Late biliary complications in pediatric liver transplantation

PURPOSE: The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children. METHODS: The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge. RESULTS: Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001). CONCLUSIONS: Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.     

同种原位肝移植术的胆管重建及其术后并发症的防治

目的探讨同种原位肝移植(OLT)的胆管重建方式及其术后并发症的防治。方法回顾性分析1999年2月至2003年1月间103例终末期肝病患者施行OLT胆管重建及术后并发症的防治情况。103例患者中,75例采用经典式原位肝移植伴体外静脉转流、17例采用经典式原位肝移植不伴转流、11例采用背驮式原位肝移植。胆道重建过程中有94例行胆管端端吻合,9例行胆肠吻合。胆管端端吻合的患者中,62例带T管引流,32例不带T管,但11例经受者胆囊管置入小橡胶管引流。术后胆管并发症的诊断主要依据临床表现、B型超声波、磁共振胰胆管成像或逆行胰胆管造影检查。所有患者均随访1年以上。结果103例OLT患者术后胆管并发症发生率为7.8%(8/103)。62例带T管引流的患者中,6例(9.6%)发生胆管并发症,其中4例术后发生胆漏,2例拔除T管后发生局限性腹膜炎;32例不带T管引流的患者中,1例(3.1%)发生胆管狭窄。9例胆肠吻合中,1例(11.1%)术后发生胆漏。7例胆漏患者,2例经再次手术引流,其余继续保持引流胆漏自愈。不带T管引流的患者中的胆管狭窄为吻合口狭窄,经内镜取出异物、球囊扩张与安放内支架后治愈。1例患者因胆漏导致肝动脉吻合口假性动脉瘤及腹腔大出血,经介入法明确诊断并行栓塞治疗后治愈。患者中无胆管并发症而引起的死亡。结论胆管吻合口的胆漏与狭窄是OLT术后最常见的胆管并发症。良好的胆管血供与胆管吻合技术是防止胆管并发症发生的关键。及时的内镜检查与放射学技术是诊断和治疗胆管并发症的有效手段。     

Predisposing factors for biliary complications following liver transplantation

INTRODUCTION: Biliary complications remain a major cause of morbidity and mortality in patients following liver transplantation. We sought to identify possible risk factors predisposing to biliary complications after OLT using duct-to-duct biliary reconstruction. MATERIALS AND METHODS: We retrospectively reviewed 5 years of prospectively collected donor and recipient data between April 1999 and April 2004. We evaluated the presence of biliary complications, donor and recipient age, cold ischemia time, hepatic artery thrombosis, non-heart-beating donor (NHBD), and graft steatosis (>30%). The results were compared with a control group of OLT patients without biliary complications. RESULTS: Among 173 OLT recipients, biliary complications occurred in 28 patients (16.2%), of whom 12 were leaks, 15 strictures, and 1 a nonanastomotic intrahepatic stricture. The mortality following biliary complications was 11%, compared to 6% in the control group. CONCLUSION: Biliary complications remain a persistent problem in OLT. Analysis of risk factors identified hepatic artery thrombosis and steatosis as predisposing factors. With greater experience, NHBD livers may also prove to be at greater risk of biliary complications.     

MR cholangiography in orthotopic liver transplantation: sensitivity and specificity in detecting biliary complications

