Biliary complications after liver transplantation

Abstract

The incidence of biliary complications after liver transplant is estimated to be 8% to 20%. Post-liver transplant biliary complications may lead to acute and chronic liver injury. The early recognition and prompt treatment of such complications improves the long-term survival of the patient and graft. An understanding of the type of biliary reconstruction, the rationale for creating a particular anastomosis, and the technical difficulties in reconstructing the biliary tract are important in assessing and managing complications after liver transplant. Because the clinical presentation of these patients may be subtle, the physician must be aggressive and thoughtful in ordering and interpreting the diagnostic tests. Important points to remember are 1) that noninvasive examinations may fail to detect small obstructions or leaks, 2) a liver biopsy often is performed prior to cholangiography to exclude rejection and ischemia, and 3) the liver biopsy can miss an extrahepatic obstruction by misinterpreting portal inflammation as rejection. Biliary leaks and strictures are the most common biliary complications following liver transplant. Less common complications include ampullary dysfunction and stone/sludge formation. The effective management of biliary complications following a liver transplant depends on understanding the natural history, the prognosis, and the available therapeutic options for each type of complication.

Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

“…It was a late complication occurring after a mean time period of 33.8 mo (range-1 to 95 mo) post OLT and was observed in 6 (8.6%) which is comparable to the quoted figure of 2.5-19% in the literature [19,48] . They have been found difficult to treat endoscopically or by PTC [26,29] so was the case in our experience. Out of 6 patients with ITBL, 4 (66%) could be treated successfully, 1 had to undergo surgery while another one had an interesting clinical course.…”

“…We failed to treat bile leakage in 1 patient (success rate 95.5%) while 3 other patients were shown to have complete dissociation and necrosis of common bile duct on ERC, hence were not considered for endoscopic therapy. These patients were managed with wide surgical debridement of necrotic and infected tissue and conversion to bilio-enteric anastomosis, similar to the management done in previous studies also [26,29,30] . Placement of T tube during OLT is still a controversial issue.…”

“…IBL has been reported to occur in the range of 1%-25% of patients post OLT [9,26] . It has been arbitrarily subdivided in the literature in to, early-presenting within 1-3 mo and late-beyond 3 mo.…”

Ischemic Type Biliary Lesions

“…Anastomotic strictures are usually easier to treat than intrahepatic lesions. Early nonanastomotic strictures demonstrate higher success rates than strictures appearing later than three months after LT [41][42][43]. Endoscopic and transhepatic treatment options are limited in patients with impaired liver function similarly to the diagnostic procedure.…”

Endoscopic management of post-liver transplant biliary complications

“…The incidence of BTC varies from 5% to 32% in various studies and has been decreasing with time; however, newer challenges are emerging with the more widespread use of living donor, donation after circulatory death and split-liver transplants [2,3] . The different complications that can be seen post LT include biliary strictures, leaks, cast formation, papillary stenosis and other less common ones [4,5] . Conventionally, post-LT biliary complications can be referred to as early (within 30 d of LT), delayed (1-3 mo post-LT) and late (beyond 3 mo post-LT).…”