Does Stricture Location Predict ERCP Success in Non-Anastomotic Biliary Strictures After Living Donor Liver Transplantation? A Buis-Based Analysis

Öz

Non-anastomotic biliary strictures (NAS) represent one of the most challenging complications after living donor liver transplantation (LDLT) and are associated with heterogeneous outcomes following endoscopic retrograde cholangiopancreatography (ERCP). While ERCP is widely accepted as first-line therapy, the impact of stricture localization on endoscopic treatment success remains insufficiently defined. This study aimed to determine whether stricture location, as defined by the Buis classification, predicts ERCP outcomes in patients with NAS after LDLT. In this retrospective single-center study, LDLT recipients who underwent ERCP for post-transplant biliary strictures between January 2020 and January 2025 were evaluated. Among 124 patients with post-transplant biliary strictures, 44 patients (35.5%) with NAS constituted the study cohort and were analyzed separately from patients with anastomotic strictures (n=80). Pre-procedural magnetic resonance cholangiopancreatography was used to classify NAS according to the Buis classification. ERCP technical success, clinical success, recurrence, complications, and the need for percutaneous or surgical interventions were assessed and compared according to Buis-defined stricture locations. Overall ERCP success rates were significantly lower in patients with NAS compared with anastomotic strictures (63.6% vs. 88.7%, p<0.001). Within the NAS cohort, ERCP success varied markedly according to stricture location. Technical success rates were highest in Buis type 1 strictures (94.4%) and progressively declined in type 2 (74.0%), type 3 (40.0%), and type 4 lesions (33.3%) (p<0.001). Strictures involving intrahepatic regions, particularly C and D zones, were associated with significantly lower sustained clinical success and a higher need for adjunctive percutaneous interventions. Percutaneous guidewire-assisted access or biliary drainage was required in 61.3% of patients with intrahepatic involvement compared with 18.2% in extrahepatic-limited disease (p=0.002). Repeat ERCP sessions were more frequent in complex NAS patterns (median 5 vs. 2 sessions, p=0.004). Post-ERCP cholangitis occurred more commonly in NAS patients with multifocal intrahepatic disease (31.8%), whereas rates of pancreatitis (6.8%), bleeding (4.5%), and perforation (0%) remained low and comparable across locations. Sustained clinical success without recurrence was highest in extrahepatic-limited strictures (81.8%) and lowest in diffuse intrahepatic disease (22.2%). Stricture location is a major determinant of ERCP success in non-anastomotic biliary strictures after LDLT. Buis classification–based pre-procedural assessment provides valuable prognostic information and may guide individualized treatment strategy selection. Early consideration of percutaneous approaches in intrahepatic NAS may improve clinical outcomes, reduce repeated ERCP sessions, and minimize procedure-related complications.

Anahtar Kelimeler

• Buis Classification
• non anastomotic stricture
• liver transplant

Canlı Vericili Karaciğer Nakli Sonrası Gelişen Non-Anastomotik Biliyer Darlıklarda Darlık Lokalizasyonu ERCP Başarısını Öngörebilir mi? Buis Sınıflamasına Dayalı Bir Analiz

