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II. ХИРУРГИЯ
THE TREATMENT OF ANASTOMOTIC STRICTURES AFTER LIVE-DONOR LIVER TRANSPLANTATION
Abdirashev Y.B.1, Abdiyev N.M.1, Doskhanov M.O.1, Skakbayev A.S.1, Basymbekov A.M.2
1JSC "National Scientific center of surgery named after A.N. Syzganov" Almaty, Kazakhstan. 2The emergency hospital of Almaty, Kazakhstan
Abstract
Liver transplantation is the only treatment for the decompensated level of cirrhosis. Due to improvement of the surgery methodology and management of patients, the survival rate of patients up to 1 year is 90%, and 5-year to 80%. However, post-transplantation complications remain the main cause of recipient morbidity and mortality. The basic reasons for the development of strictures of the bile duct after transplantation depends on: 1. The type of transplant. 2. The number and type of bile ducts carried out for the application of anastomoses, in particular liver transplantation from a living donor. 3. Type of anastomosis (biliary-biliary or choledochojejunoanastomosis). Most complications after surgery are diagnosed after live-donor liver transplantation. Since the transplant is one of the lobes with ducts of smaller diameter. Given the above, the complications of the biliary duct system after transplantation from a cadaveric donor is 5-15%, and after live-donor it reaches up to 38%. Including, when taking the right lobe of the liver in living donors, the percentage of complications varies from 24% to 60%.
УДК 616.361-089:617-089.844
ABOUT THEАUTHORS
Nurken Abdiyev - surgeon-endoscopist Endoscopy and functional diagnostic department; abdievnm@gmail.com
Yerlan Abdirashev - Head of Endoscopy and functional diagnostic department; erlan_abdirashev@mail.ru
Maksat Doskhanov - Head of hepatopan-creatobiliary surgery and liver transplantation; max8616@mail.ru
Aidar Skakbayev
Surgeon of hepatopancreatobiliary surgery and liver transplantation; dr. skakbayev@gmail.com
Akhan Basymbekov - Surgeon Emergency surgery department; ahan.mustafaevich@mail.ru
Keywords
Key words: ERCP, liver transplantation, biliary complications, biliary anastomotic stricture, bilio-biliary anastomosis, live-donor liver transplantation, endobiliary stenting, jaundice
Tipi донор бауыр транспланатциядан кейшп аностомоздык стриктуралардьщ eMi
Эбдipашeв Е.Б.1, Абдиев Н.М.1, Досханов М.О.1, Скакбаев А.С.1, Басымбеков А.М.2
1«А.Н. Cbi3FaHOB атында?ы Улттык Рылыми хирургия орталь™» АК, Алматы, Казакстан. 2Алматы каласынык Жедел шvFыл кемек керсету ауруханасы, Казакстан
Ацдатпа
Бауыр трансплантациясы - бауыр циррозыньщ ауыр сатысындат жалшз емдеу тэсШ болып табы-лады. Наукастар менеджмент'! мен ота методиканысынын жет^рущщ аркасында наукастардын вм'р сYPуi I жылга дейн 90 %-ды, ал 5жыл¥а дейнп вмiршендiгi 80 %-ды курайды. Алайда трансплантация-дан кейшп аскынулар, реципиенттердщ ауруына жэне влiмiне непзп себебiретШде калып отыр. Транс-плантациядан кейнп вт жолдары стриктурасы дамуынын непзп себеnтерi мынадай кврсеткШерге бай-ланысты: I. Трансплантаттын тур'!. 2.Анастомоздарды салу Yшiн жYргiзiлетiн вт жолдарынын тур'! мен санына, онын 1ш'1нде т!р! донордан бауыр трансплантациясы. 3. Анастомоздын тур! (билио-биллиарлы немесе гепитикоеюноанастомоз). Операциядан кеШнп аскынулар квбнесе т'р донор трансплантаци-ядан кеШн жасалган наукастарда кездесед. вткен т'^-донордан алыман бауыр трансплантатында вт жолдарыныц калибр '! ^. Жо€арыда айтылгандарды ескерсек, мэйгтт'!к донордан алыман бауыр трансплантациясынан кейнп вт жолы жYЙесiнiн аскынуы 5-15%-ды кураса, ал т'р донордан 38%-€а дейтжетедi. Сонын 1ш'1нде т!р! донорлардан бауырынын он бвлш алеан кездеп аскынулар 24%-дан Ь-€а дейн турленед.
