Correspondence / Digestive and Liver Disease 47 (2015) 816–818
needle has also been reported . Exclusive ﬁne-needle aspiration has been used, but does carry risk of recurrence . In the literature mean duration of follow-up varied from 6 to 12 months, and most patients had satisfactory outcomes after complete tumour resection. Regarding post-surgical anastomotic oedema, preventive jejunal stoma may be beneﬁcial, since it is associated with lower rates of severe complications, better nutrition status , shorter hospital stay and lower medical costs.
Conﬂict of interest None declared.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.dld.2015.05.008
References  De Perrot M, Rostan O, Morel P, et al. Abdominal lymphangioma in adults and children. British Journal of Surgery 1999;86:395–7.  Hwang SS, Choi HJ, Park SY. Cavernous mesenteric lymphangiomatosis mimicking metastasis in a patient with rectal cancer: a case report. World Journal of Gastroenterology 2009;15:3947–9.  Ryu WS, Kwak JM, Seo UH, et al. Laparoscopic treatment of a huge cystic lymphangioma: partial aspiration technique with a spinal needle. Journal of Laparoendoscopic and Advanced Surgical Techniques Part A 2008;18:603–5.  Mansour NM, Salyers Jr WJ. Recurrence of a pancreatic cystic lymphangioma after diagnosis and complete drainage by endoscopic ultrasound with ﬁneneedle aspiration. Journal of the Pancreas 2013;14:280–2.  Peng J, Cai J, Niu ZX, et al. Early enteral nutrition compared with parenteral nutrition for esophageal cancer patients after esophagectomy: a meta-analysis. Diseases of the Esophagus 2015, http://dx.doi.org/10.1111/dote.12337 (in press).
Cheng Tian Yi Zheng Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Xinyu Ren Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Binglu Li ∗ Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China ∗ Corresponding
author at: Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China. Tel.: +86 10 6915 2600; fax: +86 10 6512 4875. E-mail address: [email protected]
(B. Li) Available online 21 May 2015
Safety and efﬁcacy of extracorporeal shock-wave lithotripsy in the management of biliary stones after orthotopic liver transplantation Dear Editor, Despite continuous improvement in liver transplantation (LT), 10–40% of cases present post-LT biliary strictures, leaks, stones-sludge, ductopenia or cast syndrome. The type of biliary reconstruction, ischaemia-thrombosis and infections are the principal risk factors for the development of post-LT biliary complications . In these cases, ﬁrst-line conservative treatments are indicated, including endoscopic (sphincterotomy, stenting, dilation, stone clearance, naso-biliary tube) or percutaneous (drainage, stenting or balloon dilation) approaches. Surgery is usually limited to failure of previous techniques [2,3]. Biliary stone disease is observed in >5% of patients  and is considered a difﬁcult-to-treat condition due to altered anatomy, co-morbidities and presence of strictures. In the case of failure of endoscopic or percutaneous interventions, surgery is the only rescue strategy; since extracorporeal shock-wave lithotripsy (ESWL) was shown to be safe and effective for difﬁcult choledocholithiasis , we used this technique to reduce the need for surgery. ESWL was performed using ModulithSLX-F2 (Storz Medical, Switzerland) according to our institution protocol . The results are reported in Table 1. Six patients (33% males; median age 58.5 years, range 53–72 years) were treated from 2001 to 2012; indication for LT was hepatocellular carcinoma (HCC) in 3 patients, HCV-related end-stage liver disease (ESLD) in 2 and one fulminant hepatitis (Amanita phalloides poisoning). Four patients presented with symptomatic biliary stones with concomitant anastomotic stricture, one with symptomatic stone with concomitant redundant CBD course without stricture and one with multiple intra-hepatic stones and a hilar biloma occurred after hepatic artery thrombosis. Five patients had duct-to-duct biliary anastomosis while one had a Roux-en-Y hepatico-jejunostomy. All other concomitant biliary complications were treated according to available guidelines (i.e. multi-stenting for stricture; drainage for biloma) [2,3]. The patients underwent a median of 3 (2–5) ESWL sessions with a mean amount of shock-wave per session of 3800 (2600–4000), with intermediate-to-high power. Tolerability was excellent: no sedation or analgesia was required either during ESWL or after the procedure. No patient reported ESWL-related adverse events. ESWL allowed stone clearance in all but one case (83%) in which, despite partial stone fragmentation, surgery was necessary (Rouxen-Y choledocho-jejunostomy) because of untreatable stricture. Among the ﬁve patients with successful biliary clearance, four presented a complete and long-term resolution of biliary complications, while one patient died because of end-stage liver disease (biliary cast syndrome) complicated by sepsis. In conclusion, in patients with previous LT, the difﬁcult biliary access and the possible presence of concomitant complications signiﬁcantly reduce the efﬁcacy of ERCP for biliary stone disease. We proposed ESWL as rescue therapy to reduce the need for surgery in this setting; in our experience, >80% of patients were successfully treated with a conservative approach, with no related adverse event. These preliminary data suggest that ESWL should be considered a rescue therapy to reduce the need for surgery. Larger experiences are needed to provide evidence for further recommendations.
