A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube?

The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review

Biliary complications are one of the main concerns after liver transplantation, and to avoid these, the use of a T-tube has been advocated in biliary reconstruction. Most liver transplantation centres perform a biliary anastomosis without a T-tube to avoid the risk of complications and T-tube-related costs. Several meta-analyses have reached discordant conclusions regarding the benefits of using the T-tube. An umbrella review was performed to summarise quantitative measures about overall biliary complications, biliary leaks, biliary strictures and cholangitis associated with the T-tube use after liver transplantation. Published systematic reviews and meta-analyses related to the use of T-Tube in liver transplantation were searched and analysed. From the comprehensive literature search from PubMed, EMBASE and Cochrane Library databases on the 25th of October 2021, 104 records were retrieved. Seven meta-analyses and two systematic reviews were included in the final analysis. All the meta-analyses of RCT stated no differences in overall biliary complications and biliary leaks when using T-tube for a liver transplant (I² ≥ 90% and I² range 0-76%, respectively). The meta-analysis of the RCTs evaluating the risks of biliary strictures after liver transplantation showed that T-tube protects from the complication (I² range 0-80%). Biliary anastomosis without a T-tube has equivalent overall biliary complications and bile leaks compared to the T-tube reconstruction. The incidence of biliary strictures is attenuated in patients with T-tubes, and most meta-analyses of RCTs have very low heterogeneity. Therefore, the present umbrella review suggests a selective T-tube use, particularly in small biliary ducts or transplants with marginal grafts at high risk of post-LT strictures.

Duct-to-duct biliary reconstruction with or without an Intraductal Removable Stent in Liver Transplantation: The BILIDRAIN-T Multicentric Randomized Trial

Background & Aims

Biliary complications (BC) following liver transplantation (LT) are responsible for significant morbidity. No technical procedure during reconstruction has been associated with a risk reduction of BC. The placement of an intraductal removable stent (IRS) during reconstruction followed by its endoscopic removal showed feasibility and safety in a preliminary study. This multicentric randomised controlled trial aimed at evaluating the impact of an IRS on BC following LT.

Methods

This multicentric randomised controlled trial was conducted in 7 centres from April 2015 to February 2019. Randomisation was done during LT when a duct-to-duct anastomosis was confirmed with at least 1 of the stump diameters ≤7 mm. In the IRS group, a custom-made segment of a T-tube was placed into the bile duct to act as a stake during healing and was removed endoscopically 4 to 6 months post LT. The primary endpoint was the incidence of BC (fistulae and strictures) within 6 months post LT. The secondary criteria were complications related to the IRS placement or extraction, including endoscopic retrograde cholangio-pancreatography (ERCP)-related complications.

Results

In total, 235 patients were randomised: 117 in the IRS group and 118 in the control group. BC occurred in 31 patients (26.5%) in the IRS group vs. 24 (20.3%) in the control group (p = 0.27), including 16 (13.8%) and 15 (12.8%) strictures, respectively. IRS migration occurred in 24 patients (20.5%), cholangitis in 1 (0.9%), acute pancreatitis in 2 (1.8%), and difficulty during endoscopic extraction in 19 (19.4%). No predictive factor for BC was identified.

Conclusions

IRS does not prevent BC after LT and may require specific endoscopic expertise for removal.

Trial registration number (ClinicalTrials.gov)

NCT02356939 (https://clinicaltrials.gov/ct2/show/NCT02356939?term=NCT02356939&draw=2&rank=1).

Lay summary

Liver transplantation is a life-saving treatment for many patients with end-stage liver disease. However, it can be associated with complications involving the bile duct reconstruction. Herein, the placement of a specific stent called an intraductal removable stent was trialled as a way of reducing bile duct complications in patients undergoing liver transplantation. Unfortunately, it did not help preventing such complications.

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An IRS was placed during biliary reconstruction in bile ducts ≤7 mm; ERCP removal was 4–6 months post LT.

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The primary endpoint was the incidence of biliary complications (fistulae and strictures) within 6 months post LT.

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Biliary complications occurred in 31 patients (26.5%) in the IRS vs. 24 (20.3%) in the control group (p = 0.27).