Boraschi P, Donati F, Gigoni R, Volpi A, Salemi S, Filipponi F, Falaschi F. MR cholangiography in orthotopic liver transplantation: sensitivity and specificity in detecting biliary complications.
Clin Transplant 2010: 24: E82–E87.
© 2009 John Wiley & Sons A/S. Abstract: Background: To assess the diagnostic value of magnetic resonance cholangiography (MRC) when evaluating biliary complications in a large series of liver transplants. Methods: One hundred and twenty‐nine patients prospectively underwent magnetic resonance (MR) imaging and MR cholangiography at 1.5‐T device after orthotopic liver transplantation (OLT). After the preliminary acquisition of axial T1‐ and T2‐weighted images, MRC involved respiratory‐triggered, thin‐slab (2 mm), heavily T2‐weighted fast spin‐echo and breath‐hold, thick‐slab (10–50 mm), single‐shot T2‐weighted sequences. MR images were blindly evaluated by two experienced readers in conference to determine the biliary anatomy and the presence of complications, whose final diagnosis was based on endoscopic retrograde cholangiography, percutaneous trans‐hepatic cholangiography, and by integrating clinical follow‐up with ultrasound and/or MR findings. Results: Biliary complications were found in 60 patients (46.5%) and were represented by ischemic‐type biliary lesions (n = 21); anastomotic strictures (n = 13); non‐anastomotic strictures (n = 5); anastomotic strictures associated to lithiasis (n = 6); lithiasis (n = 6); papillary dysfunctions (n = 9). The sensitivity, specificity, positive predictive value, and negative predictive value of the reviewers for the detection of all types of biliary complications in patients with OLT were 98%, 94%, 94%, and 98%, respectively. Conclusions: MRC is a reliable technique for detecting post‐OLT biliary complications and should be recommended before planning therapeutic interventions.     

Management of biliary tract complications after orthotopic liver transplantation

INTRODUCTION: Despite improved survival, biliary complications remain a significant cause of morbidity following orthotopic liver transplantation. The aim of this study was to review the incidence, treatment and optimum management pathway of biliary complications at the Scottish Liver Transplant Unit. MATERIALS AND METHODS: All patient data were collected prospectively onto a database at the Scottish Liver Transplant Unit with review of hospital records for validation. RESULTS: A total of 379 consecutive orthotopic liver transplants were performed in 333 adult patients between November 1992 and September 2001. Biliary complications occurred in 55 grafts (51 patients) (14.6%) and their incidence decreased with time. Biliary complications occurred in 29 (10.9%) of the 265 choledocho-choledochostomies compared with 14 (25%) of the 56 with T-tubes. Twenty-eight biliary leaks occurred, 22 of which were anastomotic. Seventeen anastomotic leaks were successfully treated non-operatively. Eight patients with biliary leaks subsequently developed an anastomotic stricture. Of the 30 anastomotic strictures, stent insertion was successful in resolving six of 14 (42%) early anastomotic strictures compared with one of 12 (8%) late anastomotic strictures (p = 0.0479). Six (38%) of the 16 early anastomotic strictures required surgery for complete resolution, compared with 12 (86%) of the 14 late anastomotic strictures (p = 0.0106). CONCLUSION: The incidence of biliary complications has decreased with time. The abandonment of choledocho-choledochostomy over a T-tube has been justified. A combination of conservative, endoscopic, and radiological management has been effective in treating biliary leaks and early anastomotic stricture. However endoscopic or radiological stenting was ineffective in the management of late anastomotic strictures, which were best treated by surgical intervention.     

Endoscopic treatment of bile duct complications after orthotopic liver transplantation

AIM: To assess the indications and results of endoscopic retrograde cholangio-pancreatography (ERCP) in patients who have undergone ortotopic liver transplantation (OLT). METHODS: We reviewed data from 42 consecutive patients who underwent ERCP for biliary complications after OLT over an 8-year period, in particular recording indications and success of the treatment after a mean of 17 months follow-up. RESULTS: Cholangiograms performed in 33/42 patients (79%) displayed anastomotic strictures in 17 patients (52%), bile duct stones in 8 (24%), both bile duct stones and an anastomotic stricture in 2 (6%), papillary stenosis in 1 (3%), and anastomotic biliary leakage in 1 (3%). In contrast, the contrastogram was normal in four patients (12%). Stone extraction was completed in 9/10 patients (90%) with a mean of 1.2 sessions, while stricture dilation was achieved in 12/19 patients (63%) after a mean of 1.7 sessions, by stent positioning (n = 7), balloon dilation (n = 4), or Soehendra dilator (n = 1). Both biliary leakage and papillary stenosis were cured by ERCP. Only one procedure-related complication -- severe pancreatitis (2.4%) -- was observed and no mortality. CONCLUSION: ERCP is a safe and effective mode of management of bile duct complications after OLT. It should be attempted before a surgical approach. Better results are obtained for treatment of biliary stones than of anastomotic strictures.     