АВТОРЛАР ТУРАЛЫ
Абдиев Нуркен Махамашулы - хирург-эндоскопист; Эндоскопия и функциональдi диагностика бэл1м1; abdievnm@gmail.com
Эбд'рашев Ерлан Байтореулы -
Эндоскопия жэне функционалд диагностика бэлМш/ц мецгеруш/с/; erlan_abdirashev@mail.ru
Досханов Мачсат Оналбайулы -
Гепатопанкреатобилиарлы хирургия жэне бауыр трансплантация бэлiмiнiц мецгеруш/с/; max8616@mail.ru
Сабаев Айдар Серикулы - Хирург; Гепатопанкреатобилиарлы хирургия жэне бауыр трансплантация бэлiмi; dr. skakbayev@gmail.com
Басымбеков Ахан Мустафулы -
Хирург; Шуыл хирургия кабылдау бэлiмi; ahan.mustafaevich@mail.ru
Туйш свздер
механикалык сареаю, ет кабы жолынын темен косылуы, холе-дохолитиаз
Лечение анастомотических стриктур после трансплантации печени от живого донора
ОБ АВТОРАХ
Абдиев Нуркен Махамашович -
хирург-эндоскопист; Отделение эндоскопии и функциональной диагностики; abdievnm@gmail.com
Эбд/'рашев Ерлан Байтуреевич -
Заведующий отделением эндоскопии и функциональной диагностики; erlan_abdirashev@mail.ru
Досханов Максат Оналбаевич -
Заведующий отделением гепатопанкреа-тобилиарной хирургии и трансплантации печени; max86i6@mail.ru
Скакбаев Айдар Серикович-
Хирург отделения гепатопанкреатобилиар-ной хирургии и трансплантации печени;
il.com
Басымбеков Ахан Мустафаевич -
Хирург; Отделение приемного покоя ahan.mustafaevich@mail.ru
Ключевые слова
ЭРХПГ, трансплантация печени, биллиарные осложнения, биллиарная анастомотическая стриктура, билио-биллиарный анастомоз, ТПЖД, эндобил-лиарное протезирование, механическая желтуха
Эбдiрашев Е.Б.1, Абдиев Н.М.1, Досханов М.О.1, Скакбаев А.С.1, Басымбеков А.М.2
1АО «Национальный научный центр хирургии имени А.Н. Сызганова» Алматы, Казахстан 2ГП «Больница скорой медицинской помощи» Алматы, Казахстан
Аннотация
Трансплантация печени является единственным методом лечения при декомпенсированной стадии цирроза печени. Благодаря совершенствованию оперативной методики и менеджмента больных, выживаемость больных до 1 года составляет 90 %, а 5-летняя до 80 %. Однако, посттрансплантационные осложнения остаются основной причиной заболеваемости и смертности реципиентов. Основные причины развития стриктур желчных протоков после транспланатции зависит от: 1. Вида трансплантанта. 2. Количества и вида желчных протоков, проводимых для наложения анастомозов, в частности трансплантация печени от живого донора. 3. Вида анастомоза (билио-биллиарный либо холедохоею-ноанастомоз). Большинство осложнений после операции встречается у пациентов, перенесших трансплантацию от живого донора. Так как трансплантантом является одна из долей с протоками меньшего диаметра. Учитывая выше изложенное, осложнения протоковой системы после трансплантации печени от трупного донора составляет 5-15%, а при ТПЖД достигает до 38%. В том числе, при заборе правой доли печени у живых доноров процент осложнений варьирует от 24% до 60%.
