Management of biliary tract complications after orthotopic liver transplantation (original) (raw)
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Transplantation Proceedings, 2006
Introduction. Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis. Material and methods. We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases (n ϭ 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis. Results. In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss. Conclusion. Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.
Biliary complications following orthotopic liver transplantation: a 10-year audit
Hpb, 2011
Background: Biliary complications following liver transplantation result in major morbidity. We undertook a 10-year audit of the incidence, management and outcomes of post-transplant biliary complications at the New Zealand Liver Transplant Unit. Methods: Prospectively collected data on 348 consecutive liver transplants performed between February 1998 and October 2008 were reviewed. The minimum follow-up was 6 months. Results: A total of 309 adult and 39 paediatric transplants were performed over the study period. Of these, 296 (85%) were whole liver grafts and 52 (15%) were partial liver grafts (24 split-liver, eight reduced-size and 20 live-donor grafts). There were 80 biliary complications, which included 63 (18%) strictures and 17 (5%) bile leaks. Partial graft, a paediatric recipient and a Roux-en-Y biliary anastomosis were independent predictors of biliary strictures. Twenty-five (40%) strictures were successfully managed non-operatively and 38 (60%) required surgery (31 biliary reconstructions, three segmental resections and four retransplants). Seven (41%) bile leaks required surgical revision and 10 (59%) were managed non-operatively. There was no mortality related directly to biliary complications. Conclusions: Biliary complications affected one in five transplant recipients. Paediatric status, partial graft and Roux-en-Y anastomosis were independently associated with the occurrence of biliary strictures. Over half of the affected patients required surgical revision, but no mortality resulted from biliary complications.
Annals of Surgery, 1994
This study analyzed the incidence and timing of biliary tract complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. Summary Background Data Technical complications after OLTx have a significant impact on patient and graft survival. One of the principle technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless, biliary complications still occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications in 13.2% of transplants.
Surgery, Gastroenterology and Oncology, 2021
Background: Biliary complications are the more frequent problem following liver transplantation (LT) and have been considered the "Achiles´s heel"of this procedure. The aim of this study was to evaluate the rates of biliary complications after LT, the different therapeutic modalities currently available and their outcomes. Methods: A total of 420 LTs performed up to 2020 were retrospectively analyzed. Evaluation factors included MELD score, images, surgical techniques, type of biliary reconstruction and type of complications. We also analyzed the different therapeutic options, and the short and long-term outcome. Results: 417 deceased donors and 3 living donor transplants were performed. Biliary complications occurred in 37 patients (8,8%)-31 strictures (81%), four leaks (11%), one acute biliary peritonitis after T-tube removal (3%) and two patients biliary stones (5%). Biliary complications associated with vascular complications were seen in 10 patients (27%). In general, a minimally invasive management (percutaneous or endoscopic) was the first-line approach. Percutaneous interventional procedures were the treatment of choice in 32/37 patients (86,48%), with a success rate of 67.74% (21/31). Hepaticojejunostomy (HJ) was performed in 14 patients. Overall morbidity rate of surgical reconstruction was 14% (2/14 patients) and perioperative mortality was 7%. The median follow-up was 54,53 months. At follow-up, none of the patients in the HJ group had developed a new stricture. Conclusions: The majority of biliary complications must be treated by minimally invasive approach. However, when those fail,surgical reconstruction allows to avoid future consequences in the graft.
Biliary complications following orthotopic liver transplantation
Clinical Radiology, 1990
The gall-bladder conduit anastomosis (choledocho-cholecysto-choledochostomy) has been the most frequently used technique for the biliary tract anastomosis in the Cambridge/King's College Hospital joint liver transplantation programme since 1976. Cholangiograms and interventional biliary procedures performed over a 3 year period were reviewed retrospectively. Seventy-six of 148 patients managed post-operatively at King's College Hospital were studied (79 transplants). Cholangiograms were abnormal in 63 (80%) transplants with biliary strictures; inspissated bile formation, bile leak and T-tube malposition occurring in 50, 23, 14 and three transplants respectively. Anastomotic strictures occurred most frequently, predominantly at the proximal anastomosis, and the presence of inspissated bile and the T-tube in relation to these contributed towards subsequent biliary obstruction. Non-anastomotic strictures in the donor biliary tract were associated with a high position of the T-tube tip at or above the liver hilum. Saline irrigation of the bile ducts for inspissated bile or its removal via the endoscope were effective measures in the management of biliary obstruction but percutaneous balloon dilatation and endoscopic stent insertion for biliary strictures were found to have a limited role.