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IRS migrated in 24 (20.5%) patients, and extraction was difficult in 19 (19.4%).

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No predictive factor for biliary complications was identified.

Management of Biliary Complications in Liver Transplant Recipients

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

T-tube or no T-tube for biliary tract reconstruction in orthotopic liver transplantation: an updated systematic review and meta-analysis

Objectives: Biliary tract reconstruction with or without T-tube is commonly used in orthotopic liver transplantation (OLT). However, the efficacy and safety of T-tube usage remain controversial. This meta-analysis was conducted to assess the latest evidence of clinical outcomes.Methods: Embase, Cochrane Library, PubMed, and Web of Science were systematically searched from inception to 20 January 2021 for eligible studies. The analyses were performed using Review Manager and Stata.Results: A total of 24 trials involving 3320 participants were included in the meta-analysis. Compared with the no T-tube group, there was a higher incidence of overall biliary complications (OR:1.54; 95%CI, 1.06-2.24; P = 0.02), bile leaks (OR:2.34; 95%CI,1.57-3.48; P < 0.0001), cholangitis (OR:2.78; 95%CI,1.19-6.51; P = 0.002), and longer cold ischemia time (MD:22.27; 95%CI,0.80-43.74; P = 0.04) in the T-tube group. Furthermore, the no T-tube group had significantly higher odds of biliary strictures than the T-tube group (OR:0.60; 95%CI, 0.47-0.78; P = 0.0001).Conclusion: T-tube is still not routinely recommended, but is a good choice for OLT patients at high risk of biliary strictures. Notably, the higher rate of biliary complications in the T-tube group did not translate into an increase in endoscopic or re-operative interventions.

Biliary Complications Following Adult Deceased Donor Liver Transplantation: Risk Factors and Implications at a High-volume US Center

Biliary leaks and anastomotic strictures comprise the majority of biliary complications (BCs) following liver transplantation (LT). Currently, there are few large contemporary case series of BCs in adult deceased donor liver transplant (DDLT) recipients in the literature. The purpose of this study was to examine the pretransplant and intraoperative risk factors associated with BCs at a high-volume tertiary care center and determine the impact of these BCs on their posttransplant course and long-term transplant outcomes.

METHODS

We retrospectively reviewed all adult patients undergoing a DDLT from a donor after brain death (DBD) at Emory University between January 2015 and December 2019.

RESULTS

A total of 647 adult patients underwent DDLT from a DBD during the study period and were included in analyses. The median length of follow-up posttransplant was 2.5 y. There were a total of 27 bile leaks (4.2%) and 69 biliary strictures (10.7%). Recipient age and cold ischemic time were identified as risk factors for biliary leak, whereas alcoholic cirrhosis as transplant indication was a risk factor for biliary stricture. Placement of a biliary stent was associated with the development of both biliary leaks and anastomotic strictures. Posttransplant, biliary leaks were a significant risk factor for future episodes of acute rejection but did not impact overall survival. In contrast, biliary strictures were associated with a significantly reduced overall survival at 1- and 4-y post DDLT.

CONCLUSIONS

BCs are a major source of morbidity and mortality following DDLT, with strictures and leaks associated with distinct posttransplant complications.

A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation

Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.

To stent or not to stent: the use of transanastomotic biliary stents in liver transplantation and patient outcomes

BACKGROUND

There is no substantial evidence for the use of biliary stents in bile duct reconstruction during liver transplantation.

METHOD

A longitudinal, retrospective cohort study was performed to compare biliary complications between stented and non-stented patients between 2011 and 2015 at the Princess Alexandra Hospital, Brisbane, Australia.

RESULTS

We found no significant difference in biliary complications between stented and non-stented groups. Stented patients were 3.31 times as likely to require subsequent intervention, mainly in the form of stent removal.

CONCLUSION

These results suggest that there is limited benefit in the placement of endobiliary stents in liver transplantation. Given that this was purely an observational study, causality cannot be proven and a prospective cohort trial would be beneficial in further defining these relationships.

Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial

BACKGROUND

Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT.