Introduction
Nowadays, liver transplantation (TP) is the only treatment for the decompensated stage of liver cirrhosis (LC). Due to the improvement of the surgical methodology and management of patients, the survival rate of patients up to 1 year is 90%, and 5-year-old to 80% [1]. However, biliary complications (BC) associated with LT remain the main cause of morbidity and mortality in recipients. The main reasons for the development of strictures of the bile duct after LT depends on 1. The type of transplant. 2. The number and type of bile ducts performed to apply anastomoses, in particular liver transplantation from a living donor (LDLT). 3. Type of anastomosis (biliary-biliary or hepaticoje-junoanastomy. Most complications after LT occur in patients undergoing LDLT. Since a living donor, as a rule, one of the lobes with ducts of a smaller diameter is taken. Given the above, the complications of the ductal system after liver transplantation from a cadaveric donor (DDLT) is 5-15%, and with LDLT it reaches 38% [2,3]. In particular, when taking the right lobe of the liver in living donors, the percentage of complications varies from 24% to 60% [4.24].
Today, with LDLT, a bilio-biliary anastomosis is preferable, since the technical, one is easier and the possibility remains for subsequent retrograde interventions.
Among all BC complications after LDLT, anastomotic strictures (AS) are leading, and the period of
their occurrence is observed within a year from the moment of operation. AS develops 3 mm distal and / or proximal to the anastomosis. The main reason is associated with the technical aspects of the allocation of bile ducts from the donor and recipient, as well as biliary reconstruction of the bile ducts. AS occurs more often than non-anastomotic stricture as it is caused by the imposition of anastomosis of the ducts with a small diameter in comparison with DDLT [5,6]. Diagnosis of BC is based on changes in the biochemical aspects of liver tests, data from ultrasound (ultrasound) and magnetic resonance imaging (MRI) in cholangiography mode [7,8].
Long-time of intraductal biliary hypertension, the risk of developing cholangitis is extremely high. In this connection, the deterioration of the patient's condition and death can occur in a short time. It is worth noting that the long course of AS after LDLT affects the quality of life and can lead to transplant necrosis and death of the recipient [9,10].
There are several methods for eliminating BC after LT: endoscopic retrograde, transdermal antegrade, surgical and combined.
Endoscopic retrograde cholangiopancreatography (ERCP) technique, having gentle and minimally invasive features, is undertaken as the first stage of treatment [11,12,13]. In case of unsuccessful attempts of the retrograde method, patients undergo percutaneous transhepatic drainage (PTBD), surgical or combined methods.
PTBD is also a minimally invasive method of treatment; however, it requires the necessary con-
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2020
Characteristics of recipients with BC Quantity %
male\female 14/12 52/48
Type of biliary anatomy:
A (61 patients) 15 58
B (6 patients) 4 15
C (9 patients) 7 27
Indication:
Hepatitis B,C 23 88
HCC 1 3,8
Others 2 7,6
Type of biliary reconstruction:
Bilio-bilioanastomosis 21 80,7
Bi-bilio-bilioanastomosis 3 11,6
Bilio-bilio 2 7,7
+hepaticojejunoanastomy
anastomotic stricture 20 76
biloma 6 24
Early (before 6 months) 15 56
Late (after 6 months) 11 44
Table 1
Characteristics of recipients with biliary complications.
ditions for conducting. The main criteria is the presence of dilated intrahepatic bile ducts. If they are absent, it is impossible to perform it.
Surgical treatment of AS consists in dissociation of the bilio-bilio anastomosis and the perform cholangiojejunoanastomy. Success reaches up to 75% [7]. However, patients who underwent resur-gery against the background of the initial heavy condition have a very high risk of an adverse outcome.
Combined techniques include the Rendezvous technique, which includes a combination of en-doscopic retrograde and percutaneous drainage [23,24]. By PTBD, the conductor string is passed through the AS into the duodenum, thus providing retrograde access to the bile duct. In a similar way, a magnetic compression anastomosis (MAC) is used. It is performed by installing magnets per-cutaneously antegrade access to proximal and en-doscopically retrograde distal to part of stricture. After installation, under the force of attraction of the magnets, a pressure fistula is formed between them. MAS is removed, and a stent is installed in the zone of the formed channel [14,24].
