Biliary tract complications after liver transplantation
T. P. O'Connor, W. D. Lewis and R. L. Jenkins
Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
OBJECTIVE: To assess the incidence, type, and treatment of biliary
complications after orthotopic liver transplantation. DESIGN: Case series.
SETTING: Tertiary referral center. PATIENTS: One hundred ninety consecutive
adults who underwent 220 orthotopic liver transplantations with biliary
reconstruction between January 1, 1989, and December 31, 1993, with
follow-up of all survivors to May 1994. MAIN OUTCOME MEASURES: Incidence,
type, and treatment of biliary complications. RESULTS: Biliary
complications were identified in 65 of the 190 patients who underwent
biliary reconstruction (49 of 147 with choledochocholedochostomy and 16 of
43 with Roux-en-Y choledochojejunostomy). The group with complications who
had choledochocholedochostomy had 32 biliary leaks (22 T-tube related), 11
strictures or obstructions, and six cases of choledocholithiasis. Twelve
percent of choledochocholedochostomies were converted to
choledochojejunostomies, while 26 of 49 biliary complications in patients
who had choledochocholedochostomies were treated nonoperatively. Elective
removal of T tubes resulted in biliary leak in 15 of 89 patients, treated
nonoperatively in 12. Leaks (unrelated to scheduled removal of the tube)
occurred earlier than strictures (choledochocholedochostomy, mean +/- SEM
25.6 +/- 5.8 vs 184.7 +/- 61.0 days; choledochojejunostomy, 13.4 +/- 4.4 vs
521.0 +/- 142.0 days) and were more often treated operatively
(choledochocholedochostomy, 14 of 17 vs three of seven;
choledochojejunostomy, four of five vs three of eight). Three deaths were
associated with early biliary leaks, all in patients with preexisting
multiorgan dysfunction. There was no significant difference in the
incidence of biliary complications by type of reconstruction, year of
transplantation, age, UNOS (United Network for Organ Sharing) status,
preservation time, or indication for transplantation. CONCLUSIONS: Biliary
complications are common after orthotopic liver transplantation but are
rarely an isolated cause of death. Stenting of the
choledochocholedochostomy or choledochojejunostomy anastomosis does not
prevent strictures, and T tubes are associated with a high incidence of
biliary leakage on removal. Nonoperative interventions have an increasing
role in the treatment of biliary complications.
