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Incidence and Management of Biliary Complications After Orthotopic Liver Transplantation: Ten Years’ Experience at King Fahad National Guard Hospital
Incidence and Management of Biliary Complications After Orthotopic Liver Transplantation: Ten Years’ Experience at King Fahad National Guard Hospital K. Abdullah, H. Abdeldayem, W.O. Hali, B. Hemsi, I. Sarrag, and A. Abdulkareem
ABSTRACT Background. Despite technical modifications and application of various surgical techniques, biliary tract complications remain a major source of morbidity after orthotopic liver transplantation. We sought to assess the incidence and management of biliary complications at a single liver transplant unit. Methods. Among 184 consecutive deceased donor liver transplants performed between February 1994 and July 2004, 66 were female patients and 118 male patients of age range 21⁄2 to 69 years. We retrospectively reviewed the data regarding biliary complications in liver transplant recipients, after 115 duct-to-duct anastomoses and 65 hepaticojejunostomy. We analyzed the incidence and type of biliary complications, management sequence, and success rate. We analyzed the correlation between the modality of biliary reconstruction and the type/incidence of biliary complications. Results. Thirty-two patients developed biliary complications, giving an overall incidence of 17.4%. There was a higher incidence of complications among patients in the hepaticojejunostomy group (21.5%) than the duct-to-duct technique (15.1%). Bile leakage occurred in 12 patients, including eight successful cases (66.6%) of endoscopic stent insertion/radiological techniques and surgery in four cases (33.3%). Among the 12 patients with initial leaks, six developed a subsequent stricture (50%). There were 26 cases of biliary stricture, including 22 (84.6%) who were initially managed using nonsurgical techniques with a success rate of 59%. Conclusion. Biliary complications remain an important cause of morbidity after orthotopic liver transplantation. They can usually be managed percutaneously or endoscopically; however, tight strictures and major leaks frequently required surgical intervention.
V
ARIOUS REFINEMENTS in surgical technique, organ preservation, and immunosuppressive management have reduced the incidence of complications after liver transplantation. Biliary tract complications, however, remain a significant cause of morbidity.1 Anastomotic strictures, anastomotic leaks, stent site leaks, intrahepatic strictures, biliary lithiasis, and cholangitis account for the majority of biliary tract complications.2 In addition to surgical technique, other factors—such as organ preservation technique, ischemia time, rejection, hepatic artery thrombosis, disease recurrence, and ABO incompatibility— have been demonstrated to influence the incidence of biliary tract complications.3
PATIENTS AND METHODS A retrospective analysis of 184 consecutive deceased donor liver transplants between February 1994 and July 2004 included data on patient sex, age, etiology, and indication for transplantation as well as the method of biliary reconstruction, type of biliary tract
From the Department of Hepatobiliary Science and Liver Transplantation, King Abdul Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. Address reprint requests to Dr K. Abdullah, Consultant Hepatobiliary Science and Liver Transplantation King Fahad National Guard Hospital, Mail Code 1311, PO Box 22490, Riyadh 11426, Saudi Arabia. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.08.005
Transplantation Proceedings, 37, 3179 –3181 (2005)
3179
3180 complication, management sequence, and success rate. Sixty-six cases were female patients and 118 cases male patients of age range of 21⁄2 to 69 years. While 115 had duct-to-duct anastomoses, 65 cases underwent hepaticojejunostomy. We analyzed the correlation between the modality of biliary reconstruction and the type/ incidence of biliary complications. Biliary complications were classified a biliary leakage or biliary stricture. The treatment of biliary complications depended on the patient’s clinical condition, liver function tests, ultrasonography, and cholangiography. In general, patients who were clinically well with stable graft function as indicated by standard liver function tests and in whom radiological imaging suggested mild leaks were treated conservatively. Patients with extensive leaks or strictures with proximal biliary radical dilatation and progressive obstructivetype liver function tests were treated surgically or endoscopically. Patients who underwent laparotomy had conversion to or refashioning of a Roux-en-Y biliary anastomosis. Nonsurgical management consisted of either endoscopic or percutaneous balloon dilatation and/or stenting.
