Biliary Strictures Complicating Liver Transplantation Incidence, Pathogenesis, Management, and Outcome

Abstract

Six hundred sixty-six patients received 792 liver transplants between February 1, 1984 and September 30, 1991. Biliary reconstruction was by choledochocholedochostomy (CDCD) with T-tube (n = 509) or Roux-en-Y choledochojejunostomy (CDJ) (n = 283). Twenty-five patients (4%) developed biliary strictures. Anastomotic strictures were more common after CDJ (n = 10, 3.5%) than for CDCD (n = 3, 0.6%). Intrahepatic strictures developed in 12 patients. Six patients had occult hepatic artery thrombosis (HAT). The other six patients received grafts in which cold ischemia time exceeded 12 hours. Anastomotic strictures were successfully managed by percutaneous dilation (PD) in five patients (n = 10), operation in three (n = 6), with retransplantation required in two patients. Intrahepatic strictures were managed by PD in seven, retransplantation in one, and expectantly in four patients. Of 25 patients, 19 (76%) are alive with good graft function. In three of six deaths, the biliary stricture was a significant factor to the development of sepsis and allograft failure. The authors conclude that (1) anastomotic strictures are rare after LT; (2) the development of biliary strictures may signify occult HAT; (3) PD is effective for most strictures; and (4) extended cold graft ischemia (less than 12 hours) may be injurious to the biliary epithelium, resulting in intrahepatic stricture formation.

Intrahepatic biliary lesions after orthotopic liver transplantation

“…Some authors have observed no association between IBL and chronic rejection [4]. However, others suggest that chronic rejection is associated with chronic obliterative arteriopathy, and it has been postulated that the resulting bile duct ischemia may lead to duct loss and biliary stricture [14].…”

ENDOSCOPIC TREATMENT OF POST-LIVER TRANSPLANTATION ANASTOMOTIC BILIARY STRICTURE: systematic review andmeta-analysis

“…The involved etiological factors seems to be the small bile duct diameter, a big disproportion between graft and recipient bile ducts, the ischemia time, tension on the anastomosis, infection and other technical issues (8) . On the other hand, ischemia related to hepatic artery problems seems to be more related to the occurrence of NABS (2,13) . NABS can present as a single or multiple stenosis and has a reserved prognosis when compared to ABS (18) .…”

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.…”

“…In spite of encouraging progress in interventional non-surgical ITBL-treatment, and achievements in graft resection, up to 50% of patients with non-anastomotic strictures still require re-transplantation of the liver [30,43,47,48]. Re-transplantation of the liver is supposed to be the definitive therapy of graft damage being the last resort of therapeutical options.…”

“…Analogously, re oxigenation and warm ischemia time also seem to be involved in the pathogenesis of the disease [27,53]. Moreover, delayed re-arterialization of the graft may favor the occurrence of ITBL [2,43,54]. Therefore, the time period between explantation and reperfusion should be as short as possible under an adequate preserving temperature.…”