Postoperative Complications

Hepatic artery thrombosis (HAT) with an incidence of 1-5% following adult Ltx is a feared complication frequently leading to graft loss and retransplantation. The reason for the increased incidence of hepatic artery thrombosis in PSC patients is unclear [17]. New immunosuppressive regimens have significantly reduced rejection episodes in liver allograft recipients. Patients with PSC, PBC or autoimmune hepatitis seem to experience more acute rejections compared with patients with alcoholic cirrhosis or chronic viral hepatitis who are thus on a higher level of immunosuppression [23]. On the other hand, some centres have also reported fully satisfactory results after early steroid withdrawal in patients with PSC [24]. With regard to postoperative infection episodes, positive bacterial cultures are found in bile samples from a large portion of PSC patients at the time of Ltx [25].

Another major concern is recurrent disease. Strictures can be single or multiple, anastomotic or nonanastomotic, and they can develop early within the first 3 months or later [26]. Differentiation of PSC-associated or nonrelated complications can be a challenge in follow-up. An increased rate of biliary problems in PSC liver allograft recipients, especially after duct-to-duct reconstruction of the biliary system, was identified by Sheng et al. more than 10 years ago [27].

Diagnostic criteria, prevalence and prognosis of PSC recurrence are not established. Cholangiography has been complicated because it is usually impossible to perform an endoscopic retrograde cholangiogra-

phy in patients in whom a hepaticoenterostomy has been constructed. However, magnetic resonance cholangiography (MRC) now permits noninvasive cholangiography to be performed in these patients.

Even in a graft biopsy, PSC recurrence can be difficult to identify. In some cases, typical fibrous cholangitis and/or fibro-obliterative lesions are seen, supporting the diagnosis of recurrent PSC. About 20-40% of PSC patients will experience recurrent disease. The Mayo Clinic has defined PSC recurrence as either cholangiographic changes occurring more than 90 days after Ltx or characteristic liver biopsy findings, such as fibrous cholangitis and/or fibro-obliterative lesions with or without ductopenic biliary fibrosis or cirrhosis, namely in a PSC patient without HAT or stenosis, ABO incompatibility, chronic ductopenic rejection, early biliary complications or biliary strictures [28]. Therefore, the diagnosis of recurrent PSC should be made only in patients with typical cholangiographic findings and/or positive histology as well as patent arterial circulation. The improving quality of MRC will probably enable us to diagnose and characterise PSC recurrence more precisely in the near future. Pretransplantation colec-tomy has been claimed to be associated with a lower rate of recurrence [29]. The impact of different immunosuppression regimens has not yet been resolved. Cytomegalovirus (CMV) and donor-recipient gender mismatch have also been proposed as risk factors for recurrence [30].

The prognosis of PSC recurrence was originally thought to be favourable, with no cases progressing to graft failure [20], but more recent reports question this [28]. To date, no one can propose strategies for retransplantation.

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