ERCP is highly effective, the possibility of repeated treatment sessions and a low percentage of complications [8]. A feature of the endoscopic technique is transpapillary cannulation, cholan-giography, preliminary dilatation of the stricture and installing PS or self-expandable metal stent (SEMS). Balloon dilatation (BD) in combination with biliary stenting is much more effective, in comparison with only one BD. The success of stricture dilatation without stenting is 40%. The installation of only one PS gives a positive result in up to 75% of cases [15,16]. In this case, the AS of two or more
PS provides a faster resolution of the stricture. Clinical efficacy ranges from 67% to 100%, and the risk of stricture recurrence is up to 9% [15, 16, 17, 18, 22, 24].
Materials and methods
This article includes the data of 76 recipients who underwent LDLT from December 2015 to December 2018.
70 (94.6%) patients transplantated the right lobe, the left lobe - 5 (4%) patients and the posterior lateral sector in 1 (1.4%) cases. Among 76 recipients, 26 (35%) patients developed various types of BS. Of 26 patients, anastomotic strictures (AS) occurred in 20 (77%) patients. In the remaining 6 (23%) patients, AS appeared due to partial failure of the biliary-biliary anastomosis with the formation of biloma.
Endoscopic retrograde technique was used as the first stage of BC correction in this category of patients. For the prophylactic purpose of post-ER-CP pancreatitis (PEP), an non-steroidal antiinflammatory drug 100 mg rectally was prescribed an hour before the intervention [19]. ERCP was performed under endotracheal anesthesia. For catheteriza-tion of the bile duct and the risk of reducing post-catheterization pancreatitis, a guide wire of 0.035 or 0.025 inches was used. With the introduction of X-ray contrast, the level, extent of stricture and / or the presence of leakage were determined. After interpretation of cholangiography, a dissection (papillosphincterotomy) of the orifice of the large duodenal papilla was performed for the subsequent outflow of bile, pancreatic juice and to easy implantation of the several PS [16]. Depending on the type of length and diameter of the stricture, a prelimi-
Fig. 2
Types of resolving biliary strictures
nary balloon dilatation of the stricture with an exposure of 30 to 60 seconds was used. At the same time, dilatation was carried out under the control of fluoroscopy until the stenosis was completely straightened. Subsequently, the PS was installed of the required size and length. PS are separated by diameter (5.0, 7.0, 8.5 or 10 service jackets (Fr.)) and type (straight, curved, like a "pig tail"). During the first ERCP session, stenting was performed by one PS, and with the technical possibility, up to two or more stents were installed. In that category patients, we did not use SEMS.
In the early post-ERCP period, patient monitoring was based on the levels of amylase, bilirubin, alanine aminotransferase, aspartate aminotransferase, general blood count and ultrasound of the liver-transplant's duct system.
In the late period, while maintaining positive dynamics, the patient underwent only reimplantation of the previously established PS. Subsequent repeated planned interventions were performed at intervals of 2 to 3 months. Each repeated session included replacement of the PS with a larger diameter and / or additional installation of the PS to expand the stricture to the diameter of the common bile duct. Replacement of PS was required to prevent obstruction of the biliary prosthesis and the development of cholangitis [20,21].
Results
The BO were eliminated by endoscopic retrograde, percutaneous antegrade, and through open surgery. Also, in some cases, a combined method of treatment was used, including antegrade and retrograde methods.
The total number of patients with BO, endo-scopic correction was performed in 21 (80%) patients. Among which, only 14 (53%) recipients had
technical success. In 7 (26.5%) patients, various types of stricture expansion were preliminarily performed followed by PS implantation. In 7 (27%) cases, the stricture was removed by stenting in the AC 10 Fr. without dilatation of stenosis. With severe stenosis, the first stage was a plastic stent 7.0 or 8.5 Fr. The stent was later replaced by 10 Fr. Subsequently, after 3-4 months, additional PSs were implanted. 8 (48%) patients underwent more than 3 ERCP sessions with the installation of up to 3 plastic stents. A total of 62 retrograde interventions were performed in 21 patients.
