LT who were referred for endoscopic retrograde cholangiopancreatography between June 2009 and July 2011. All patients underwent SOC with biopsy of the biliary anastomosis. Sixteen patients were included: 12 with biliary anastomotic strictures (ASs), 2 with common bile duct stones, 1 with a bile leak, and 1 with sphincter of Oddi dysfunction. Patients with ASs displayed 1 of 2 patterns: (A) mild erythema (n = 9) or (B) edema, ulceration, and sloughing (n = 3). Those without ASs displayed a pale mucosa with mild edema at the anastomosis. Patients with ASs and pattern B required a longer period of stenting than patients with pattern A (457 versus 167 days, P = 0.02). In addition, patients with pattern A had a better response and better resolution of their strictures with endoscopic therapy than those with pattern B (66% versus 33%, P = 0.13). Histological examinations of ASs showed nonspecific intraepithelial inflammation in patients with patterns A and B. Biopsy samples from patients without ASs showed normal columnar epithelial bile duct cells. The total cholangioscopy time for all procedures was 26.8 ± 10.1 minutes. In conclusion, SOC in LT recipients is feasible and allows adequate visualization and tissue sampling of ASs and bile ducts. Two distinct visual patterns that are easily identified with SOC may help to predict the outcomes of endoscopic therapy in patients with biliary complications after LT.