|Year : 2016 | Volume
| Issue : 1 | Page : 2-5
The Durazo technique is beneficial in Egyptian liver transplant programs
Abd Elrazek M Ali Hussein
Visiting Assistant Project Scientist, Transplant Hepatology at UCLA and Consultant Hepatologist, Al-Azhar School of Medicine Asuit, Egypt
|Date of Submission||11-Nov-2015|
|Date of Acceptance||12-Nov-2015|
|Date of Web Publication||18-Apr-2016|
Abd Elrazek M Ali Hussein
Visiting Assistant Project Scientist Liver Surgery and Liver Transplant, UCLA
Source of Support: None, Conflict of Interest: None
For nearly four decades, the American people have partnered with the people of Egypt to promote an environment where all groups in Egyptian society – including women and minorities – can lead healthy, productive lives. USAID's program in Egypt, helped scientists and researchers collaborate with American universities aiming to learn about modern American scientific innovations. I was lucky that I have collaborated with one of the most premier USA universities in Hepatology and Liver surgery; UCLA, where I can apply all the liver new techniques I have learned in UCLA in Egypt. Durazo technique is one of very interesting method-post liver transplant, would decrease morbidities and mortalities not only in USA and Egypt, but also Globally.
Keywords: Durazo, Egypt, ERCP, liver transplant, UCLA
|How to cite this article:|
Ali Hussein AM. The Durazo technique is beneficial in Egyptian liver transplant programs. Al-Azhar Assiut Med J 2016;14:2-5
| Introduction|| |
Endoscopic treatment has almost totally replaced surgical treatment of bile duct stones. In addition, a variety of benign and malignant conditions such as iatrogenic strictures [after cholecystectomy/after liver transplantation (LT)], primary sclerosing cholangitis (PSC), papillary adenoma, or malignant tumors of the bile duct or pancreas are now amenable to endoscopic treatment. In the early years, ERCP served as a diagnostic and therapeutic tool. With the development of noninvasive imaging alternatives, ERCP became a purely therapeutic procedure. The use of ERCP appears to be increasing with time. A population-based study from Olmstead County in the USA revealed that the average utilization of ERCP increased from 58 to 105 ERCPs per 100 000 persons-years over a 10-year period from 1997 to 2006. Biliary complications (bile duct strictures, leaks, and stones) following LT can be categorized as early (within 4 weeks) or late ,,,,,,,,,,. Biliary strictures after LT can be further divided into anastomotic, nonanastomotic, and diffuse intrahepatic strictures [Table 1]. Other complications such as bile casts, sphincter of Oddi dysfunction, mucocele, and hemobilia are rare, and most of them can be managed successfully with endoscopic retrograde cholangiography. In recent years, advanced ERCP techniques have become standard in many centers worldwide ,,,,,,,,. David Geffen School of Medicine at UCLA, USA, has been a highly reputed center for LT since 1984 when Ronald Busuttil (The Fujiyama of UCLA Liver Transplant Program) founded the Liver Transplant Program at UCLA. It has since grown to become one of the largest liver transplant centers in the world. In 2013 the UCLA liver transplant team presented the world's largest reported single-institution experience with 5347 orthotropic liver transplants (OLTs) performed between 1984 and 2012, with overall, 1-, 5-, 10-, and 20-year patient and graft survival estimates of 82, 70, 63, 52%, and 73, 61, 54, and 43%, respectively. Recipient survival was best in children with biliary atresia and worst in adults with malignancy . However, biliary complications are an important cause of morbidity and mortality in LT recipients. Here, we will shed light on the recent and advanced techniques of ERCP after LTs performed at UCLA.
|Table 1: Biliary complications after liver transplantation would be managed by ERCP|
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| Diagnosis and Advanced Techniques|| |
Biliary complication is usually first suspected in asymptomatic LT recipients who have unexplained elevations of serum aminotransferases, bilirubin, alkaline phosphatase, and γ-glutamyl transferase levels. Occasionally, some patients have nonspecific symptoms such as fever, general malaise and anorexia, right upper-quadrant abdominal pain (especially with bile leaks), itching, jaundice, and bile ascites. Exposure of the peritoneum and other visceral structures to bile usually results in abdominal pain. However, pain may be subtle in other patients because of immunosuppressant medications and anatomic hepatic denervation.
The initial evaluation should include conventional two dimensional ultrasound (US) with a Doppler evaluation of the hepatic and portal vessels to rule out any vascular occlusion. If hepatic artery stenosis or occlusion is suspected by Doppler US, hepatic angiography is usually indicated before other tests. Further, the liver biopsy need not exclude rejection, if there is biliary dilation and/or the presence of common bile duct stones/casts, strictures or evident leaks. In addition, histologic features of bile duct obstruction can sometimes be misleading and confused with rejection or recurrent hepatitis C virus. However, the absence of bile duct dilation on US should not preclude further evaluation with more sensitive techniques in patients in whom there is clinical suspicion of biliary tract complications. When diagnosis of biliary stricture or leak is considered, ERCP has the best sensitivity and specificity for diagnosis compared with other noninvasive investigation modalities such as computed tomography (CT) or magnetic resonance cholangio-pancreatography (MRCP), in addition to its therapeutic options.
