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