Safety and efficacy of the percutaneous treatment of bile leaks in hepaticojejunostomy or split-liver transplantation without dilatation of the biliary tree

Abstract

Biliary leaks complicating hepaticojejunostomy (HJA) or fistulas from cut surface are severe complications after liver transplantation (LT) and split-liver transplantation (SLT). The aim of the study was to describe our experience about the safety and efficacy of radiological percutaneous treatment without dilatation of intrahepatic biliary ducts. From 1990 to 2006, 1595 LTs in 1463 patients were performed in our center. In 1199 LTs (75.2%), a duct-to-duct anastomosis was performed, and in 396 (24.8%), an HJA was performed. One hundred twenty-nine anastomotic or cut-surface bile leakages occurred in 115 patients. Sixty-two biliary leaks occurred in 54 patients with HJA; in 48 cases, an anastomotic fistula was found. Cut-surface fistulas occurred in 14 cases: 5 in right SLTs and 5 in left SLTs. Twenty-two patients were treated with 23 percutaneous approaches for 17 HJA fistulas and 6 cut-surface leaks without intrahepatic bile duct dilatation. Two percutaneous therapeutic approaches were used: percutaneous transhepatic biliary drainage (PTBD) for fistula alone and PTBD with percutaneous drainage of biliary collection in patients with both complications. PTBD was successful in 21 cases (91.3%); the median delay from catheter insertion and leak resolution was 10.3 days (range: 7-41). The median maintenance of drainage was 14.8 days. In 1 patient, fistula recurrence after PTBD needed a surgical approach; after that, an anastomotic fistula was still found, and a new PTBD was successfully performed. In another patient, PTBD was immediately followed by retransplantation for portal vein thrombosis. There were no complications related to the interventional procedure. In conclusion, biliary fistulas after HJA in LT or after SLT can be successfully treated by PTBD. The absence of enlarged intrahepatic biliary ducts should not be a contraindication for percutaneous treatment. Liver Transpl 14:611-615, 2008. © 2008 AASLD. Received June 26, 2007 accepted October 31, 2007. Biliary complications after liver transplantation (LT) have an incidence of 10% to 30% 1 ; reduced-size LT, split-liver transplantation (SLT), and living-donor LT are associated with increased rates of biliary complications.2 A lower rate of complications directly related to hepaticojejunostomy (HJA) versus duct-to-duct anastomosis has been described.3-5 Surgical repair and endoscopic management have been reported to successfully treat post-LT biliary fistulas from duct-to-duct anastomosis, but when the biliary leaks complicate HJA or they rise from the cut surface of the liver, an endoscopic approach is not possible. The aim of this study was to evaluate the safety and efficacy of percutaneous treatment of post-LT biliary leakages occurring in HJA or in split-liver recipients in the absence of biliary tree dilatation. PATIENTS AND METHODSFrom 1990 to 2006, 1595 LTs in 1463 patients were performed in our center; in 1199 LTs (75%), a duct-toAbbreviations: HLA, hepaticojejunostomy; LT, liver transplantation; PTBD, percutaneous transhepatic biliary drainag...

Percutaneous Transhepatic Biliary Drainage in Patients with Postsurgical Bile Leakage and Nondilated Intrahepatic Bile Ducts

“…The overall clinical success rate in this study was 69.8% (44/63), a little lower than rates reported in other studies, ranging from 70 to 100% [8,21,22,25,26,30]. The difference can be explained by the complexity and the severity of the underlying diseases of our patients.…”

“…To the best of our knowledge, this study encompassed the largest time span and sample size of its kind. Over the last 20 years a number of small studies in at least 10 patients also reported high technical success rates (91-100%), high clinical success rates (70-100%), and low major complication rates (0-13%) [8,19,21,22,25,26,30]. …”

“…More recent small series have shown that PTC and subsequent drainage for a variety of indications can be feasible in patients with nondilated bile ducts as well; the technical success rates were similar to those in patients with dilated bile ducts (91-100%) [17,19,20,21,22,23,24,25,26]. Several studies have described the management of biliary leakage both after hepaticojejunostomy or post-hepatectomy, however a PTBD was performed in the minority of patients [27,28].…”

The role of interventional radiology in the treatment of biliary strictures after paediatric liver transplantation

“…Interventional radiology is an effective therapeutic option in the treatment of biliary complications (stenosis or bile leak) after liver transplantation in adults [6]. In paediatric transplantation, however, surgery is the treatment of choice for bile leaks [2], but not for stenoses where it is burdened with high morbidity and mortality [1,2]: therefore, percutaneous therapy can be considered an effective treatment option, according to the experience of many liver transplantation centres.…”

Hepaticojejunostomy leak after pancreaticoduodenectomy

“…When the suspected infectious fluid was detected on CT scan and the existing drainage was insufficiency, the ultrasound guided percutaneous drainage was performed, and most leaks could heal. 15 There are four reoperations in HJ leak group (29 vs. 6% in non-HJ leak group, p=0.010). ALL the 4 patients had "early" or "high-output" HJ leaks, and developed a deteriorated condition, even after aggressive percutaneous drainage.…”