Results of choledochjejunostomy in the treatment ofbiliary complications after liver transplantation in the era of nonsurgical therapies

Advances in radiological and endoscopic techniques have allowed many biliary complications after orthotopic liver transplantation (OLT) to be managed without surgery. The influence of nonsurgical management on the outcome of patients requiring surgical revision has not been addressed. We reviewed our 10-year experience (October 1988 to January 1998) of Roux-en-Y choledochojejunostomy (CDJ) to treat biliary complications after OLT. Forty-six patients underwent CDJ for biliary complications (32 men, 14 women; age, 22 to 65 years; median, 60 years). Biliary reconstruction at the time of OLT was duct to duct in 41 patients, primary CDJ in 3 patients, and gall bladder conduit in 2 patients. T -tubes were used only in patients with gallbladder conduit. The indication for CDJ was biliary leak (23 patients), stricture (20 patients), biliary stones (2 patients), and biliary sludge (1 patient). Two patients (4.3%) had associated hepatic artery thrombosis. The bile leaks were diagnosed at a median of 29 days post-OLT (range, 2 to 65 days) and strictures at a median of 2 years (range, 33 days to 6.5 years) post-OLT. Before surgery, 25 patients (54%) underwent an attempt at radiological or endoscopic therapeutic intervention that failed. Median follow-up was 5 years (range, 9 months to 10 years). Early complications occurred in 12 patients (26%); the most common was chest infection (4 patients). There were 3 perioperative deaths (6%); 1 death was directly related to surgery. Late complications, mainly anastomotic strictures, occurred in 10 patients (22%), half of which were successfully treated by biliary balloon dilatation. The complication rate post-CDJ was less in those who underwent a failed nonsurgical approach than those proceeding straight to surgery (9 of 25 patients; 36% v 13 of 21 patients; 62%; P = .21, not significant). The procedure-related mortality for surgical revision of biliary complications after OLT is low, but early and late complications are common. A failed attempt at nonsurgical management does not increase the complications of reconstructive surgery. Strictures after CDJ should be considered for biliary balloon dilatation.     

Biliary reconstruction and complications of left lobe living donor liver transplantation

Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living donor liver transplantation. The aim of this study was to analyze the clinical implications of three methods of biliary reconstruction in left lobe adult living donor liver transplantation. We retrospectively compared three groups of patients who underwent various biliary reconstructions: those who had Roux-en-Y hepaticojejunostomy (HJ) (n = 11); duct to duct hepaticohepaticostomy (HH) with an external stent (n = 11); or HH with T-tube (n = 6). The median follow-up for each group was 29, 28, and 8 months, respectively. Bile leaks were observed in 45.5% of both the HJ and the HH with external stent groups. Biliary anastomotic strictures occurred in 9.1% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with an external stent. No biliary complications were observed in the HH over a T-tube group (P = .049). Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up, these encouraging preliminary results warrant further studies of this biliary reconstruction technique for left lobe adult living donor liver transplantations.     

Biliary complications following adult right lobe ex vivo split liver transplantation.

