Biliary Tract Complications after Liver Transplantation: A Review

Abstract

Biliary complications continue to be a major cause of morbidity in liver transplant recipients with an incidence of 10–30% following whole-organ transplantation and a mortality rate of up to 10%. Biliary leaks and strictures are most common but sphincter of Oddi dysfunction, hemobilia, and biliary obstruction are also observed. Biliary complications may be related to various factors such as hepatic artery patency, preservation injury, cytomegalovirus infection, chronic ductopenic rejection, ABO incompatibility, and technical reasons. The latter include imperfect anastomosis, T-tube-related complications and the use of partial liver grafts when cut surface biliary leaks or inadvertent bile duct injuries may occur during parenchymal division. The usage of a T-tube for duct-to-duct anastomosis in whole-organ liver transplantation remains controversial, mainly because of the high rates of T-tube-related complications observed in many series. In this article we review the etiology, as well as the main types of biliary complications according to the technique of biliary reconstruction and liver transplant procedure performed. Their management is also discussed with interventional radiology and endoscopic techniques emerging as the preferred treatment option, obviating the need for surgery in a selected majority of patients.

Value of T-tube in biliary tract reconstruction during orthotopic liver transplantation: a meta-analysis

“…Biliary tract reconstruction is a crucial factor in orthotopic liver transplantation (OLT) (Wojcicki et al, 2008;Duailibi and Ribeiro, 2010), and biliary complications, particularly biliary leaks and strictures, are major causes of morbidity and mortality after surgery (Verdonk et al, 2006;Welling et al, 2008). The end-to-end or side-to-side choledochocholedochostomy (CCS) reconstruction program for OLT has been accepted by most transplant centers (Davidson et al, 1999;Castaldo et al, 2007).…”

Endoscopic Management of Biliary Complications After Liver Transplantation

“…Moreover, Bile leakage after transplantation has been considered as a significant risk factor for the development of strictures (Lee et al, 2008;Shah et al, 2007;Verdonk et al, 2006). Other uncommon etiological factors that may present with biliary obstruction are posttransplantation lymphoproliferative disease and recurrent or de novo cancer (Wojcicki et al, 2008). In a review article published in 2005 (Todo et al, 2005), authors broadly classified the factors that must be considered while contemplating biliary complications, namely, biliary strictures after LDLT into two categories: anatomical and technical.…”

“…Having said that, Roux-en-Y reconstruction is still indispensable in pediatric LDLT, patients with bile duct diseases or prior biliary surgery, retransplantation (Todo et al, 2005), left lateral segment split liver grafts, left lateral segment and left lobe living donor grafts in presence of separate segmental II and III ducts, segment IV duct draining into the confluence, and the presence of multiple small bile ducts in grafts harvested with caudate lobe; and still an option in right lobe graft with multiple small bile ducts (Cuinaud's classification, types C-F). It is worth to mention that both duct-to-duct anastomosis and jujenal loop could be used in the same patient having a graft with multiple small ducts (Wojcicki et al, 2008). In an article published in 2005 (Yazumi & Chiba, 2005), the incidence of biliary complications has been reviewed and it had been shown the incidence of anatomotic leakage in right lobe living donor liver transplantation (RL-LDLT) with Roux-en-Y hepatico-jujonostomy (RYHJ) was higher than that with duct-to-duct anastomosis (12.4%-18.2% and 4.7%-7.3%, respectively), while on the other side, the incidence of anastomotic stricture in RL-LDLT with RYHJ was found to be less than that with duct-to-duct anastomosis (8.3%-16.3% and 24.3%-31.7% , respectively) (Yazumi & Chiba, 2005).…”

“…On the other hand, biliary drains were considered by opponents to increase complication rates as shown by frequent reports of biliary leak following bile drain removal, dislodgement, cholangitis and/or biliary obstruction (Greif et al, 1994;Scatton et al, 2001). The incidence of biliary drain related complications was found to range between 10 and 22% (Wojcicki et al, 2008), with bile leak after bile drain removal occurring in 5-15% of patients (Scatton et al, 2001;Vougas et al, 1996). The use of T tube in deceased-donor liver transplantation has been widely abandoned.…”

“…Yet, this has not shown uniformly reproducible results (Sharma et al, 2008). Stenting or no stenting of biliary reconstruction in living donor liver transplantation is still a debate that is far from being settled (Wojcicki et al, 2008).…”