In 7 (27%) cases, it was not possible to eliminate BS using the retrograde method. 3 (11.5%) patients were eliminated by PTBD.
For 2 (7,7%) patients successful retrograde catheterization were achieved by using the Rendezvous method. In addition, 1 (3.8%) patient underwent the installation of a magnetic compression anastomosis (MCA) by antegrade and retrograde ways. In the early period after implantation of the MCA, the length of the stricture decreased. However, on the 6-7th day, the dislocation of the MCA happened. Subsequently, by reducing the length of the stricture, the elimination of the stricture was successfully resolved ERCP with the installation of PS.
The remaining 5 (19%) patients with AS were promptly resolved by relaporotomy with hepatico-jejunastomy. 1 (3.8%) patient required liver retransplantation.
The initial success of retrograde correction was in 14 (54%) recipients. The combined technique has been shown to be effective in 3 (11.5%) patients.
In the early period, 8 (31%) patients developed PEP with an increase in amylase from 700 to 3000. At the same time, 4 (15%) patients with severe and prolonged stricture, a transient increase in amy-
Treatment Quantity Complications Lethal
ERCP:
BD+PS 7 Cholangitis - 3 Liver failure - 1
PS 7 Biloma - 1
PEP - 8
Randezvous:
Cannulation 2
MCA 1
PTBD: 3 Cholangitis - 1 Liver failure - 1
Surgery:
Hepaticojejunoanastomy 4 Cholangitis - 1 Transplant necrosis - 1
Retransplantation 1 Not related - 1
Table 2.
Description in text
lase, we associate with primary stricture dilatation and implantation PS. By the way that the symptoms of PEP in all patients were safely stopped conservatively.
In the case of unsuccessful of ERCP cases, the PTBD was used in 4 (16%) patients. Also, in 4 (16%) cases initially the resolution of BC were done by rel-aporotomy with cholangiojuojenoanastomosis on the Ru loop and 1 (4%) patient required retransplantation.
The combined method was used after unsuccessful ERCP. In 2 cases, the Rendezvous method was carried out, and in 1 case, the MCA installation. In the latter case, it was not possible to completely resolve the stricture. However, due to the reduction in the length of the stenosis, implantation of a PS has become technically possible.
The 4 (15%) recipients in the group with post-transplant complications were died. In 2 cases, in-terventional procedures were unsuccessful, thereby severe multiorganic failure developed.
In 5 patients after surgical treatment of BC, 1 patient had transplant necrosis and 1 patient in the early postoperative period the severe cardiovascular failure occurred.
All 26 patients with BC were with bile ducts of anatomical type B and C. So, for example, with type A out of 61 patients BC developed in 15 (58%), type B out of 6 in 4 (67 %) and with type C out of 9 in 7 (78%) patients.
Discussion
The success of endoscopic correction of BC depends directly on the timely start of therapeutic measures. It is more difficult to obtain a favorable outcome if patients are treated at the top of clinical
manifestations. Endoscopic treatment of AS that occurred during the first 6 months from the time of transplantation has a more favorable outcome, is technically easier and requires less repeated interventions [22, 24]. Correction, started later than 6 months, is less effective, more laborious and requires more ERCP procedures.
A favorable treatment outcome depends on several factors. Firstly, early diagnosis and timely treatment of BC. Secondly, the presence of a wide range of necessary tools. Thirdly, a specialist with high qualifications and sufficient competence for retrograde interventions.
In this regard, we believe that recipients need more delicate monitoring in the post-transplant period. Since this category of patients requires a multi-team approach, which should include: hepa-tologist, surgeon, endoscopist.
The success rate of our experience in eliminating such complications at the initial stage was not high enough. However, with the accumulation of experience, on time begin correction and the necessary resources, the number of unsuccessful ERCP interventions decreased. In addition, we considering that the development of AS could be associated with the technical aspects of biliary anastomosis.
Conclusion
The endoscopic retrograde method of treatment is the most effective, at the first sign of the development of biliary strictures after LDLT. However, if technical difficulties are happened, recommended to use the PTBD (Rendezvous, MCA) to provide access to the papilla. After that endoscopist should treat recipients.
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