Biliary complications are common following split liver transplantation (SLT). We analyzed the incidence, treatment, and outcome of biliary complications following adult right lobe ex vivo SLT performed between November 1992 and January 2005. There were 72 patients, of which 70 were analyzed. Early postoperative deaths resulted in 2 being excluded from the analysis. There were 44 males (median age, 48 yr; range, 19-70 yr). Biliary reconstruction was by duct-to-duct (DD) anastomosis in 52 (74%) and Roux-en-Y hepaticojejunostomy (RYHJ) in 18 (26%) patients. Until mid-2001, no T-tube was used for DD anastomosis (DD/non-T-tube) in 26 (37%) patients; subsequent to this, DD over a T-tube (DD/T-tube) was performed in 26 (37%) patients. Eighteen (26%) biliary complications occurred in 16 patients. Two anastomotic leaks of RYHJ were associated with hepatic artery thrombosis. The most frequent biliary complication was parenchymal radical leak from the transected liver surface (11%; 8/70), with anastomotic leaks in 6% (4/70) and strictures in 4% (3/70). There were also 2 cases of biliary leaks from T-tube exit site following T-tube removal, and 1 leak from the donor cystic duct stump. DD anastomosis without a T-tube was associated with a higher rate of cut surface and anastomotic biliary leaks (7/26), compared to the DD/T-tube group (1/26; P = 0.05). Six patients (9%) died following biliary complications, including 3 due to cut surface leaks in the DD/non-T-tube group and 2 cases with fatal biliary peritonitis following T-tube removal. A patient in the RYHJ group died due to biliary sepsis associated with hepatic artery thrombosis. In conclusion, biliary complications following right lobe ex vivo SLT are associated with significant morbidity and mortality. Our results suggest that T-tube biliary drainage of DD anastomosis may reduce parenchymal cut surface and biliary anastomotic leaks. However, bile leak following T-tube removal could lead to potentially fatal biliary peritonitis, which should always be anticipated and treated promptly.     

Biliary complications after deceased-donor orthotopic liver transplantation

A wide range of potential biliary complications can occur after orthotopic liver transplantation (OLT). The most common biliary complications are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dyfunction, which may occur in up to 20%-40% of OLT recipients. Leaks predominate in the early posttransplant period; stricture formation typically develops gradually over time. However, with the advent of new techniques, such as split-liver, reduced-size, and living-donor liver transplantation, the spectrum of biliary complications has changed. Risk factors for biliary complications comprise technical failure; T-tube or stent-related complications; hepatic artery thrombosis; bleeding; ischemia/reperfusion injury; and other immunological, nonimmunological, and infectious complications. Noninvasive diagnostic methods have been established and treatment modalities have been modified towards a primarily nonoperative, endoscopy-based strategy. Besides, the management of biliary complications after OLT requires a multidisciplinary approach, in which interventional and endoscopic treatment options have to be weighed up against surgical treatment options. The etiology and spectrum of bile duct complications, their diagnosis, and their treatment will be reviewed in this article.     

Ischemic cholangiopathy after liver transplantation from controlled non-heart-beating donors-a single-center experience

BACKGROUND: Previous reports have shown that livers from controlled non-heart-beating-donors (NHBD) are associated with higher rates of primary failure and ischemic cholangiopathy of orthotopic liver transplantation (OLT) as a complication of the prolonged warm ischemia. METHODS: This retrospective review of activities from 1999 to 2006 examined donor characteristics of age, liver function tests, warm ischemic time before (1WITa) and after cardiac arrest (1WITb), cold ischemic time (CIT) and transplant results. RESULTS: Eleven NHBD retrieved livers were transplanted from "ideal" donors except for one elderly donor (73 years). Of the 11 recipients, 3 developed biliary cholangiopathy (27%). There were no episodes of primary graft nonfunction, but one recipient displayed primary graft dysfunction. Two recipients died: one due to biliary complications with sepsis (long CIT >10 hours, fatty liver), and the other due to aspiration pneumonia and hypoxic brain damage with normal liver function. One recipient required retransplantation owing to ischemic cholangiopathy (1WITb 45 min) at 6 months after OLT with a good result. The other eight recipients are alive (observation period 72 to 14 months) including six with normal liver function, one with biopsy-proven biliary ischemia and one with recurrent primary sclerosing cholangitis without biliary ischemic changes on biopsy. Among 164 heart-beating donors recipients transplanted in the same period, biliary complications occurred in 27 patients (16%), of whom 12 were leaks and 15 anastomotic strictures. CONCLUSION: NHBD were a good source for livers with reasonable early results. To avoid late complications especially ischemic cholangiopathy, caution is urged with the use of these organs as well as strict donor and ischemic time criteria.     

