Endoscopic Evaluation in Transplantation Candidates - Frequency and Prognostic Relevance of Upper and Lower Gastrointestinal Tract Findings
The introduction of a MELD (model for end-stage liver disease) based necessity-oriented
allocation system for liver transplantation (OLT) has lead to an increasing number of
patients with advanced liver disease on the waiting list. Hence it is essential to optimize
outcome after transplantation in this high-risk patient collective in order to best utilize
the limited supply of donor organs. To achieve this goal, the careful selection of
appropriate transplantation candidates is based on an extensive evaluation of the patients
including cardiac, pulmonary and renal testing and different imaging methods to exclude
malignancies or an infective focus. As in many other institutions also in the Medical School
Hannover (MHH) esophagogastroduodenoscopy (EGD) and colonoscopy are standard procedures
during evaluation for liver transplantation. The rationale to perform these procedures is to
identify patients with medical conditions that might limit their outcome after OLT. Some
endoscopic findings as for example esophageal varices, gastric or duodenal ulcer or colon
adenoma can be treated before transplantation, so that the patient enters the waiting list
in a better medical condition. If gastrointestinal malignancies are detected, the patient
will no longer be considered a candidate for OLT, unless curative treated. The detection of
premalignant changes (high grade adenomas, barrett's esophagus etc.) is of great importance,
since the immunosuppressed liver transplantation recipients are probably at a higher risk to
progress to malignancy.
So far the data regarding the prevalence of upper and lower gastrointestinal pathologies in
transplantation candidates are contradictory and are based on only a few retrospective
studies. These studies often include only a subgroup of transplantation candidates. Many
centres perform screening colonoscopy during OLT evaluation only in patients greater than
age 45 or 50, although until today there is no clear evidence, that younger patients do not
have a benefit from screening colonoscopy.
So far it is not known if certain preoperative endoscopic findings correlate with
postoperative gastrointestinal complications. Such a correlation, e.g. between
diverticulosis and postoperative colon perforation or peritonitis due to diverticulitis,
could be highly relevant for patient management before and after OLT.
After signing informed consent the results of EGD and colonoscopy of all patients evaluated
for OLT at the MHH together with laboratory and clinical data will be entered in a database.
After follow up for at least one year these data will be analyzed. Descriptive statistics as
well as a multivariate analysis will be performed, to find out the frequency of endoscopic
diagnoses in transplantation candidates and to look for correlations between these findings
and patient outcome after OLT.
Observational Model: Cohort, Time Perspective: Prospective
Jochen Wedemeyer, MD
Germany: Ethics Commission