RESULTS Incidence of Biliary Complications
Thirty-two of 184 patients who had undergone orthotopic liver transplantation developed biliary complications: an overall incidence of 17.4%. Correlation With the Modality of Biliary Reconstruction
There was a higher incidence of complications among patients in the hepaticojejunostomy (14 of 65, or 21.5%) compared with the duct-to-duct anastomosis group (18 of 119, or 15.1%). Types of Biliary Complications
Bile leakage occurred in 12 patients (6.5%). Of these, 6 (50%) developed a subsequent stricture. Biliary strictures occurred in 26 patients (14.1%): anastomotic in 22 and multiple intrahepatic in four patients. Associated stones were present in two patients.
ABDULLAH, ABDELDAYEM, HALI ET AL
DISCUSSION
Biliary complications are common among patients who have undergone orthotopic liver transplantation. Their incidence ranges from 9% to 34% in different centers.2 In our series, the incidence of biliary complications was 17.4%. The two main complications associated with the biliary reconstruction were biliary stricture and leakage. Ischemia is generally believed to play an important role in the development of some biliary strictures.4 Treatment of bile leaks varies between centers: some physicians use operative management almost exclusively5 while others attempt percutaneous or endoscopic methods first.6 In our current study, the success rate of nonoperative methods for bile leaks was 66.6%. Several studies have shown that endoscopic retrograde access and percutaneous access not only are useful and reliable methods to diagnose biliary strictures in these patients, but also may be safely and successfully applied for dilatation and stenting.7 Uncomplicated anastomotic strictures usually respond to either percutaneous or endoscopic dilatation.5 Nonoperative management of biliary strictures is becoming more prevalent.6 We had a 59% success rate. Nonoperative approaches to biliary strictures afford the ability to treat multiple lesions anywhere in the biliary tree.7 Kuo and coworkers8 reported an 83% success rate with balloon dilation of selected strictures, but only a 45% 1-year patency. Zajko and colleagues9 successfully treated 64 of 72 strictures using a percutaneous transhepatic approach, with a 6-month patency rate of 81%. For surgical repair of stenoses, the hilar plate is often severely adherent to the hepatic artery and/or portal vein; it is therefore difficult to isolate the bile duct safely.7 In most centers,10 as well as in our series, the duct-to-duct anastomosis was converted directly to the hepaticojejunostomy. In conclusion, biliary complications which remain an important cause of morbidity after orthotopic liver transplantation, can usually be managed percutaneously or endoscopically; however, tight strictures and major leaks frequently require surgical intervention.
Management of Biliary Complications
Definitive treatment of leaks and/or strictures was accomplished with an endoscopic and/or a percutaneous technique in 15 patients (46.9%), while surgery was required in 17 patients (53.1%). Of the 12 patients who developed biliary leaks, endoscopic treatment in the form of papillotomy with or without stenting was successful in 8 (66.6%); surgery was required in 4 (33.3%). Of the 26 patients who developed biliary strictures, 22 (84.6%) were initially managed using nonsurgical techniques in the form of endoscopic (n ⫽ 10) or percutaneous (n ⫽ 12) balloon dilatation and/or stenting, yielding a success rate of 59% (n ⫽ 13). Thirteen patients required surgery in the form of conversion to a Roux-en-Y hepaticojejunostomy (n ⫽ 9) or takedown of the bilioenteric anastomosis with reconstruction of a wider anastomosis (n ⫽ 4).
