Cremone, Cristiano (2017) Endoscopic vs surgical treatment of biliary stenosis after liver transplantation. [Tesi di dottorato]

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Item Type: Tesi di dottorato
Lingua: English
Title: Endoscopic vs surgical treatment of biliary stenosis after liver transplantation.
Creators:
CreatorsEmail
Cremone, Cristianocristiano.cremone@libero.it
Date: 9 April 2017
Number of Pages: 52
Institution: Università degli Studi di Napoli Federico II
Department: Scienze Biomediche Avanzate
Dottorato: Scienze biomorfologiche e chirurgiche
Ciclo di dottorato: 29
Coordinatore del Corso di dottorato:
nomeemail
Cuocolo, Albertocuolcolo@unina.it
Tutor:
nomeemail
Santangelo, MicheleUNSPECIFIED
Sobhani, IradjUNSPECIFIED
Date: 9 April 2017
Number of Pages: 52
Uncontrolled Keywords: biliary stenosis; liver transplantation; endoscopic treatment of biliary stenosis;
Settori scientifico-disciplinari del MIUR: Area 06 - Scienze mediche > MED/12 - Gastroenterologia
Area 06 - Scienze mediche > MED/18 - Chirurgia generale
Area 06 - Scienze mediche > MED/36 - Diagnostica per immagini e radioterapia
Date Deposited: 18 Apr 2017 11:48
Last Modified: 14 Mar 2018 09:46
URI: http://www.fedoa.unina.it/id/eprint/11711
DOI: 10.6093/UNINA/FEDOA/11711

Abstract

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.

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