STUDY DESIGN

Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak.

RESULTS

Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003).

CONCLUSIONS

Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications.

Biliary Duct-to-Duct Reconstruction with a Tunneled Retroperitoneal T-Tube During Liver Transplantation: a Novel Approach to Decrease Biliary Leaks After T-Tube Removal

The benefit of placing a T-tube for duct-to-duct biliary reconstruction during orthotopic liver transplantation (OLT) remains controversial because it could be associated with specific complications, especially at the time of T-tube removal. While the utility of T-tube during OLT represents an eternal debate, only a few technical refinements of T-tube placement have been described since the report of the original technique by Starzl and colleagues. Herein, we present a novel technique of T-tube placement for duct-to-duct biliary reconstruction during OLT, using a tunneled retroperitoneal route. On the basis of our experience of 305 patients who benefitted from the reported technique, the placement of a tunneled retroperitoneal biliary T-tube appears to be safe and results in a low rate of biliary complications, especially at the time of T-tube removal.

Biliary reconstruction with or without an intraductal removable stent in liver transplantation: study protocol for a randomized controlled trial

Background

The incidence of biliary complications following liver transplantation (LT) remains high, ranging from 10 to 50 % of patients, especially when the diameter of the bile duct is smaller than 7 mm. Biliary reconstruction is most often performed by duct-to-duct anastomosis. In a preliminary study (n = 20), we previously reported a technique of biliary reconstruction using an intraductal stent tube followed by its endoscopic removal and showed both the feasibility and safety of this innovative procedure. The next step is to validate the potential benefit of this procedure in a randomized controlled trial.

Design

This is a multicenter randomized controlled trial in France comparing the efficacy of biliary reconstruction with or without a removable intraductal stent on reducing biliary complications. Inclusion and randomization are performed during LT when a duct-to-duct biliary anastomosis smaller than 7 mm in diameter is envisioned. In the intraductal stent group, a custom-made segment of a T-tube is placed into the bile duct and removed endoscopically 4 to 6 months later. The surgical technique is described in a video during randomization and is available on the secure website used for inclusion and randomization. The primary endpoint is the occurrence of biliary complications, including biliary fistulae and strictures, during the 6 months of follow-up. Secondary evaluation criteria are the incidence of complications related to the stent placement and its extraction by endoscopy. The inclusion of 248 patients in total has been determined based on an expected incidence of biliary complications of 25 % in the non-IST group and a 60 % reduction of biliary complications (10 %) in the IST group.

Discussion

Biliary complications following LT are significant causes of morbidity, retransplantation, and mortality. Although controversial, the use of a T-tube has been proven to be useless and even responsible for specific complications related to the external part of the tube in many studies, including several randomized trials. However, several studies have identified a small bile duct diameter as a risk factor for biliary stenosis. A threshold of 7 mm was found to be significantly associated with biliary stenosis. Our team published a preliminary study that included 20 patients using a new technique of intraductal stenting. Only four complications were reported in the overall study population, whereas no biliary complication occurred in the subgroup of patients who received a whole graft LT. Moreover, no technical failures and no procedure-related complications were noted before and during the drain removal. Although an intraductal stent tube in duct-to duct biliary anastomosis seems feasible and safe, a multicenter randomized controlled trial is needed to validate its benefit as a protective tool against the occurrence of biliary complications. One original aspect of this protocol is the video demonstration of the surgical procedure, which is available on the web to standardize and homogenize the technique. The surgical community may be inspired by this type of tool in the future to minimize technical bias related to technical issues.

Trial registration

NCT02356939, date of registration 2 February 2015.

Impact of abdominal drainage systems on postoperative complication rates following liver transplantation

BACKGROUND

Depending on the extent of surgery, coagulation status and the number of anastomoses, drains are routinely used during liver transplantation. The aim of this study was to compare different drain types with regard to abdominal complication rates.

METHODS

All consecutive full-size orthotopic liver transplantations (LTX) performed over a 7-year period were included in this retrospective analysis. Abdominal drain groups were divided into open-circuit drains and closed-circuit drains. Data are reported as total number (%) or median (range); for all comparisons a p value <0.05 was considered statistically significant.

