Rajat Garg, MD

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%; 

= .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%; 

 <.001). Patients who underwent ERCP ≤ 30 days at significantly high rates of post-procedure bleeding (12.8% vs 3.9%; 

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. 

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Patients who underwent ERCP ≤ 30 days post-transplant had greater rates of early post-procedure bleeding but similar rates of technical and clinical success compared to late ERCP.

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

The fecal immunochemical test (FIT) and FIT-DNA test are stool-based tests that are recommended by all recognized gastroenterology societies and the United States Preventative Services Taskforce (USPSTF) for average-risk 

 (CRC) screening. FIT is adopted as the primary CRC screening tool for the majority of European countries, Canada and Australia and in programmatic approaches to screening in the US. The goal of stool testing is to identify early-stage CRC but optimally would also detect benign precursors to CRC including advanced adenomatous or serrated polyps. Most CRC develop from an adenoma while approximately 20-30% originate from SSPs. Previous studies reported a higher adenoma detection rate (ADR) with FIT-DNA than FIT. However, similar data are lacking for performance of stool-based tests on sessile serrated polyp/lesions (SSPs) detection. 

Therefore, we performed a meta-analysis aimed at evaluating the sessile serrated polyp detection rate (SSPDR) of FIT and FIT-DNA test in individuals undergoing average-risk CRC screening.

We performed a comprehensive literature search of multiple databases (until September 2022) to identify studies reporting SSPDR in patients with positive FIT or FIT-DNA for average-risk CRC screening. The outcome was overall detection rates of SSP and advanced serrated polyps (ASP; SSP ≥10 mm). SSPDR and ASPDR were compared between FIT and FIT-DNA cohorts. Subgroup analyses were performed based on FIT cutoff, continent, and study type.

A total of 482,405 patients were included from 23 studies (Table 1). The mean age was 62.3±4.4 years, and there were 52.4% females from 21 studies. The pooled SSLPR for all positive stool-based tests was 5.2% (95% confidence interval [CI], 4.0 - 20.3; I

 = 99.5%, 18 studies).The pooled SSPDR in FIT-DNA positive individuals was 11.3% (95% CI, 6.6 – 18.6; I

 = 95.4%) which was significantly higher compared to FIT positive individuals (4.1%; 95% CI, 2.9 – 5.6; I

The overall pooled ASPDR was 1.4% (95% CI, 0.81 – 2.3; I

 = 96.7%).ASP detection rate was higher in FIT-DNA positive individuals (3.8 %; 95% CI, 1.7 – 8.6; I

 = 92.8%) as compared to FIT positive individuals (0.71%; 95% CI, 0.36 – 1.4; I

SSPDR in FIT-DNA positive individuals was also significantly higher than FIT positive individuals in North American subgroup (11.3% vs 7.2%; 

<.001) (Figure 2a) and FIT ≥10 ug/g group (11.3% vs 5.8%; 

<.001) (Figure 2b). Pooled SSPDR was significantly higher in FIT ≥10 ug/g group as compared to FIT ≥20 ug/g group (5.8% vs. 2.1%; 

Our study reports SSP and ASP detection rate of 5.2% and 1.4% for positive stool-based screening tests in average risk population. FIT-DNA outperformed FIT tests in both SSP and ASP detection. Individuals undergoing colonoscopy after positive FIT-DNA had significantly higher rates of SSL as compared to the FIT ≥10 ug/g group and North American subgroup. 

Whether this higher detection of SSPs translates into decreased incidence of CRC will need to be determined in future studies.In addition, different screening interval, qualitative versus quantitative FIT, and different test kits all add to variability in FIT performance. In the era of moving towards non-invasive screening modalities, FIT-DNA with wider screening interval is likely going to outperform FIT, but its long-term impact on further decrease in CRC incidence and mortality remains to be seen.

 Forest plot showing pooled SSP (A) and ASP (B) detection rate of FIT and FIT-DNA positive groups.

 Forest plot showing pooled SSP detection rate of FIT-DNA positive individuals as compared to FIT in North American group (A) and FIT ≥10 ug/g group (B).

Investigators assess the detection rate of FIT and FIT-DNA among average-risk colorectal cancer screening individuals.

Sessile Serrated Polyp Detection Rate in Asymptomatic Average Risk Individuals with Positive Fecal Immunochemical and Multitarget Stool DNA Test: A Systematic Review And Meta-Analysis