REFERENCES 1. Scatton O, Meunier B, Cherqui D, et al: Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 233:432, 2001 2. Icoz G, Kilic M, Zeytunlu M, et al: Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations. Liver Transpl 9:575, 2003 3. Park JS, Kim MH, Lee SK, et al: Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation. Gastrointest Endosc 57:78, 2003 4. Sawyer RG, Punch JD: Incidence and management of biliary complications after 291 liver transplants following the introduction of transcystic stenting. Transplantation 66:1201, 1998 5. Mahajani RV, Cotler SJ, Uzer MF: Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 32:943, 2000
BILIARY COMPLICATIONS POSTTRANSPLANTATION 6. Johnson MW, Thompson P, Meehan A, et al: Internal biliary stenting in orthotopic liver transplantation. Liver Transpl 6:356, 2000 7. Mosca S, Militerno G, Guardascione MA, et al: Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol 15:654, 2000 8. Kuo PC, Lewis WD, Stokes K, et al: A comparison of operation, endoscopic retrograde cholangiopancreatography,
3181 and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation. J Am Coll Surg 179:177, 1994 9. Zajko AB, Sheng R, Zetti GM, et al: Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience. J Vasc Intervent Radiol 6:79, 1995 10. Schwartz DA, Petersen BT, Merucha JJ, et al: Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 51:169, 2000
ABSTRACT Background. Despite technical modifications and application of various surgical techniques, biliary tract complications remain a major source of morbidity after orthotopic liver transplantation. We sought to assess the incidence and management of biliary complications at a single liver transplant unit. Methods. Among 184 consecutive deceased donor liver transplants performed between February 1994 and July 2004, 66 were female patients and 118 male patients of age range 21⁄2 to 69 years. We retrospectively reviewed the data regarding biliary complications in liver transplant recipients, after 115 duct-to-duct anastomoses and 65 hepaticojejunostomy. We analyzed the incidence and type of biliary complications, management sequence, and success rate. We analyzed the correlation between the modality of biliary reconstruction and the type/incidence of biliary complications. Results. Thirty-two patients developed biliary complications, giving an overall incidence of 17.4%. There was a higher incidence of complications among patients in the hepaticojejunostomy group (21.5%) than the duct-to-duct technique (15.1%). Bile leakage occurred in 12 patients, including eight successful cases (66.6%) of endoscopic stent insertion/radiological techniques and surgery in four cases (33.3%). Among the 12 patients with initial leaks, six developed a subsequent stricture (50%). There were 26 cases of biliary stricture, including 22 (84.6%) who were initially managed using nonsurgical techniques with a success rate of 59%. Conclusion. Biliary complications remain an important cause of morbidity after orthotopic liver transplantation. They can usually be managed percutaneously or endoscopically; however, tight strictures and major leaks frequently required surgical intervention.
V
ARIOUS REFINEMENTS in surgical technique, organ preservation, and immunosuppressive management have reduced the incidence of complications after liver transplantation. Biliary tract complications, however, remain a significant cause of morbidity.1 Anastomotic strictures, anastomotic leaks, stent site leaks, intrahepatic strictures, biliary lithiasis, and cholangitis account for the majority of biliary tract complications.2 In addition to surgical technique, other factors—such as organ preservation technique, ischemia time, rejection, hepatic artery thrombosis, disease recurrence, and ABO incompatibility— have been demonstrated to influence the incidence of biliary tract complications.3
PATIENTS AND METHODS A retrospective analysis of 184 consecutive deceased donor liver transplants between February 1994 and July 2004 included data on patient sex, age, etiology, and indication for transplantation as well as the method of biliary reconstruction, type of biliary tract
From the Department of Hepatobiliary Science and Liver Transplantation, King Abdul Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. Address reprint requests to Dr K. Abdullah, Consultant Hepatobiliary Science and Liver Transplantation King Fahad National Guard Hospital, Mail Code 1311, PO Box 22490, Riyadh 11426, Saudi Arabia. E-mail: [email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.08.005
Transplantation Proceedings, 37, 3179 –3181 (2005)
3179
3180 complication, management sequence, and success rate. Sixty-six cases were female patients and 118 cases male patients of age range of 21⁄2 to 69 years. While 115 had duct-to-duct anastomoses, 65 cases underwent hepaticojejunostomy. We analyzed the correlation between the modality of biliary reconstruction and the type/ incidence of biliary complications. Biliary complications were classified a biliary leakage or biliary stricture. The treatment of biliary complications depended on the patient’s clinical condition, liver function tests, ultrasonography, and cholangiography. In general, patients who were clinically well with stable graft function as indicated by standard liver function tests and in whom radiological imaging suggested mild leaks were treated conservatively. Patients with extensive leaks or strictures with proximal biliary radical dilatation and progressive obstructivetype liver function tests were treated surgically or endoscopically. Patients who underwent laparotomy had conversion to or refashioning of a Roux-en-Y biliary anastomosis. Nonsurgical management consisted of either endoscopic or percutaneous balloon dilatation and/or stenting.
RESULTS Incidence of Biliary Complications
Thirty-two of 184 patients who had undergone orthotopic liver transplantation developed biliary complications: an overall incidence of 17.4%. Correlation With the Modality of Biliary Reconstruction
There was a higher incidence of complications among patients in the hepaticojejunostomy (14 of 65, or 21.5%) compared with the duct-to-duct anastomosis group (18 of 119, or 15.1%). Types of Biliary Complications
Bile leakage occurred in 12 patients (6.5%). Of these, 6 (50%) developed a subsequent stricture. Biliary strictures occurred in 26 patients (14.1%): anastomotic in 22 and multiple intrahepatic in four patients. Associated stones were present in two patients.