肝移植术后并发症的防治(附39例报告)

目的探讨同种原位肝移植术后并发症发生的常见原因与预防及处理措施。方法回顾性分析39例原位肝移植病人的临床资料。结果术后并发症发生20例次:腹腔内出血8例,肝动脉狭窄1例,胆瘘2例,急性排斥反应1例,肺部感染2例,顽固性胸腔积液2例,术后肾功能不全3例,GVHD1例。结论围手术期纠正凝血功能、预防肾功能不全,控制感染及营养支持能减少术后并发症的发生,手术技术的完善是预防肝移植后血管、胆道并发症的关键。     

Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation

Background

Biliary complications, a major source of morbidity after orthotopic liver transplantation (OLT), are increasingly being treated by endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has been shown to be superior to percutaneous therapy and surgery. Covered self-expandable metal stents (CSEMSs) may be an alternative to the current endoscopic standard treatment with periodic plastic stent replacement.

Objective

To assess the safety and efficacy of temporary CSEMS insertion for biliary complications after OLT.

Methods

From November 2001 to December 2009, the 242 OLT performed in 226 patients included 67 cases that developed post-OLT leaks or strictures (29.6%), excluding ischemic biliary complications. CSEMSs were used in 22 patients (33%), 18 male and 4 female, with an overall median age of 55 years (range, 29-69). In-house OLT patients underwent an index ERCP at 26 days (range, 8-784) after OLT. Their records were reviewed to determine ERCP findings, technical success, and clinical outcomes.

Results

ERCP with sphincterotomy was performed in all 22 patients, revealing 18 with biliary strictures alone (82%), 3 with strictures and leaks (14%), and 1 with strictures and choledocholithiasis (4%). All strictures were anastomotic. All patients had 1-2 plastic stents inserted across the anastomosis (11 had prior balloon dilation); stones were successfully removed, for an initial technical success rate of 100% (22/22). CSEMSs, were placed at the second ERCP in 14 patients, at the third in 7, and at the fourth in 1. With a median follow-up of 12.5 months (range, 3-25) after CSEMS removal, 21/22 patients (95.5%) remain stricture free and one relapsed, requiring repeat CSEMS insertion. Four patients experienced pain after CSEMS insertion. At CSEMS removal, migration was noted in 5 cases, into either the distal duodenum (n = 4) or the proximal biliary tree (n = 1), and embedding was seen in 1 case. There were no serious complications; no patients needed hepatojejunostomy.

Conclusions

ERCP is a safe first-line approach for post-OLT biliary complications. It was highly successful in a population with anastomotic leaks and strictures. The therapeutic role of ERCP to manage biliary complications after OLT in the long term is not well known. In our experience, the high rate (close to 95%) of efficacy and its relative safety allowed us to use CSEMS to manage refractory biliary post-OLT strictures. CSEMS insertion may preclude most post-OLT hepatojejunostomies.     

Reduction of Biliary Complication Rate Using Continuous Suture and No Biliary Drainage for Duct-to-Duct Anastomosis in Whole-Organ Liver Transplantation

