Short-term results of percutaneous transhepatic interventions for anastomotic biliary strictures after living donor liver transplantation using a right lobe graft

• Popov M.V.
• Sergey E. Voskanyan
• Artemiev A.I.
• Alexander I. Sushkov
• Moisey S. Aronov
• Kolyshev I.Yu.
• Shcherbin V.V.
• Mal’tseva A.P.
• Vladimir S. Rudakov
• Andrey N. Bashkov
• Sadykhov Z.A.
• Muktarzhan M.U.

Abstract

Aim. To study the short-term results of percutaneous transhepatic treatment of anastomotic biliary strictures developed in recipients after living donor liver transplantation of the right lobe, and to analyze the technical success of this intervention and the factors influencing it.

Material and methods. The results of 274 living donor liver transplantations of the right lobe performed in the period from 2010 to the end of 2019 were analyzed. 67 patients were excluded from the subsequent analysis (follow-up period of less than 10 months, lack of patient compliance with the required list and terms of examinations, death or transplant loss in the early post-transplant period, liver retransplantation). 20 of the remaining 207 recipients in the analysis showed the development of biliary anastomotic strictures (9.7%), and the results of their treatment were analyzed. All patients underwent antegrade percutaneous transhepatic interventions for developed strictures of biliary anastomoses. The distribution of patients by gender was equal (10 men and 10    women), the median age was 41 years (from 28 to 60 years). The groups of general clinical factors, technical features of biliary reconstruction and cholangiographic characteristics of anastomotic strictures, potentially predicting/affecting the direct technical success of antegrade recanalization of anastomotic strictures, by the method of constructing binary logistic regression models are analyzed.

Results. First of all, percutaneous transhepatic bile duct puncture and cholangiography were performed for all patients. An attempt to simultaneously overcome the stricture zone and perform balloon plastic surgery of the affected area was performed in 9 cases (1^st group); in the remaining 11    cases external drainage was established, and directly antegrade intervention was delayed after 3-77 days (median - 13 days) (2^nd group).

In 1^st group technical success was observed in 5/9 (55.6%) patients, and in 2^nd group - in 7/11 (63.6%) patients (p>0.05). If the first attempt failed, repeated attempts were made in 9 cases with a positive outcome in only one of nine patients. The overall technical success of the antegrade percutaneous treatment of anastomotic biliary strictures in this series of observations was 60%.

In the model of multiple binary logistic regression a tendency toward greater success of the procedure was noted in women (OR=12.09; 95% CI 1.21-316.68; p=0.06) and in patients with a body mass index (BMI) <23 kg/m² (OR=19.23; 95% CI 1.60-760.07; p=0.05). At the same time, there was no effect on the success of the antegrade treatment of other analyzed factors, including a number of technical features of biliary reconstruction and X-ray characteristics of the stricture. 

Conclusion. Percutaneous transhepatic interventions are the treatment of choice for the treatment of anastomotic biliary strictures after living donor liver transplantation. Positive prognostic factors for the success of this approach are the female gender of the patient and BMI <23 kg/m². The probability of success of the analyzed method of treatment of anastomotic strictures is not related to the technical features of biliary reconstruction and cholangiographic picture of stricture.

Keywords:living donor liver transplantation, biliary anastomotic stricture, transhepatic percutaneous treatment, antegrade approach

References

1. Kulkarni C.B., Prabhu N.K., Kader N.P., Rajeshkannan R., Pullara S.K., Moorthy S. Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients. Indian J Radiol Imaging. 2017; 27 (1): 92–9. DOI: https://doi.org/10.4103/0971-3026.202950

2. Voskanyan S.E., Sushkov A.I., Artem’ev A.I., et al. Salvage liver transplantation in the treatment of hepatocellular carcinoma. Khirurgiya. Zhurnal imeni N.I. Pirogova. [Surgery. The Journal Named after N.I. Pirogov]. 2019; (10): 21–8. DOI: https://doi.org/10.17116/hirurgia201910121 (in Russian)

3. You M.S., Paik W.H., Choi Y.H., et al. Optimal biliary drainage for patients with biliary anastomotic strictures after right lobe living donor liver transplantation.

4.    Sarhan M.D., Osman A.M.A., Mohamed M.A., et al. Biliary complications in recipients of living-donor liver transplant: a single-center review of 120 patients. Exp Clin Transplant. 2017; 15 (6): 648-57. URL: https://doi.org/10.6002/ect.2016.0210

5.    Mizuno S., Inoue H., Tanemura A., et al. Biliary complications in 108 consecutive recipients with duct-to-duct biliary reconstruction in living-donor liver transplantation. Transplant Proc. 2014; 46 (3): 850-5. DOI: https://doi.org/10.1016/jrtransproceed.2013.11.035

6.    Server S., Sabet S., Sahin T., et al. Novel application of internal-external drainage catheter as biliary stent for percutaneous transhepatic treatment of biliary strictures in living donor liver transplantation recipient patients. Transplant Proc. 2019; 51 (7): 2469-72. DOI: https://doi.Org/10.1016/j.transproceed.2019.01.153

7.    Wadhawan M., Kumar A., Gupta S., et al. Posttransplant biliary complications: an analysis from a predominantly living donor liver transplant center. J Gastroenterol Hepatol. 2013; 28 (6): 1056-60. URL: https://doi.org/10.1111/jgh.12169

