Biliary Tract Complications After Liver Transplantation

Biliary Tract Complications After Liver Transplantation in a Single Center H. Salahi, A. Razmkon, A.R. Mehdizadeh, M. Saberi-Firoozi, A. Bahador, K. Bagheri-Lankarani, M.H. Imanieh, and S.-A. Malek-Hosseini ABSTRACT Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to determine the incidence of biliary complications and analyze methods of treatment. From 1993 to 2004, 14 cases (10%) among 140 patients who had undergone liver transplantation developed biliary complications, third to respiratory and neurologic complications. In addition to biliary leakage in six cases, obstruction/stenosis occurred in three cases. One case of biliary fistula and one vanishing bile duct syndrome were observed. There was no death or need for retransplantation; all cases were treated surgically without recurrence. Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory and safe in selected cases.

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IVER TRANSPLANTATION has become the treatment of choice for many types of chronic liver disease. Biliary complications are a significant cause of morbidity (10% to 35%) and mortality (2% to 7%) following liver transplantation.1– 6 The aim of this study was to analyze the incidence of biliary complications after liver transplantation in our center.

PATIENTS AND METHODS The first 140 consecutive liver transplantations performed between April 1993 and November 2004 were evaluated retrospectively using patient files in addition to the Persian Network for Organ Transplant (PNOT). The most common causes of liver failure were cryptogenic (21%) and viral (18.6%). One hundred twenty-eight patients (91.4%) received a full-size and the others, a partial (8 cases) or split (4 cases) cadaveric transplant. All cases were first transplants. All operations were performed by the same team. The operative procedure used a duct-to-duct anastomosis in 78% of cases and Roux-en-Y choledochojejunostomy in the remaining cases. A tube was only used in the initial 35 cases. Venovenous bypass was employed in the initial six cases; A piggyback technique, in the remaining (96%). The immunosuppressive regimen included mycophenolate mofetil. (azathioprine for the first 10 cases), cyclosporine and methylprednisolone. Intravenous cyclosporine was used for induction in the first 39 cases and the enteral preparation in the remaining cases. Uniform regular indefinite follow-up was performed for all patients.

RESULTS

Fourteen patients (10.0%) developed biliary complications, third to respiratory and neurologic problems. Postoperative biliary leakage, which developed in nine cases (6.9%), was the most common complication with obstruction/stenosis in three cases. One case of biliary fistula and one vanishing bile duct syndrome also occurred. In seven cases of leakage (out of nine) and all cases of obstruction and fistula a simple duct-to-duct anastomosis had been used. There was no mortality directly due to biliary complication; however, the case with vanishing bile duct syndrome died 1 year later due to graft-versus-host disease. All cases of biliary leakage were treated surgically. Obstruction was also managed surgically by Roux-en-Y choledochojejunostomy in all cases. The fistula was managed by successful hepaticojejunostomy. No recurrence or need for retransplantation was seen. DISCUSSION

The incidence of biliary complications in our series of patients (10.0%) was less than that in many other reports (10% to 30%).2– 6 Strictures and leakage represent the majority of biliary complications after liver transplantaFrom the Southern Organ Transplant Center, Shiraz, Iran. Address reprint requests to Heshmatollah Salahi, P.O. Box 71455-166 Shiraz, Iran. E-mail: [email protected]

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0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.07.006

Transplantation Proceedings, 37, 3177–3178 (2005)

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tion7–9; the same event occurred in our patients. Due to the small number of cases with biliary complications, we cannot evaluate the role of any risk factors, including the biliary reconstruction technique. Endoscopic therapeutic interventions for treatment of biliary complications are less invasive than surgery. However, because of the absence of experienced, well-trained interventional radiologists in this center, we used surgical intervention as the initial therapy for all biliary complications. Surgery caused no morbidity or mortality in all of the cases. We recommend choledochojejunostomy for cases of obstruction in the absence of experienced interventional radiologists. REFERENCES 1. Catalano MF, Van Dam J, Sivak MV Jr: Endoscopic retrograde cholangiopancreatography in the orthotopic liver transplant patient. Endoscopy 27:584, 1995 2. Stratta RJ, Wood RP, Langnas AN, et al: Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation. Surgery 106:675, 1989

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