Öz

Non-anastomotik biliyer darlıklar (NAD), canlı vericili karaciğer nakli (CVKN) sonrası gelişen en zorlu biliyer komplikasyonlardan biridir ve endoskopik retrograd kolanjiyopankreatografi (ERCP) tedavi sonuçları oldukça heterojendir. ERCP ilk basamak tedavi olarak kabul edilmesine rağmen, darlığın anatomik yerleşiminin endoskopik tedavi başarısı üzerindeki etkisi tam olarak ortaya konulamamıştır. Bu çalışmanın amacı, Buis sınıflamasına göre belirlenen darlık lokalizasyonunun, CVKN sonrası gelişen NAD olgularında ERCP başarısını öngörmedeki değerini araştırmaktır. Bu retrospektif tek merkezli çalışmada, Ocak 2020 ile Ocak 2025 tarihleri arasında karaciğer nakli sonrası biliyer darlık nedeniyle ERCP uygulanan canlı vericili karaciğer nakli alıcıları değerlendirildi. Nakil sonrası biliyer darlığı bulunan toplam 124 hastanın 44'ü (%35,5) non-anastomotik darlık tanısı ile çalışma grubunu oluştururken, anastomotik darlığı bulunan 80 hasta ayrı olarak değerlendirildi. Tüm NAD olguları işlem öncesi manyetik rezonans kolanjiyopankreatografi bulgularına göre Buis sınıflamasına ayrıldı. ERCP'nin teknik ve klinik başarısı, nüks oranı, komplikasyonlar ile perkütan veya cerrahi girişim gereksinimi değerlendirildi ve Buis sınıflamasındaki darlık lokalizasyonlarına göre karşılaştırıldı. ERCP başarı oranı, non-anastomotik darlığı olan hastalarda anastomotik darlığı olan hastalara göre anlamlı olarak daha düşüktü (%63,6'ya karşı %88,7; p<0,001). NAD grubunda teknik başarı oranları Buis tip 1 (%94,4), tip 2 (%74,0), tip 3 (%40,0) ve tip 4 (%33,3) arasında kademeli olarak azaldı (p<0,001). Özellikle C ve D zonlarını içeren intrahepatik darlıklarda kalıcı klinik başarı daha düşük, perkütan girişim gereksinimi ise anlamlı olarak daha yüksekti (%61,3'e karşı %18,2; p=0,002). Kompleks NAD paternlerinde tekrarlayan ERCP gereksinimi daha fazlaydı (medyan 5'e karşı 2 seans; p=0,004). Çok odaklı intrahepatik hastalığı bulunan olgularda post-ERCP kolanjit daha sık görülürken (%31,8), pankreatit (%6,8), kanama (%4,5) ve perforasyon (%0) oranları düşük olup lokalizasyonlar arasında benzerdi. Nüks gelişmeden sürdürülebilir klinik başarı ekstrahepatik sınırlı darlıklarda en yüksek (%81,8), diffüz intrahepatik hastalıkta ise en düşük (%22,2) olarak saptandı. Canlı vericili karaciğer nakli sonrası gelişen non-anastomotik biliyer darlıklarda darlığın anatomik yerleşimi, ERCP başarısını belirleyen en önemli faktörlerden biridir. İşlem öncesi Buis sınıflamasına dayalı değerlendirme, tedavi başarısını öngörmede değerli prognostik bilgi sağlamaktadır ve bireyselleştirilmiş tedavi stratejisinin belirlenmesine katkıda bulunabilir. Özellikle intrahepatik yerleşimli darlıklarda perkütan girişimlerin erken dönemde değerlendirilmesi, klinik sonuçları iyileştirebilir, tekrarlayan ERCP gereksinimini azaltabilir ve tedavi sürecini optimize edebilir.

Anahtar Kelimeler

• buis sınflaması
• non-anastomoz darlıklar
• karaciğer nakli

Kaynakça

1. 1.Campbell WL, Sheng R, Zajko AB, Abu-Elmagd K, Demetris AJ. Intrahepatic biliary strictures after liver transplantation. Radiology. 1994;191:735–740.
2. 2.Ryu CH, Lee SK. Biliary strictures after liver transplantation. Gut Liver. 2011;5(2):133–142. doi:10.5009/gnl.2011.5.2.133.
3. 3.Kochhar G, Parungao JM, Hanouneh IA, Parsi MA. Biliary complications following liver transplantation. World JGastroenterol. 2013;19(19):2841–2846. doi:10.3748/wjg.v19.i19.2841.
4. 4.Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol. 2021;13(1):66–79. doi:10.4254/wjh.v13.i1.66.
5. 5.Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: current knowledge and therapeutic advances. World J Hepatol. 2021;13(1):66–79.
6. 6.Chang JH, Lee I, Choi MG, et al. Current diagnosis and treatment of benign biliary strictures after living donor livertransplantation. World J Gastroenterol. 2016;22:1593–1606.
7. 7.Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and newchallenges. Am J Transplant. 2013;13(2):253–265. doi:10.1111/ajt.12034
8. 8.Holt AP, Thorburn D, Mirza D, Gunson B, Wong T, Haydon G.A prospective study of standardized nonsurgical therapy in the management of biliary anastomotic strictures complicating liver transplantation. Transplantation. 2007;84:857–863.