Correspondence / Digestive and Liver Disease 47 (2015) 816–818
Table 1 Summary of clinical, surgical characteristics, extracorporeal shock-wave lithotripsy sessions and treatment outcomes. Patients
Indication for LT
Type of biliary reconstruction
Biliary complication and indication for ESWL
Stone fragmentation and CBD clearance
Female, 54 years
Fulminant hepatitic failure due to Amanita phalloides poisoning (1990) End-stage cholestatic cirrhosis (August 2006) HCC on compensated HCV-cirrhosis (March 2003) HCV-related cirrhosis (July 1998)
Cholangitis due multiple intra-hepatic stones (up to 10 mm) and anastomotic stricture Anastomotic stricture with pre-anastomotic stone (15 mm)
3 sessions; intermediate power (July 2001)
Complete stone fragmentation; percutaneous biliary clearance
5 sessions; intermediate power (October 2007) 3 sessions; intermediate or high power (May 2009) 5 sessions; intermediate power (March 2011) 2 sessions; intermediate-high power (May 2012)
Partial stone fragmentation; CBD clearance failure Complete stone fragmentation with CBD clearance
No biliary event within the ﬁrst year; lost in follow-up (January 2003) Surgery. (November 2007). No complications until June 2014 No biliary event until June 2014
Complete stone fragmentation. Persistence of biloma Complete stone fragmentation with CBD clearance
Death – ESLD complicated by sepsis (December 2013) Death – metastatic CRC (September 2013)
3 sessions; intermediate-high power (February 2012)
Complete stone fragmentation with CBD clearance
No biliary event until June 2014
Female, 54 years
Female, 72 years
Male, 53 years
Female, 63 years
Male, 70 years
HCC on compensated HCV-cirrhosis (April 2006) HCC on compensated alcoholic cirrhosis (January 2008)
Anastomotic stricture with pre-anastomotic stone (10 mm)
Acute cholangitis due to multiple stones (up to 10 mm) within hilar biloma (30 mm) Redundant CBD course with pre-anastomotic stones (up to 15–20 mm) Anastomotic stricture with pre-anastomotic stones (up to 22 mm).
LT, orthotopic liver transplantation; ESWL, extracorporeal shock-wave lithotripsy; CBD, common bile duct; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; ESLD, end-stage liver disease; CRC, colorectal cancer.
Conﬂict of interest None declared. Acknowledgements Authors thank Dr. Giulio Cariani and Prof. Francesco Azzaroli for their endoscopic, clinical and conceptual contribution. References  Dubbeld J, van Hoek B, Ringers J, et al. Biliary complications after liver transplantation from donation after cardiac death donors: an analysis of risk factors and long-term outcome from a single center. Ann Surg 2015;261:e64.  Shin M, Joh JW. Endoscopic management of biliary complications in adult living donor liver transplantation. Transplantation 2014;97(Suppl. 8):S36–43.  Ko GY, Sung KB. Radiological intervention approaches to biliary complications after living donor liver transplantation. Transplantation 2014;97(Suppl. 8):S43–6.  Cecinato P, Fuccio L, Azzaroli F, et al. Extracorporeal shock wave lithotripsy for difﬁcult common bile duct stones: a comparison between 2 different lithotripters in a large cohort of patients. Gastrointest Endosc 2015;81: 402–9.
Andrea Lisotti a,b,∗ Alessandra Caponi a,b Giulia Gibiino a,b Rosangela Muratori a,b a Gastroenterology Unit, S.Orsola-Malpighi Hospital, Bologna, Italy b Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Italy ∗ Corresponding
author at: U.O. Gastroenterologia, Policlinico S’Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy. Tel.: +39 0516363888; fax: +39 0516364112. E-mail addresses: [email protected]
(A. Lisotti), [email protected]
(A. Caponi), [email protected]
(G. Gibiino), [email protected]