Elsevier

Transplantation Proceedings

Volume 44, Issue 6, July–August 2012, Pages 1545-1549
Transplantation Proceedings

Liver transplant complications
Biliary
Biliary Complications after Orthotopic Liver Transplantation: A Review of Incidence and Risk Factors

https://doi.org/10.1016/j.transproceed.2012.05.008Get rights and content

Abstract

Biliary complications (BCs) are a common source of morbidity after liver transplantation, leading to long-term and repeated therapies. The incidence of BCs currently ranges from 5% and 25%. Biliary strictures and leaks are the most common complications after deceased donor liver transplantation (DDLT), occurring in 9%–12% and 5%–10% of cases, respectively. Hepatic artery complications are recognized as the major risk factor for BCs; however, other circumstances such as advanced donor age, prolonged cold and warm ischemia times, grafts from donors after cardiac death, occurrence of a previous bile leak, T-tube use, cytomegalovirus infection, or graft steatosis have also been reported to be potential risk factors. Use of various preservation solutions has not significantly improved the biliary complication rate after DDLT. Technical modifications in biliary reconstruction have been proposed to improve outcomes after DDLT; the use of a T-tube for biliary reconstruction continues to be controversial. Non anastomotic strictures (NAS) are recognized to be different from anastomotic strictures. Although they have been associated with ischemic or immunological mechanisms, bile salt toxicity has recently been recognized as a potential factor for NAS. Donation after cardiac death is a significant source of organs that has been associated with decreased graft survival due to the increased BCs.

Section snippets

Incidence and Types

BC rates of up to 50% were reported in early publications.6 After advances in OLT, BC incidence is currently reported to range from 5% to 25%.2 The University of Pittsburgh reported an evolution of BC rate from 19% in 1983 to 11.5% in 1994.7 In the same article, 66% of BCs occurred in the first 3 months, but some of them, mainly strictures, occurred up to several years after transplantation.

Biliary strictures and anastomotic leaks (ALs) are the most common complications. Other complications

Risk Factors

Hepatic artery complications, both thrombosis and stenosis, have been recognized as major risk factors for anastomotic and nonanastomotic BCs.10 However, most patients with BCs have no arterial complications. A variety of factors have been reported to be related to recipients, grafts, surgical procedures, and postoperative courses.

Sundaram et al8 recently analyzed the risk factors for BCs among 1798 adult DDLTs from 1997 to 2008. Multivariate logistic regression analysis showed the factors

Technical Issues

EE-CC and hepaticojejunostomy (HJ) with a Roux-en-Y loop are the 2 most common biliary reconstruction techniques. EE-CC reconstruction is the procedure of choice in 80–90% of adult DDLTs.1, 18 Bilioenterostomy is the method of choice for patients with a gross discrepancy in bile duct size, diseased ducts, or biliary complications requiring surgical repair. Various technical issues, such as an inadequate surgical technique, small duct size, inappropriate suture material, and tension at the

T-Tube and Not T-Tube

Biliary reconstruction over a T-tube used to be the gold standard technique in most transplant centers. However, various reports have addressed the problem of the high incidence of complications directly related to T-tubes. O'Connor et al5 reported, 45% of biliary complications to be related to the T-tube, with a 17% complication rate after elective removal. Saab et al24 reported a similar complication rate after elective removal (16%). Moreover, some prospective, randomized studies25, 26, 27

Non Anastomotic Strictures

The reported incidence of NAS after DDLT ranges from 1% to 20%.34 The mechanism of injury in NAS remains unclear, but it is believed to be ischemic in nature because they seem to be identical to strictures seen after hepatic artery thrombosis. They are therefore also called ITBL or ischemic cholangiopathy. Damage to the vascular endothelium leading to an impaired blood supply and ischemic injury seems to be the origin of this cholangiopathy.35 HAT is a well-documented cause of NAS.36 However,

DCD

DCD is a growing source of liver grafts in the current era of an organ shortage. DCDs are divided into controlled (Maastricht categories III and IV) and uncontrolled grafts (categories I and II).43 Experience with controlled DCD organs has grown in the last decade with encouraging results. However, some centres have reported decreased graft survival rates, mostly related to a higher incidence of vascular complications and NAS.44, 45, 46 According to the experience from the University of

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