Transplantation Proceedings, 2007
Biliary complications are known as a weak point of liver transplantation. Their occurence can be related to the practice of draining the biliary anastomosis performed at the time of transplantation. At our institution, routine of anastomotic biliary drainage was abandoned in June 2004. Aim. We sought to assess the occurence and character of biliary complications following orthotopic liver transplantation in relation to the technique of anastomosis. Materials and Methods. In two groups of transplantees: last 100 transplantations with biliary drainage (48 females and 52 males aged 17 to 64 years) and last 100 transplantations without drainage (52 females and 48 males aged 18 to 67 years). The results of treatment were compared, for biliary complications and their influence on further management. In both groups, the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In most cases (167) we performed a cholangiojejunal Roux-en-Y (CBD) end-to-end anastomosis, less commonly (33 cases) hepaticojejunal anstomoses. Results. In the first group, biliary complications (bile leak at the site of drainage, bile leak after T-tube removal, CBD strictures) requiring surgical or endoscopic intervention, occurred in 17% recipients. In one case, the biliary complication resulted in retransplantation. In the second group, biliary complications occured in 11% patients. None of them caused organ loss. Conclusion. Abandoning drainage of the biliary anastomosis has reduced the occurrence of early biliary complications after orthotopic liver transplantation.
Biliary Complications Following Liver Transplantation: Single-Center Experience
Transplantation Proceedings, 2006
The aphorism that reconstruction of the biliary anastomosis is the ''Achilles heel'' of liver transplantation remains valid as biliary complications following liver transplantation remain a major source of morbidity with an incidence of 5-32%. Biliary complications include biliary strictures, biliary leaks, and stones. Biliary strictures can be divided into anastomotic and non-anastomotic. The management of biliary complications previously relied on surgical intervention. However, advances in endoscopic and radiological interventions have resulted in less-invasive options. The management of biliary complications post-liver transplantation requires a multidisciplinary approach and continues to evolve. Biliary complications also reflect the continued expansion of the donor pool with extended, live, and non-heart beating donors.
Biliary tract complications in human orthotopic liver transplantation
The results of 393 consecutive orthotopic liver transplants in 313 patients were reviewed to determine the incidence of primary biliary tract complications. There were 52 biliary tract complications in 393 grafts (13.2%), and 5 directly related deaths. Choledochojejunostomy over an internal stent to a Rouxen-Y limb of proximal jejunum (RYCJ-S) was the most frequently used technique (175 cases) and the most successful with only 9 technical failures (5.2%). Choledochocholedochostomy over a T tube (CC-T) was used in 159 cases and was successful in all but 20 cases (12.6%). Other methods of reconstruction were associated with high failure rates or technical complexity that do not justify their use. Biliary leak and obstruction were the most common complications. Leakage after CC-T at the T tube exit site was usually directly repaired, but anastomotic leakage required conversion to RYCJ-S. Obstruction may be relieved by percutaneous balloon dilatation but definitive treatment also usually required conversion to RYCJ-S. The most common complication after RYCJ-S is functional obstruction by a retained stent, which has a low morbidity but may necessitate surgical removal. Anastomotic leaks, which occurred in 2 cases, were successfully managed by revision of the choledochojejunostomy. The use of cyclosporine-prednisone therapy and standardization of techniques of liver procurement and implantation have resulted in dramatic improvement in patient survival after orthotopic liver transplantation (1-3). Nevertheless, technical complications are still responsible for substantial morbidity and mortality. We have previously reported our experience with biliary tract complications after orthotopic liver transplantation for 90 transplants in 78 patients (4). This report extends our experience to a consecutive series of 393 orthotopic liver transplantations in 313 patients.