9. 9.Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Clin Transplant. 2011;25(1):E49–E63. doi:10.1111/j.1432-2277.2010.01202.x.
10. 10.Londoño MC, Balderramo D, Cárdenas A. Management ofbiliary complications after orthotopic liver transplantation: the role of endoscopy. World J Gastroenterol. 2008;14(4):493–497. doi:10.3748/wjg.14.493.
11. 11.Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: an evidence-based review. World J Gastrointest Endosc. 2015;7(6):606–616.doi:10.4253/wjge.v7.i6.606.Ryu CH, Lee SK. Biliary strictures after liver transplantation. Gut Liver. 2011;5(2):133–142.
12. 12.Zhang CC, Rupp C, Exarchos X, Mehrabi A, Koschny R, Schaible A, Sauer P. Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation. Gastrointest Endosc. 2023;97(1):146–156. doi:10.1016/j.gie.2022.08.034.
13. 13.Buis CI, Verdonk RC, Van der Jagt EJ, van der Hilst CS, SlooffMJH, Haagsma EB, Porte RJ. Nonanastomotic biliary strictures after liver transplantation, part 1: radiological features and risk factors for early vs late presentation. Liver Transpl. 2007;13:708–718.
14. 14.Morelli J, et al. Endoscopic management of biliary stricturesafter liver transplantation. Gastrointest Endosc.2008;67(7):1080–1085.
15. 15.Tabibian JH, et al. Endoscopic treatment of biliary strictures after liver transplantation. Clin Gastroenterol Hepatol. 2010;8(8):713–719.
16. 16.Williams ED, Draganov PV. Endoscopic management ofbiliary strictures after liver transplantation. World JGastroenterol. 2009;15:3725–3733.
17. 17.Hintze RE, Abou-Rebyeh H, Adler A, et al. Endoscopic therapy of ischemia-type biliary lesions in patients following orthotopic liver transplantation [German]. Z Gastroenterol. 1999;37:13–20.
18. 18.Pfau PR, Kochman ML, Lewis JD, et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc. 2000;52:55–63.
19. 19.Park JS, Kim MH, Lee SK, et al. Efficacy of endoscopic and percutaneous treatments for biliary complications aftercadaveric and living donor liver transplantation. Gastrointest Endosc. 2003;57:78–85.
20. 20.Schwartz DA, Petersen BT, Poterucha JJ, et al. Endoscopic therapy of anastomotic bile duct strictures occurring after livertransplantation. Gastrointest Endosc. 2000;51:169–174.
21. 21.ASGE Standards of Practice Committee, Anderson MA, FisherL, Jain R, Evans JA, Appalaneni V, et al. Complications ofERCP. Gastrointest Endosc. 2012;75(3):467–473.
22. 22.Mallery JS, Baron TH, Dominitz JA, et al; Standards ofPractice Committee, American Society for Gastrointestinal Endoscopy. Complications of ERCP. Gastrointest Endosc. 2003;57(6):633–638.
23. 23.Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc. 2004;60(5):721–731. doi:10.1016/S0016-5107(04)02169-8.
24. 24.Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK.Salvage PTBD in post living donor liver transplant patients with biliary complications: a single centre retrospective study.Br J Radiol. 2020;93(1108):20191046. doi:10.1259/bjr. 20191046.