Predictors of Biliary Leakage After T-Tube Removal in Living Donor Liver Transplantation Recipients

Biliary complications after adult to adult right-lobe living donor liver transplantation (A-ARLLDLT): Analysis of 245 cases during 16 years period at a single high centre- A retrospective cohort study

OBJECTIVES

Biliary complications (BCs) after adult to adult living donor liver transplantation (A-ALDLT) result in poor graft and patient survival. This study aimed to analyze these complications.

METHODS

We retrospectively analyzed BCs in 245 recipients who underwent A-ALDLT using the right-lobe graft during 16 years period in our centre. The overall male/female ratio was 215/30.

RESULTS

One hundred fifty-five BCs affected 102 of our recipients (95 early (≤3months) and 60 late (≥3months)). They were classified as 67/245(27.3%) early bile leak, 10/245(4.1%) early biliary stricture, 44/245(17.9%) late biliary stricture, 4/245(1.6%) early cholangitis, 10/245(4.1%) late cholangitis, 14/245(5.7%) early biloma, and 6/245(2.4%) late cholangitic abscesses. Multiple biliary anastomoses were independently correlated with Post liver transplantation (LT) overall BCs; moreover, post LT hepatic artery thrombosis or stenosis (HAT/S) was an independent predictor of overall BCs, strictures and leaks. The mortality affected 96(39.2%) cases mostly due to sepsis, bleeding and multi-organ failure (MOF). On the other hand, the biliary related mortality was 10.6% of cases. Multiple cholangitic hepatic abscesses were significant predictors of poor graft and patient outcomes. Conclusions: Multiple biliary anastomoses and post LT HAT/S lead to a poor biliary outcome, furthermore, cholangitis, cholangitic abscesses and sepsis lead to poor graft and patient outcomes, so proper management of those variables is mandatory to improve outcomes after A-ARLLDLT.

Usefulness of T-Tube in Liver Transplantation: Still Effective or Outmoded Strategy?

Introduction: T-tube placement during liver transplantation (LT) is still debated. We performed a retrospective study to evaluate the usefulness of T-tube after LT in two cohorts differing in post-transplant risk. Methods: A total of 327 LTs performed between 2015 and 2018 were included in the analysis. LTs from donation after circulatory death and living donation, split-liver transplants, and LTs with hepaticojejunostomy were excluded. T-tube was reserved for marginal grafts, high-risk recipients, and bile duct size discrepancy. A balance of risk (BAR) score of ≤9 defined the low-risk cohort (232 patients, 68 with and 164 without T-tube), while a BAR score of >9 defined the high-risk cohort (95 patients, 43 with and 52 without T-tube). Postoperative complications were estimated with the comprehensive complication index (CCI). Postoperative biliary complications were classified in anastomotic stricture (AS), non-anastomotic stricture (NAS), and biliary leakage (BL). Results: In the low-risk cohort, LTs with and without T-tube had similar rates of NAS (0 vs. 2.9%, p = 0.36), AS (2.9 vs. 2.4%, p = 0.83), and BL (1.4 vs. 2.4%, p = 0.64). Analogous outcomes were found in the high-risk cohort: NAS (0 vs. 0), AS (0 vs. 5.7%, p = 0.11), and BL (0 vs. 1.3%, p = 0.27). There were more postoperative complications among patients with T-tube, in both the low-risk (CCI 29 vs. 21, p < 0.001) and high-risk (CCI 51 vs. 29, p < 0.001) cohort. No differences in primary non-function, hepatic artery thrombosis, and mortality were observed. Conclusions: T-tube placement did not influence postoperative biliary complications. Although the two cohorts were normalized for post-transplant risk, LT recipients with T-tube had a more complicated course.

An Italian survey on the use of T-tube in liver transplantation: old habits die hard!

There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.