Efficacy of enteroscopy-assisted ERCP in liver transplant patients with Roux-en-Y reconstruction and suspected bile duct pathology
(2020) 32nd edition of the Belgian Week of Gastroenterology — Location: Hilton Hotel, Antwerp, Belgium (4.March.2020)
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Sokal, Etienne 
- Abstract
- T. MOREELS (1), P. DEPREZ (1), G. DAHLQVIST (1), B. DELIRE (1), L. COUBEAU (2), O. CICCARELLI (2), E. BONACCORSI RIANI (2), P. GOFFETTE (3), E. SOKAL (4), H. PIESSEVAUX (1) / [1] Cliniques universitaires Saint-Luc, Brussels, Belgium, Hépato-Gastroentérologie, [2] Cliniques universitaires Saint-Luc, Brussels, Belgium, Transplantation abdominale, [3] Cliniques universitaires Saint-Luc, Brussels, Belgium, Radiologie, [4] Cliniques universitaires Saint-Luc, Brussels, Belgium, Gastroentérologie & Hépatologie Pédiatrique Introduction Biliary complications after liver transplantation are frequently dealt with by means of endoscopic retrograde cholangiopancreatograpy (ERCP) using a duodenoscope. However, when the bile duct is anastomosed on a Roux-en-Y jejunal limb, the biliary system is out of reach for conventional ERCP, and it is accessed usually via percutaneous transhepatic cholangiography (PTC) or surgery. Aim We retrospectively studied the feasibility of enteroscopy-assisted ERCP to evaluate and treat biliary complications in liver transplant patients with Roux-en-Y reconstruction. Methods Between 2016 and 2019 all enteroscopy-assisted ERCP procedures in liver transplant patients were analysed for indications and ERCP technical success and complication rates. Clinical success was measured by the evolution of liver function tests (without other interventions). Enteroscopy-assisted ERCP was performed using different types of single-balloon enteroscopes (SBE). Results A total of 32 patients (25 males) with a mean age of 42±3 years (range 16-81) underwent 51 enteroscopy-assisted ERCP procedures. Indications were suspicion of anastomotic stricture (53%), cholangitis (31%), bile duct stones (10%), biliary leak (3%) and sepsis of unknown origin (3%). Technical ERCP success rate per patient was 81.25% (26/32). Failure was due to inability to reach the hepaticojejunal anastomosis. ERCP was normal in 10/26 (39%), confirmed the anastomotic stricture in 9/26 (35%), bile duct stones in 5/26 (19%) and biliary leak and an indwelling metallic stent both in 1/26 (4%). Biliary endoscopic interventions: balloon dilatation (6-9 mm), plastic stent insertion (4-7 Fr), stone extraction, bile duct biopsy and direct cholangioscopy in 1 to 6 ERCP procedures per patient with a median number of 1 procedure. Only minor adverse events (self-limiting cholangitis) were encountered in 4/32 patients (12,5%). Of all 51 ERCP procedures, 49% were considered easy, 27% were difficult or very difficult (8%) and 17% were impossible. Technical success rate was highest when the prototype XSIF-180JY SBE was used (100% for 14 procedures) and lowest with the commercially available SIF-Q180 SBE (50% for 6 procedures). Clinical success of therapeutic ERCP was measured by the evolution of biliary liver function tests before the start of the ERCP procedure, 1 day after and 30 days after the last ERCP procedure. There was a significant decrease in gamma-GT serum levels (345±90 U/L before, 257±73 U/L after and 146±27 U/L after 30 days, p=0.023) and alkaline phosphatase levels (337±70 U/L before, 343±89 U/L after and 198±53 U/L after 30 days, p=0.044), whereas the decrease in bilirubine serum levels was not significant. Conclusions Endoscopic evaluation of the bile duct system is feasible and safe using enteroscopy-assisted ERCP in liver transplant patients with Roux-en-Y reconstruction. It allows close examination of the hepaticojejunostomy and the intrahepatic bile ducts, and endoscopic therapy leads to clinical improvement of liver function tests. Enteroscopy-assisted ERCP may be considered as an alternative to PTC to evaluate and treat the biliary system in these patients.
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Citations
Moreels, T., Deprez, P., Dahlqvist, G., Delire, B., Coubeau, L., Ciccarelli, O., Bonaccorsi Riani, E., Goffette, P., Sokal, E., & Piessevaux, H. (2020). Efficacy of enteroscopy-assisted ERCP in liver transplant patients with Roux-en-Y reconstruction and suspected bile duct pathology. 32nd edition of the Belgian Week of Gastroenterology, Hilton Hotel, Antwerp, Belgium. https://hdl.handle.net/2078.5/169293