Endoscopic vs surgical treatment of biliary stenosis after liver transplantation.

BACKGROUND: The biliary anastomosis is often considered as the Achilles’ heel of liver transplantation (LT). Although the incidence has decreased over the last decade, patients undergoing liver transplantation are still affected by biliary complications. The diagnostic and therapeutic management of the anastomotic biliary stricture (ABS) is controversial. Early diagnosis is crucial for patient and graft survival. METHODS: We focused our study on the role of the endoscopic and surgical treatment on liver transplanted patients, at Henry Mondor University Hospital (Creteil, France), who had developed ABS. The data we have retrospectively collected from patients’ files were: characteristics of patients and organs, indications for transplantation , type of intervention, liver function tests, MRCP and ERCP results and need of surgery, with related outcomes. If a biliary complication was suspected, based on clinical and laboratory data, a magnetic resonance or CT scan were performed. In our center, for ABS, the endoscopic treatment is preferred unless contraindications . The study protocol contemplate to maintain a fully covered metallic stent for 1 year with replacement of the stent every six months or in emergency in case of migration or occlusion before the planned replacement. In case of endoscopic failure, patients underwent surgical treatment. The sensibility and specificity of MRCP was tested and compared to ERCP. RESULTS: Between 2010 and 2015, 465 liver transplantations have been done: among them, 55 patients developed an ABS needing a treatment. The characteristics of those patients were analyzed and compared in order to find out the risk factors of development an ABS. Male gender is significantly associated with higher rate of biliary complications in our analysis. 42 of 55 patients underwent endoscopic treatment and 26 of them concluded 1 year of metallic stenting: mean number of ERCP per patient was 3.77. No major complications were observed. 4 of the remaining 16 and 1 of 26 were operated with good results. 14 of 26 have a minimum follow up of 1 year (mean follow-up is 24 months); only 1 patient needed other treatment and was operated 20 months after the ablation of the stent. The recurrence of the stenosis, evidenced by the control MRCP, is strongly associated to the length of the ABS and to the dilatation of the intra hepatic bile duct. The normalization of liver function tests is influenced by the organ age and MELD score. The sensitivity and the specificity of MRCP in our series in detecting biliary stenosis were 95% and 100% respectively. For the diameter, the congruence between MRCP and ERCP measurement was of the 84%, less for other parameters. CONCLUSIONS: ERCP for treatment of ABS is feasible and safe. Successful long-term results have been obtained in 93% of cases treated by endoscopy and 100% of cases treated by endoscopy followed by surgery. Nevertheless one of the five patients who underwent surgery died consequently to the treatment. Highest advantages in endoscopic treatment were observed in patients with small stenosis length and without dilatation of the Intra hepatic bile ducts. It is still necessary to work on the correct therapeutic decision tree including predictor factors for ABS. MRCP is an accurate method to examine the biliary tree in transplant patients with suspected biliary complications

Total colectomy for cancer: analysis of factors linked to patients' age.

Total colectomy (TC) is a valid option for cancer treatment in selected cases. Emergency presentation, association to familial adenomatous polyposis (FAP) or intestinal bowel disease (IBD), hereditary non-polyposis cancer (HNPCC), and synchronous tumors are the common indications to TC for cancer. Despite potential high morbidity and mortality rates for worse general health conditions of the advanced age it has even suggested for elderly patients. We reviewed our experience to analyze the current role of TC comparing different results between young and elderly patients. During the period 1990-2012, 76 patients were operated on TC for cancer. Patients were divided in two groups according to the age [65 years old - group B (elderly)] and were compared their systemic and surgical complication, considering the presence of comorbidities, ASA score, lifestyle habits, elective or emergency presentation. Morbidity rate was 7.7% and 38.8% in young and elderly patients respectively.21 systemic complications (3 in group A and 18 in group B) occurred in 17 patients (22.36%) (with the coexistence of two complications in 4 patients belonging to the group B. There were 6 surgical complications (7.9%) (3 in group A and 3 in group B): anastomotic leakage 3, major wound infections 2, postoperative bleeding 1; no intra-abdominal abscess were observed. In 2 cases (2.6%) (1 anastomotic leak and 1 intra-abdominal postoperative hemorrhage) was needed a reoperation. We observed only 2 deaths in the elderly. High ASA score and emergency were associated with worst results. Systemic complications were more frequent in elderly patients cause of significant comorbidities, while the incidence of surgical complications was similar and according to literature. Besides the classic indications, it is a viable surgical option also in cancer associated with complicated diverticulitis. Our data show that TC is a safe and effective procedure providing good results even in elderly patients, when combined with a careful preoperative evaluation and age is not an absolute controindication to this procedur

Long-Term Results of Endoscopic Metal Stenting for Biliary Anastomotic Stricture after Liver Transplantation

(1) Background: Anastomotic biliary stricture (ABS) is a well-known complication of liver transplantation which can lead to secondary biliary cirrhosis and graft dysfunction. The goal of this study was to evaluate the long-term outcomes of endoscopic metal stenting of ABS in the setting of deceased donor liver transplantation (DDLT). (2) Methods: Consecutive DDLT patients with endoscopic metal stenting for ABS between 2010 and 2015 were screened. Data on diagnosis, treatment and follow-up (until June 2022) were collected. The primary outcome was endoscopic treatment failure defined as the need for surgical refection. (3) Results: Among the 465 patients who underwent LT, 41 developed ABS. It was diagnosed after a mean period of 7.4 months (+/−10.6) following LT. Endoscopic treatment was technically successful in 95.1% of cases. The mean duration of endoscopic treatment was 12.8 months (+/−9.1) and 53.7% of patients completed a 1-year treatment. After a mean follow-up of 6.9 years (+/−2.3), endoscopic treatment failed in nine patients (22%) who required surgical refection. Conclusions: Endoscopic management with metal stenting of ABS after DDLT was technically successful in most cases, and half of the patients had at least one year of indwelling stent. Endoscopic treatment long-term failure rate occurred in one fifth of the patients