Biliary complications (BC) following orthotopic liver transplantation (OLT) are related to various factors including surgical technique and use of biliary drains for a duct-to-duct (DD) anastomosis. Herein we have reported the influence of changes in surgical technique on BC following OLT in our center. From February 2002 to February 2007, we performed 101 whole-organ OLT with a DD anastomosis in 99 adults, of whom we analyzed 84 subjects. We excluded recipients who died within 30 days of OLT without any evidence of BC and 1 patient with a biliary stricture secondary to a hepatic artery thrombosis. Until late 2004, a DD anastomosis with interrupted sutures over an external biliary drain (DD/BD) was performed in 35 patients (Group I). Subsequently, no biliary drain was used for the DD anastomosis (DD/non-BD), using a continuous suture in 49 patients (Group II). The DD anastomosis with interrupted sutures over a biliary drain was associated with a higher incidence of both total (31% vs 8%; P = .008) and late BC (>30 days; 20% vs 2%; P = .008) with a trend toward more leaks (17% vs 4%; P = .06). All biliary leaks in patients with DD/BD reconstruction occurred at the exit site of the biliary drain following its removal. No significant differences were observed when we compared the incidence of biliary strictures and the necessity for surgical intervention. One patient died due to a BC. Our results indicated that a DD anastomosis performed with a continuous suture technique and no external biliary drainage reduced the incidence of BC after whole-organ OLT.     

Surgical complications after intestinal transplantation in infants and children—UK experience

Surgical complications have a significant impact on morbidity and mortality following intestinal transplantation (ITx). Birmingham Children's Hospital commenced intestinal transplantation in 1993 and the following surgical strategies evolved: (a) pretransplant abdominal tissue expanders, 1998; (b) combined en-bloc reduced liver and intestinal transplantation (CRLITx), 1998; (c) staged abdominal closure, 2001; (d) preservation of graft duodenal artery, 2005.

Aim

An internal audit was performed to document the surgical complications after ITx and to evaluate strategies in the management and prevention of complications.

Methods

A retrospective analysis of the medical records from January 1993 to June 2007 was conducted to identify surgical complications, evaluate management strategies, and report outcome following ITx.

Results

Forty-six children underwent 49 ITx (9 isolated intestinal, 39 combined liver and intestinal [CLITx], and 1 multivisceral transplant). Twenty three children had CRLITx since 1998, although there were none before 1997. The median donor: recipient weight ratio in CLITx was 2.2:1 (range, 0.67:1-6.70:1). Twenty-six children experienced 29 (59%) surgical complications: portacaval shunt thrombosis (n = 2, none alive); graft duodenal stump leakage (n = 3, 2 alive); spontaneous bowel perforation(n = 6, 2 alive); sub-acute bowel obstruction (n = 6, all alive); abdominal compartment syndrome ([ACS], n = 4, 2 alive); pancreatic leak (n = 3, 2 alive); biliary complications (n = 22, 17 alive ) failed staged abdominal closure with wound sepsis requiring skin grafting into the bowel (n = 1, alive), wound dehiscence (n = 1, alive), anastomotic leak (n = 1, alive) and intra-abdominal bleeding (n = 1,alive), primary nonfunction (n = 1, 1 died). Following the complications of ACS in children with primary abdominal closure and graft duodenal stump leaks in 2004, we modified our strategies in 2005 to include staged abdominal closure with recipient to donor weight mismatch, and preservation of the gastroduodenal artery during donor organ procurement in addition to pre transplant abdominal tissue expansion. Fifteen children with recipient and donor weight mismatch subsequently required staged closure of the abdomen and none of them developed ACS. Twelve children had gastroduodenal artery preserved and none developed graft duodenal stump leaks. Twenty-four of the 46 (52%) are alive 6 months to 10 years post transplant.

Conclusion

Evolving strategies may avoid or reduce surgical complications commonly seen after intestinal transplantation and thus contribute to an improved outcome.     

Biliary Complications in Orthotopic Liver Transplantation Using Choledochocholedochostomy with a T-tube

Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube.Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT.     

