title: Risk factors and outcomes of failed endoscopic retrograde cholangiopancreatography in liver transplant recipients with anastomotic biliary strictures: a case-control study.
abstract: Anastomotic strictures (ASs) of the biliary duct after liver transplantation (LT) are primarily managed with endoscopic retrograde cholangiopancreatography (ERCP), but in some cases, this fails because of difficulties in passing the strictures. The aim of this case-control study was to examine specific risk factors for initial ERCP failure and the outcomes of percutaneous transhepatic cholangiography (PTC) as a second-line approach in LT recipients with ASs. Between January 2002 and December 2010, we identified LT recipients with ASs who experienced initial ERCP failure (which was defined as the inability to traverse the AS with guidewires in 2 or more consecutive procedures). A period-matched control group (ratio = 1:2) with ASs and initial ERCP success was analyzed. Preoperative, intraoperative, postoperative, and endoscopic variables were evaluated as risk factors. The outcomes of PTC and the need for hepaticojejunostomy (HJ) or retransplantation were evaluated. Seventeen cases who experienced initial ERCP failure were compared with 34 controls. The median times from LT to ERCP were similar (8.7 months for cases and 8.6 months for controls, P = not significant). A multivariate analysis revealed that previous bile leaks [odds ratio (OR) = 6.07, 95% confidence interval (CI) = 1.0-36.5] and more than 4 U of intraoperatively transfused red blood cells (OR = 11.51, 95% CI = 1.9-71.2) were independent risk factors for failure. PTC was an effective second-line treatment in only 3 of 12 cases (25%). The need for HJ was more frequent for the cases (13/17 or 76.5%) versus the controls (7/34 or 20.6%, P < 0.001). One patient in each group underwent retransplantation (P = not significant). In conclusion, previous bile leaks and high packed red blood cell transfusion requirements during surgery are risk factors for initial ERCP failure in LT recipients with ASs. A high proportion of these patients will need surgery as their final therapy.
authors.affiliation: Gastrointestinal/Endoscopy Unit, Institute of Digestive and Metabolic Diseases, University of Barcelona, Barcelona, Spain.
authors.forename: Domingo
authors.initials: D
authors.lastname: Balderramo
authors.forename: Oriol
authors.initials: O
authors.lastname: Sendino
authors.forename: Marta
authors.initials: M
authors.lastname: Burrel
authors.forename: Maria Isabel
authors.initials: MI
authors.lastname: Real
authors.forename: Annabel
authors.initials: A
authors.lastname: Blasi
authors.forename: Graciela
authors.initials: G
authors.lastname: Martinez-Palli
authors.forename: Josep M
authors.initials: JM
authors.lastname: Bordas
authors.forename: Juan
authors.initials: J
authors.lastname: Carlos Garcia-Valdecasas
authors.forename: Antoni
authors.initials: A
authors.lastname: Rimola
authors.forename: Miguel
authors.initials: M
authors.lastname: Navasa
authors.forename: Josep
authors.initials: J
authors.lastname: Llach
authors.forename: Andres
authors.initials: A
authors.lastname: Cardenas
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D003251:Constriction, Pathologic; D005260:Female; D006085:Graft Survival; D006801:Humans; D007582:Jejunostomy; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000009:adverse effects*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013030:Spain; D013997:Time Factors; D017211:Treatment Failure