title: A retrospective study on risk factors associated with failed endoscopic treatment of biliary anastomotic stricture after right-lobe living donor liver transplantation with duct-to-duct anastomosis.
abstract: OBJECTIVE
  This aim of this study is to determine the risk factors in failed endoscopic retrograde cholangiography (ERC).
  
  
  BACKGROUND
  Endoscopic treatment is considered the first-line intervention for biliary anastomotic stricture (BAS) after right-lobe living donor liver transplantation with duct-to-duct anastomosis.
  
  
  METHODS
  A retrospective study was performed on 287 patients who received right-lobe living donor liver transplantation with duct-to-duct anastomosis. The morphology of BAS was defined according to the shape of the distal side of duct-to-duct anastomosis shown on cholangiogram and was categorized into 3 types: pouched, intermediately pouched, and triangular. All cases of ERC were performed by operating surgeons.
  
  
  RESULTS
  Fifty-nine patients (20.6%) had BAS and received ERC and balloon dilatation with or without stenting. The success rate was 73.2%. The median number of sessions needed for successful ERC was 3. In the 15 patients with failed ERC, 4 were successfully treated with percutaneous transhepatic biliary drainage and balloon dilatation and 11 underwent conversion hepaticojejunostomy (6 had external percutaneous transhepatic biliary drainage as a temporizing measure). On multivariate analysis, recipient age [odds ratio (OR): 0.922; 95% confidence interval (CI): 0.85-1.00; P = 0.049], operation time (OR: 1.007; 95% CI: 1.001-1.013; P = 0.025), and morphology of stricture (OR: 6.722; 95% CI: 1.31-34.48; P = 0.022) were independent risk factors associated with failed ERC. The success rates for the 3 types of BAS-pouched, intermediately pouched, and triangular-were 42.9%, 63.6%, and 88.9%, respectively (P = 0.021). Association was found between bile leak and pouched BAS (P = 0.008).
  
  
  CONCLUSIONS
  ERC is highly effective in treating BAS. A success rate of 73%, the highest ever reported, has been achieved. Morphology of stricture is associated with outcome of ERC. Radiological or surgical intervention should be considered for patients with pouched BAS after endoscopic treatment fails for the first time.
authors: *Department of Surgery, The University of Hong Kong, Hong Kong, China †State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China.
authors: Kenneth S H
authors: KS
authors: Chok
authors: See Ching
authors: SC
authors: Chan
authors: Tan To
authors: TT
authors: Cheung
authors: William W
authors: WW
authors: Sharr
authors: Albert C Y
authors: AC
authors: Chan
authors: Sheung Tat
authors: ST
authors: Fan
authors: Chung Mau
authors: CM
authors: Lo
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D002760:Cholangiopancreatography, Endoscopic Retrograde; D001651:Cholestasis, Extrahepatic / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D004106:Dilatation / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000379:methods*; D019520:Living Donors; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D017211:Treatment Failure