8.    Kim P.T.W., Marquez M., Jung J., et al. Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation. Clin Transplant. 2015; 29 (5): 46 5 - 74. DOI: https://doi.org/10.1111/ctr.12538

9.    Nakamura T., lida T., Ushigome H., et al. Risk factors and management for biliary complications following adult living-donor liver transplantation. Ann Transplant. 2017; 22: 671-6. DOI: https://doi.org/10.12659/aot.905485

10. Popov M.V., Voskanyan S.E., Dunaev A.P., Bashkov A.N., Mal’tseva A.P. Anastomotic biliary strictures after liver transplantation. Saratovskiy nauchno-medit-sinskiy zhurnal [Saratov Journal of Medical Scientific Research]. 2019; 15 (2): 296-301. (in Russian)

11.    Lee S.-G. A complete treatment of adult living donor liver transplantation: a review of surgical technique and current challenges to expand indication of patients. Am J Transplant. 2015; 15 (1): 17-38. DOI: https://doi.org/10.1111/ajt.12907

12.    Sharma S., Gurakar A., Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies. Liver Transpl. 2008; 14 (6): 75969. DOI: https://doi.org/10.1002/lt.21509

13.    Saad W.E.A. Percutaneous management of postoperative anastomotic biliary strictures. Tech Vasc Interv Radiol. 2008; 11 (2): 143-53. DOI: https://doi.org/10.1053/j.tvir.2008.07.008

14.    Koch M., Garden O.J., Padbury R., et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011; 149 (5): 680-8. DOI: https://doi.org/10.1016/j.surg.2010.12.002

15.    Kim E.S., Lee B.J., Won J.Y., Choi J.Y., Lee D.K. Percutaneous transhepatic biliary drainage may serve as a successful rescue procedure in failed cases of endoscopic therapy for a post-living donor liver transplantation biliary stricture. Gastrointest Endosc. 2009; 69 (1): 38-46. DOI: https://doi.org/10.1016/j.gie.2008.03.1113

16.    Lee Y.Y., Gwak G.-Y., Lee K.H., et al. Predictors of the feasibility of primary endoscopic management of biliary strictures after adult living donor liver transplantation. Liver Transpl. 2011; 17 (12): 1467-73. DOI: https://doi.org/10.1002/lt.22432

17.    Yoshiya S., Shirabe K., Matsumoto Y., et al. Rendezvous ductoplasty for biliary anastomotic stricture after living-donor liver transplantation. Transplantation. 2013; 95 (10): 1278-83. DOI: https://doi.org/10.1097/tp.0b013e31828a9450

18.    Omary R.A., Bettmann M.A., Cardella J.F., et al. Quality improvement guidelines for the reporting and archiving of interventional radiology procedures. J Vasc Interv Radiol (JVIR). 2003; 14 (9 Pt 2): S293-5. DOI: https://doi.org/10.1097/01.rvi.0000094601.83406.e1

19.    Kim J., Ko G.-Y., Sung K.-B., et al. Percutaneously placed covered retrievable stents for the treatment of biliary anastomotic strictures following living donor liver transplantation. Liver Transpl. 2010; 16 (12): 1410-20. DOI: https://doi.org/10.1002/lt.22173

20.    Kulkarni C., Sreekumar K., Moorthy S., Prabhu N., Kader N., Kannan R. Percutaneous transhepatic balloon dilatation of benign bilioenteric strictures: analysis of technique and long-term outcome. Gastrointest Interv. 2015; 4: 112-9. DOI: https://doi.org/10.18528/gii150001

21.    Piardi T., Greget M., Audet M., et al. Biliary strictures after liver transplantation: is percutaneous treatment indicated? Ann Transplant. 2011; 16 (2): 5-13. DOI: https://doi.org/10.12659/aot.881858

22.    Seehofer D., Eurich D., Veltzke-Schlieker W., Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant. 2013; 13 (2): 253-65. DOI: https://doi.org/10.1111/ajt.12034

23.    Melcher M.L., Pomposelli J.J., Verbesey J.E., et al. Comparison of biliary complications in adult living-donor liver transplants performed at two busy transplant centers. Clin Transplant. 2010; 24 (5): E137-44. DOI: https://doi.org/10.111Vj.1399-0012.2009.01189.x

24.    Miyagi S., Kawagishi N., Kashiwadate T., et al. Relationship between bile duct reconstruction and complications in living donor liver transplantation. Transplant Proc. 2016; 48 (4): 1166-9. DOI: https://doi.org/10.1016/j.transproceed.2015.10.073

25.    Na G.H., Kim D.G., Choi H.J., Han J.H., Hong T.H., You Y.K. Interventional treatment of a biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis. HPB (Oxford). 2014; 16 (4): 312-9. DOI: https://doi.org/10.1111/hpb.12151

26.    Voskanyan S.E., Artem’ev A.I., Sushkov A.I., et al. Features of vascular reconstructions and the results of 220 living donor liver transplantation of right lobe to adult patients. Al’manakh klinicheskoy meditsiny [Almanac of Clinical Medicine]. 2018; 46 (6): 598-608. DOI: https://doi.org/10.18786/2072-0505-2018-46-6-598-608 (in Russian)

27.    Heinemann M., Tafrishi B., Pischke S., et al. Endoscopic retrograde cholangiography and percutaneous transhepatic cholangiodrainage in biliary strictures after liver transplantation: Long-term outcome predictors and influence on patient survival. Liver Int. 2019; 39 (6): 1155-64. DOI: https://doi.org/10.1111/liv.13995

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)