One trial found that performing an ERC only when there was evidence of a bile duct obstruction or leak on imaging studies, laboratory tests, or liver biopsy led to a high-yield study .
| Techniques|| |
Maximal stent therapy
The maximal stenting protocol for anastomotic biliary strictures (ABSs) is rarely associated with ABS recurrence and is conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment . We followed Dr Francisco A. Durazo, Chief of Transplant Hepatology at UCLA, for around 6 months to learn his outstanding techniques for patients with biliary complications after OLT. Initiation of moderate to deep sedation was induced with intravenous meperidine or fentanyl and midazolam. ERCP was performed with a therapeutic side-viewing endoscope (TJF 160; Olympus Optical Co. Ltd, Center Valley, Pennsylvania) in the conventional manner with standard accessories. The endoscope was passed with ease. Dr Durazo always performs the short shaft endoscopic technique with minimal air inflation in the stomach. After selective cannulation of the common bile duct, a cholangiogram was obtained to evaluate the biliary system. Once the ABS was identified, a guidewire was passed through it into the donor's ducts to perform dilation. According to the Durazo recommendation, the implementation of maximal stenting depended on the length of time since OLT and the dose of steroids: if the patient had undergone LT within the past 3 months or was taking more than 5 mg of prednisone per day, dilation was performed with a 10-Fr biliary dilator (Soehendra dilator; Cook Endoscopy, Winston-Salem, North Carolina, USA), and a 10-Fr stent was placed for 12 weeks. During a subsequent ERCP, the stent was removed, and balloon dilation was performed (balloon dilator; Cook Endoscopy) with a balloon 6–10 mm in diameter, according to the size of the donor's and recipient's ducts (the duct with the smaller diameter, donor's or recipient's, determined the diameter of the balloon), for 1 min. When balloon dilation was completed, a sphincterotomy was performed following the standard technique (Ultratome; Boston Scientific, Natick, Massachusetts, USA), and a maximal number up to 10 stents of 8.5–11.5 Fr (Cotton-Leung; Cook Endoscopy) were placed across the anastomosis ([Figure 1]). We concluded that the maximal stenting technique (Francisco Durazo technique) for ABSs would be highly beneficial in our Egyptian liver transplant programs, in which only living donor operations are performed and there is a probability of biliary complications. In addition, following up patients at UCLA showed us that the technique is very effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with our conventional techniques.
|Figure 1: Many stents emerging from an ampulla of a transplanted patient presented with biliary stricture after orthotropic liver transplant (OLT); the Durazo technique is highly beneficial in Egyptian living donor liver transplantation (LDLT) programs because many biliary complications are reported in LDLT than in OLT because of anastomotic stricture.|
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Intraductal cooling through a nasobiliary tube during radiofrequency
We have observed the safety and efficacy of intraductal perfusion of chilled 5% dextrose in water (D5W) through an endoscopic nasobiliary tube for the prevention of thermal bile duct injury in patients undergoing percutaneous radiofrequency ablation of central liver tumors . The technique is especially beneficial for those awaiting LT as there is no other solution to prevent ductal injury during RFA in these patients if their tumor is close to a biliary ductal branch; the technique mentioned above would help prevent thermal biliary injury during radiofrequency ablation of central liver tumors without increasing the rates of local tumor progression.
IG4-related disease investigations
Immunoglobulin IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that is often characterized by the presence of a pseudotumor with locally expansive behavior. Such patients are often misdiagnosed initially as having a malignancy. Other patients present with systemic symptoms including fever, malaise, and weight loss. These different presentations, which are only some of the ways in which IgG4-RD can present, are not mutually exclusive, especially in patients previously diagnosed with PSC. According to the Durazo recommendations we have to rule out IGg4-RD in each patient with PSC diagnosis and/or those with biliary stricture of unknown etiology using both Ig4 laboratory test and ductal biopsy using SpyGlass endoscopy [Figure 2], [Figure 3], [Figure 4]. Histologically, IGg4-RD is characterized by the typical histopathological features of a dense lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, a high ratio of IgG4-positive to IgG-positive cells, storiform fibrosis (cellular fibrosis organized in an irregular whorled pattern), obliterative phlebitis, and variable presence of eosinophils. The clinical presentation depends on the involved tissues. However, the histopathologic findings seem to be similar regardless of location, and diagnosis is therefore based on histopathology and immunohistochemistry. In addition, patients often respond well to corticosteroid and immunosuppressive therapy ,.
|Figure 2: Intraductal apperance of common bile duct (CBD) and hepatic ducts; left and right using SpyGlass endoscopy.|
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|Figure 3: SpyGlass appears from the channel of ERCP. Note the biopsy forceps.|
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|Figure 4: SpyGlass (Boston Scientific), useful for demonstration of intraductal pathology. ABS; Anastomotic Biliary Stricture (s), ERCP; Endoscopic Retrograde Cholangio-pancreatography, RFA; Radio-Frequency Ablation.|
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Dr Abd Elrazek M. Ali Hussein and Al Azhar School of Medicine at Assiut, Assiut, Egypt thank Professor Dr Francisco A. Durazo, the Director of Transplant Hepatology at David Geffen School of Medicine, UCLA, for his scientific support and prompt help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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