劈离式肝移植术后胆管并发症

目的 探讨体外劈离式肝移植术后胆管并发症的危险因素及其防治措施.方法 2006年6月至2010年9月,我院共施行劈离式肝移植术33例,其中1例于术后10 d死亡,予以排除.其余32例患者中男性18例,女性14例,平均年龄33.4岁(6个月～65岁).胆管重建方式胆管端端吻合20例,胆肠吻合12例.胆管并发症的诊断依靠T管造影、经皮经肝胆管造影(PTC)、经内镜逆行胆胰管造影、磁共振胰胆管造影(MRCP)等方法.胆管并发症定义为存在需要外科、介入、内镜等方法治疗的胆漏或胆管狭窄.结果 受者中位随访时间13.5个月(3～54个月).32例患者中11例患者发生12次胆管并发症(37.5％),其中肝断面胆漏3例(9.3％),胆管吻合口漏4例(12.5％),左肝管残端漏1例(3.1％),胆管吻合口狭窄1例(3.1％),缺血性胆管狭窄3例(9.3％).8例发生胆漏的受者中6例经手术或穿刺放置引流后痊愈,2例因腹腔内感染死亡.单因素分析表明,移植物类型、胆管重建方式等均不是肝断面胆漏的危险因素.结论 与全肝移植和活体肝移植相比,劈离式肝移植术后胆管并发症尤其是胆漏更为常见.进一步防治胆管并发症是改善劈离式肝移植预后的重要因素.     

The incidence and management of biliary complications following liver transplantation in children

Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988–1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) — one intrahepatic and one anastomotic stricture — developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.     

Surgical treatment of biliary tract complications after liver transplantation

Objective

Biliary strictures are the most common biliary tract complication after liver transplantation. There are scarce data on the results of hepaticojejunostomy (HJ) in the management of biliary complications after orthotopic liver transplantation (OLT). Thus, the role of surgery in this setting remains to be established. The aim of this study was to evaluate the results of surgical treatment of patients with biliary complications at our institution.

Patients and Methods

We reviewed 1000 consecutive liver transplantations performed at our institution from 1984 to 2007. We used a prospectively recorded database to identify patients who underwent HJ to treat any biliary tract complication.

Results

Overall, 62 patients (6.2%) underwent HJ, 40 for an anastomotic and 7 for a non-anastomotic stricture as well as 15 for biliary leaks. Postoperative morbidity was 16%, and postoperative mortality 1.6%. There were 7 cases of anastomotic stenosis (11.3%). Four patients (5%) required retransplantation.

Conclusions

HJ is a safe procedure to manage biliary complications after OLT. It may be the first treatment choice especially for cases with anastomotic strictures.     

肝移植术后胆道并发症的诊断与治疗

目的 探讨肝移植术后胆道并发症的诊断与治疗.方法 分析2007-2009年肝移植术后不同类型胆道并发症的患者的临床资料,评价胴道并发症的类型,处理方式及术后恢复情况.结果 肝移植术后胆道并发症患者23例,包括胆漏患者12例,计胆管吻合口漏7例,肝断面胆管漏3例,胆囊管漏1例,迷走胆管漏1例;移植术后胆管狭窄患者11例,其中吻合口狭窄4例,非吻合口性狭窄7例.7例吻合口漏患者中,胆管重建2例(Roux-en-Y吻合和胆肠襻式Warren吻合);胆道吻合口修补1例;单纯依靠外引流管引流1例,活体双供肝肝移植的患者剖腹探查纠正胆漏失败后行再次肝移植1例;行经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)植入支架2例.肝断面胆管漏3例中,行肝断面胆管缝扎1例,ERCP联合B超引导下穿刺引流2例,引流2个月后胆漏闭合,拔除引流管,但是随后又出现胆道狭窄,ERCP术后,病情好转.胆囊管漏1例,行胆囊管缝扎.迷走胆管漏1例,行胆囊床缝扎.吻合口狭窄的患者4例,3例经ERCP治愈,1例行胆肠吻合重建胆道后治愈.非吻合口性狭窄的7例,行ERCP治疗3例,ERCP失败后,行经皮肝穿刺胆管引流(percutaneous transhepatic cholangiographic drainage,PTCD)1例;再次肝移植3例,2例患者术后恢复良好,1例死于严重感染.结论 肝移植术后胆道并发症危害大,关键在于预防.