An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%–45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques—such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy—combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

Short term donor outcomes after hepatectomy in living donor liver transplantation

Objective: to determine the outcome of living-donor liver transplant [LDLT] donors from the first liver transplant program in Pakistan

Study Design: cohort study

Place and Duration of Study: shifa International Hospital, Islamabad, from April 2012 to August 2014

Methodology: a total of 100 live donors who underwent hepatectomy were included. Demographics, etiologies, graft characteristics and operative variables were retrospectively assessed. Outcome was assessed based on morbidity and mortality

Results: median donor age was 28 [17 - 45] years and median body mass index [BMI] was 24 kg/m[2] [15 - 36]. Male to female ratio was 1.5:1. Hepatitis B and C were the most common underlying etiologies and accounted for 79/100 [79%] of LDLT's. Overall, 93/100 [93%] donors donated a right lobe graft. Median estimated graft weight to recipient body weight [GW/BW] ratio was 1.03 [0.78 - 2]. Standard arterial anatomy was present in 56% donors. The 90-day morbidity was 13/100 [13%] and overall morbidity was 17/100 [17%]. Bile leak was encountered in 3 [3%] patients. There was no donor Mortality

Conclusion: acceptable short-term donor outcomes were achieved in an LDLT program in Pakistan with careful donor selection and planning

Paediatric living donor liver transplantation: a single centre experience from Pakistan

Objective: To determine the outcomes of paediatric living donor liver transplantation [LDLT] recipients from Pakistan in terms of 90-day morbidity and mortality

Study Design: Cohort study

Place and Duration of Study: Shifa International Hospital, Islamabad, Pakistan, between April 2012 and April 2015

Methodology: All patients in paediatric age group [17 years] who underwent LDLT with a minimum follow-up of 3 months, were included. All grade 2 and above complications on Clavien-Dindo system were included as morbidity. The main outcome measure was 90-day morbidity and mortality

Results: Fourteen paediatric LDLTs were performed. Median age of the recipients was 8.5 years ranging between 6 months and 17 years. Wilson's disease and cryptogenic cirrhosis were the most common etiologies [28.6% each]. Acute liver failure was present in 5 [35.7%] patients. Overall 90-day morbidity and mortality was 71.4% and 14.2%; both were attributable to pulmonary infection. No difference was observed in morbidity [21.3% vs. 42.8%, p=0.3] and mortality rates [20% vs. 11%, p=1.0] between patients with acute and chronic liver failure. Estimated 3-year survival was 85%

Conclusion: Paediatric LDLT offers a promising treatment option for acute and chronic liver failure. Mortality was attributable to post-transplant pulmonary infections

Comparability and validity of siriraj stroke score and allen stroke score in differentiation of acute ischemic and haemorrhagic stroke

To compare and validate Alien stroke score [ASS] and Siriraj stroke scores [SSS] in differentiating acute cerebral hemorrhage [CH] and cerebral infarction [CI]. This comparative, analytical study was conducted at Khyber Teaching Hospital Peshawar, Pakistan from July 2000 to February 2002. Study included 100 patients of acute ishemic or hemorrhagic stroke confirmed on CT scan brain after clinically evaluation. ASS and SSS were calculated for each patient and compared with the results of CT scan for comparability [Kappa Statistics] and validity by using SPSS 10. Out of 100 patients, 69 had CI and 31 had CH. The overall comparability of ASS and SSS was fair [Kappa=0.51]. ASS and SSS were uncertain in 27 and 18 cases respectively; with Kappa showing worst comparability in term of certain results [K= 0.23]. In 64 cases with both scores in the diagnostic range, the Kappa showing excellent comparability [K=0.91].The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of ASS was 38.70%, 91.30%, 66.67%, 76.82% respectively for CH and 71.1%, 80.64%, 89.09% and 55.56% respectively for CI, with overall predictive accuracy of 61%. The sensitivity, specificity, PPV and NPV of SSS was 67.74%, 94.2%, 84% and 86.67% respectively for CH and 78.26%, 90.32%, 94.73% and 65.11% respectively for CI, with overall predictive accuracy of 75%. Although, SSS being simple with more accuracy is better than ASS, both these scores lack sufficient validity to be used for exclusion of cerebral haemorrhage before offering antithrombotic or thrombolytic therapy

Hypertension in acute ischemic and haemorrhagic stroke

To know the pattern of systolic and diastolic blood pressure in hypertensive patients with acute ischemic and hemorrhagic stroke. Material and This study was conducted on 100 patients with acute stroke, admitted in Khyber Teaching Hospital from July 2000 onward. Hypertensive patients were finally selected for analysis. BP was recorded at arrival and 24 hours after admission. Out of 100 patients with stroke, hypertension was present in 72 cases. Out of these 72 patients, 44 cases [61.1%] had cerebral infarction [CI] and 28 cases [38.9%] had cerebral haemorrhage [CH]. Overall mean systolic BP at arrival [SBP-A] was 163 [ +/- 35.606] mm Hg. Mean SBP-A in patients with CI was 152.3 [ +/- 34.397] mm Hg and in patients with CH was 181.25 [ +/- 30.357] mm Hg. Overall 68% of hypertensive stroke patients had uncontrolled systolic BP at arrival. Overall mean diastolic BP at arrival [DBP-A] was 95. 97 [ +/- 20.733] mm Hg. Mean DBP-A in CI was 88.75[ +/- 17.854] mm Hg and in CH was 107.32[ +/- 20.115] mm Hg. The mean difference of DBP-A in CH and CI was 18.57mm Hg. Mean systolic BP and Mean diastolic BP, 24 hours after admission were 157.85 mm Hg and 92.08 mm Hg respectively. Majority of hypertensive stroke patients have uncontrolled blood pressure. Hypertension is a risk factor for both ischemic and hemorrhagic stroke. More elevation of blood pressure is more frequently associated with cerebral hemorrhage than cerebral infarction

audit of diagnostic upper GI endoscopy and comparison of booked versus open access cases

A retrospective analysis of 2568 consecutive diagnostic upper GI endoscopies at the GI Unit of the Postgraduate Institute, Lady Reading Hospital, Peshawar, was carried out to assess the indications, final outcome and subgroup analysis of the major diagnoses, with comparison of the outcome according to the source of referral. Patients were selected from the gastroenterology OPD and wards [Booked] and referred by other physicians from the outpatient and wards of medical, surgical and allied specialties [Open Access]. Results showed significant predominance of male patients [65.72% Vs 35.28%] p=<0.001. Abdominal pain [52.21%], dyspepsia and heartburn [24.96%], haematemesis and/or melaena [15.65%], vomiting [13.94%] and dysphagia [13.27%] making the bulk of the most common indications. There were 943 [36.72%] normal endoscopies more with females dominance [49.12% Vs 29.97%] p = < 0.001. Gastrooesophageal reflux disease was the most common endoscopic finding [23.48%] followed by gastroduodenal Inflammation [16.62%], peptic ulcer disease [15.42%], malignancy [10.00%] and varices [8.09%]. Three fifty eight patients [13.94%] showed multiple pathologies. There was no significant difference of outcome on endoscopy between the gastroenterologist and non gastroenterologist selected patients except the varices which were picked up more by non gastroenterlogist for various reasons. The study highlights the significant presence of peptic ulcer disease, upper GI malignancy and oesophageal/gastric varices in our community and sets a baseline for future research and studies with a need for evolving better management strategies for these important health problems