Safety, Outcomes of Early Versus Late ERCP in Liver Transplant Recipients

Rajat Garg, MD

Credit: Cleveland Clinic

Biliary complications remain a common source of morbidity following liver transplantation. The most common post-transplant biliary complications are strictures and leaks. Endoscopic retrograde cholangiopancreatography (ERCP) has become the first line of therapy for post-transplant biliary complications. However, outcomes of ERCP in early as compared to late liver transplant period are not known. We aimed to study the safety and outcomes of late (> 30 days) versus early (≤ 30 days) ERCP in liver transplant recipients with biliary complications.  

After IRB approval, we conducted a retrospective analysis of patients who underwent ERCP after liver transplant at Cleveland Clinic. Variables including transplant indication; MELD score at the time of transplant; baseline labs prior to ERCP; and procedure factors such as antibiotic use, prior medication use, and post-procedure outcomes were collected. Patients were then divided into 2 groups: ERCP ≤ 30 and ERCP > 30 days after liver transplant. The outcomes were technical success, clinical success, and adverse events post-ERCP.

A total of 174 patients were included in our analysis. Mean age, gender, race, BMI, etiology of liver disease, type of liver graft, and type of anastomosis were similar in both groups. Patients who had ERCP in ≤ 30 days after liver transplant had significantly lower hemoglobin, alkaline phosphatase, bilirubin, and albumin as well as higher white cell count compared to patients who underwent ERCP > 30 days post-transplant. More patients in the ERCP ≤ 30 days group were on anticoagulation (10.6% vs 3.2%; P = .049) with no difference in antiplatelet drugs.

ERCP ≤ 30 days after transplant was performed more commonly for indication of bile leak (36.2% vs 4.7%), whereas ERCP > 30 days post-transplant was more often performed for biliary stricture (90.6% vs 57.4%; P <.001). Patients who underwent ERCP ≤ 30 days at significantly high rates of post-procedure bleeding (12.8% vs 3.9%; P = .03) (Figure 1).

Figure 1. Adverse outcomes in both groups.

In terms of procedural details, there were no significant differences in patients with prior ERCP and sphincterotomy done, history of Roux-en-Y anatomy, antibiotic use during the procedure, or advanced cannulation technique. However, there were significantly high rates of balloon dilation in patients who underwent ERCP > 30 days post-liver transplant.

Technical success, late postprocedural bleeding, post-ERCP pancreatitis, stent deployment, dislodgment, and cardiopulmonary complications were similar in both groups. The need for future ERCP, interventional radiology, or surgical interventions was also similar in both groups. In this study, we report high rates of early post-procedure bleeding in patients who underwent ERCP ≤ 30 days after liver transplant as compared to ERCP > 30 days with overall similar rates of technical and clinical success. These data will help risk stratify patients prior to ERCP and raise awareness of the higher risk of bleeding in the early liver transplant period.