ABDULLAH, ABDELDAYEM, HALI ET AL
DISCUSSION
Biliary complications are common among patients who have undergone orthotopic liver transplantation. Their incidence ranges from 9% to 34% in different centers.2 In our series, the incidence of biliary complications was 17.4%. The two main complications associated with the biliary reconstruction were biliary stricture and leakage. Ischemia is generally believed to play an important role in the development of some biliary strictures.4 Treatment of bile leaks varies between centers: some physicians use operative management almost exclusively5 while others attempt percutaneous or endoscopic methods first.6 In our current study, the success rate of nonoperative methods for bile leaks was 66.6%. Several studies have shown that endoscopic retrograde access and percutaneous access not only are useful and reliable methods to diagnose biliary strictures in these patients, but also may be safely and successfully applied for dilatation and stenting.7 Uncomplicated anastomotic strictures usually respond to either percutaneous or endoscopic dilatation.5 Nonoperative management of biliary strictures is becoming more prevalent.6 We had a 59% success rate. Nonoperative approaches to biliary strictures afford the ability to treat multiple lesions anywhere in the biliary tree.7 Kuo and coworkers8 reported an 83% success rate with balloon dilation of selected strictures, but only a 45% 1-year patency. Zajko and colleagues9 successfully treated 64 of 72 strictures using a percutaneous transhepatic approach, with a 6-month patency rate of 81%. For surgical repair of stenoses, the hilar plate is often severely adherent to the hepatic artery and/or portal vein; it is therefore difficult to isolate the bile duct safely.7 In most centers,10 as well as in our series, the duct-to-duct anastomosis was converted directly to the hepaticojejunostomy. In conclusion, biliary complications which remain an important cause of morbidity after orthotopic liver transplantation, can usually be managed percutaneously or endoscopically; however, tight strictures and major leaks frequently require surgical intervention.
Management of Biliary Complications
Definitive treatment of leaks and/or strictures was accomplished with an endoscopic and/or a percutaneous technique in 15 patients (46.9%), while surgery was required in 17 patients (53.1%). Of the 12 patients who developed biliary leaks, endoscopic treatment in the form of papillotomy with or without stenting was successful in 8 (66.6%); surgery was required in 4 (33.3%). Of the 26 patients who developed biliary strictures, 22 (84.6%) were initially managed using nonsurgical techniques in the form of endoscopic (n ⫽ 10) or percutaneous (n ⫽ 12) balloon dilatation and/or stenting, yielding a success rate of 59% (n ⫽ 13). Thirteen patients required surgery in the form of conversion to a Roux-en-Y hepaticojejunostomy (n ⫽ 9) or takedown of the bilioenteric anastomosis with reconstruction of a wider anastomosis (n ⫽ 4).
REFERENCES 1. Scatton O, Meunier B, Cherqui D, et al: Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 233:432, 2001 2. Icoz G, Kilic M, Zeytunlu M, et al: Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations. Liver Transpl 9:575, 2003 3. Park JS, Kim MH, Lee SK, et al: Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation. Gastrointest Endosc 57:78, 2003 4. Sawyer RG, Punch JD: Incidence and management of biliary complications after 291 liver transplants following the introduction of transcystic stenting. Transplantation 66:1201, 1998 5. Mahajani RV, Cotler SJ, Uzer MF: Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 32:943, 2000
BILIARY COMPLICATIONS POSTTRANSPLANTATION 6. Johnson MW, Thompson P, Meehan A, et al: Internal biliary stenting in orthotopic liver transplantation. Liver Transpl 6:356, 2000 7. Mosca S, Militerno G, Guardascione MA, et al: Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol 15:654, 2000 8. Kuo PC, Lewis WD, Stokes K, et al: A comparison of operation, endoscopic retrograde cholangiopancreatography,
3181 and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation. J Am Coll Surg 179:177, 1994 9. Zajko AB, Sheng R, Zetti GM, et al: Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience. J Vasc Intervent Radiol 6:79, 1995 10. Schwartz DA, Petersen BT, Merucha JJ, et al: Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 51:169, 2000