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Abstract
Liver transplantation is the therapy of choice for many patients with end stage liver disease, liver cancer, fulminant hepatic failure and metabolic liver disease. The viral hepatitis is considered to be an important indication for the liver transplantation. In Egypt, overall HCV antibodies in the population represent 19.3%. Of those with HCV antibodies, 61.5% had chronic HCV infection positive HCV/RNA. In Egypt, the use of cadaveric donor is still prohibited, forcing some capable patients to seek this service abroad and living donor liver transplantation is the only available possible option for end stage liver disease egyptian patients.
The biliary tract has been described as the ‘Achilles Heel’ of liver transplantation. So the biliary complications is the most important factor in morbidity and even responsible for mortality post liver transplantation. The previous studies showed higher incidence of surgical cholestasis with the living donor recipients.
The aim of this study was to document the occurrence, diagnosis and treatment of biliary complications from 3 months post LTx and up to 2 years. This was performed via comparison of two groups; Cadaveric group (26) recipients who received cadaveric livers abroad and the other group was (26) recipients who underwent LDLT in DAF. Also, a comparison was performed between the surgical cholestasis versus medical cholestasis.
The Child Paugh score was not statistically significant between the two groups before performing liver transplantation (P value=0.98).The viral hepatitis represent the main leading etiology for the liver transplantation. It was the leading cause in 17 cases (65%) in the cadaveric group vs 23 cases (88.5%) in the LDLT group. Overall the viral hepatitis was the leading etiology for LTx in 40 cases (76.5%).
Hyperbilirubinemia was detected post liver transplantation in 10 cases (38%) in cadaveric group and in 13 cases (50%) in the living donor group. The cadaveric group had 5 cases (50%) of surgical cholestasis of who developed cholestasis vs 11 cases (84.5%) of surgical cholestasis in LDLT group of who developed hyperbilirubinemia.
The signs of infections include elevation of white blood cells, increase in temperature &/or elevation of CRP with the surgical cholestasis were higher in comparison to medical cholestasis which was statistically significant (P value=<0.01).
The cadaveric group showed calcification in 4 grafts which may be accompanied with long cold ischemia time.
Ultrasound diagnosed surgical cholestasis in 10 cases (62.5%) from the 16 cases that was determined by ERCP where ERCP was the corner stone in the diagnosis of type of cholestasis. The liver biopsy gave differential diagnosis rather than definite diagnosis in 5 cases (62.5%) of whom performed liver biopsy. The hepatitis C shows new pattern post transplantation called Fibrosing cholestatatic Hepatitis (FCH). FCH is a special form of HCV infection which occur post LTx which was detected in 3 cases in the cadaveric group vs only one case in the LDLT group. FCH may lead to graft dysfunction with in 1-2 years post transplantation.
ERCP succeeded in treatment of surgical cholestasis in 8 cases (50%), PTC/D succeeded in treatment surgical cholestasis in 4 cases, and surgical intervention (hepaticojejunostomy) was the solution for two cases of surgical cholestasis where ERCP failed and PTC/D could not performed.
In conclusion, surgical cholestasis was higher but not statistically significant among the LDLT group may be due to small number of cases. The diagnostic tool of choice for the type of cholestasis post LTx was the ERCP. Management of surgical cholestasis may need a combined work of hepatologist, endoscopist, radiologist and surgeon.
Recommendations
1- Post liver transplantation the surgical cholestasis can not excluded by ultrasound alone.
2- ERCP is considered to be the diagnostic tool of choice for the differential of type of cholestasis whether surgical or medical.
3- PTC/D and Hepaticojejunostomy must be considered as a successive alternative of ERCP failure for treatment of surgical cholestasis.