RESULTS

A total of 256 LTX [age 56.89 (0.30-75.21) years; MELD 14.5 (7-40)] was included; 56 (21.8 %) patients received an open-circuit Easy Flow Drain (Group 1) and 200 (78.2 %) a closed-circuit Robinson Drainage System (Group 2). For Groups 1 and 2, overall infection rates were 78.6 and 56 % (p = 0.001), abdominal infection rates 50.82 and 21.92 % (p = 0.001), yeast infection rates 37 and 23 % (p = 0.02), abdominal bleeding rates 26.78 and 17 % (p = 0.07), biliary complication rates 14.28 and 13.5 % (p = 0.51), respectively.

CONCLUSIONS

In this retrospective series, open-circuit drains were associated with more abdominal complications, mainly due to intraabdominal infections, than were closed-circuit drains.

Biliary tract reconstruction with or without T-tube in orthotopic liver transplantation: a systematic review and meta-analysis

INTRODUCTION

At present whether to use T-tube or not during orthotopic liver transplantation (OLT) in biliary tract reconstruction still remains controversial. Most transplant centers choose not to use T-tube because the T-tube can increase the incidence of cholangitis, but some centers still use T-tube because the T-tube can decrease the incidence of anastomotic strictures.

AIM

The purpose of this study is to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT.

METHODS

systematic review and meta-analysis of a collection of 15 studies (six randomized control trails (RCTs) and nine comparative studies) to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT.

RESULTS

The data showed that the biliary tract reconstruction with T-tube and without T-tube had equivalent outcomes for overall biliary complications (six RCTs p = 0.76; odd ratio [OR] = 1.19; 95% CI: 0.40, 3.58; all studies p = 0.14; OR = 1.50; 95% CI: 0.88, 2.57), bile leaks (six RCTs p = 0.61; OR = 0.86; 95% CI: 0.49, 1.52; all studies p = 0.09; OR = 1.39; 95% CI: 0.95, 2.02), cholangitis (six RCTs p = 0.13; OR = 5.54; 95% CI: 0.62, 49.79; all studies p = 0.08; OR = 4.27; 95% CI: 0.86, 21.16), hepatic artery thrombosis (two RCTs p = 1.00; OR = 1.00; 95% CI: 0.22, 4.49; all studies p = 0.75; OR = 1.19; 95% CI: 0.41, 3.44). However, in the group with T-tube there were better outcomes for biliary strictures (six RCTs p = 0.0003; OR = 0.34; 95% CI: 0.19, 0.61; all studies p < 0.0001; OR = 0.49; 95% CI: 0.34, 0.69).

DISCUSSION

Although most organizations choose not to use T-tube in OLT, we suggest that use of T-tube in biliary tract reconstruction during OLT for the recipients who possibly have high risks of biliary stricture is useful and necessary.

Radiologic assessment of hepatobiliary surgical complications

The complexity of hepatobiliary procedures continues to evolve at a rapid rate, with an increasing number of living donor liver transplants and extensive cancer resections being performed. The associated complications are a significant cause of morbidity and mortality, and are often complex injuries, involving both vascular and biliary structures. In this paper we describe the complications associated with laparoscopic cholecystectomy, liver transplant surgery, and hepatic resection. Focus is on the classical imaging appearances, imaging modality options, and varying management strategies for these injuries, to show how the radiologist's role is vital in ensuring the correct diagnosis is made and the appropriate treatment is instigated.

Biliary complications after orthotopic liver transplantation: a review of incidence and risk factors

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.

Value of T-tube in biliary tract reconstruction during orthotopic liver transplantation: a meta-analysis

OBJECTIVE

To compare biliary complications after biliary tract reconstruction with or without T-tube in orthotopic liver transplantation.

METHODS

Randomized control trials (RCTs) and comparative studies were identified by a computerized literature search of the Cochrane Library, MEDLINE (1966/1-2010/4), Scopus (1980/1-2010/4), ClinicalTrials.gov (2010/4), the Cochrane Hepato-Biliary Group Controlled Trials Register, and the Cochrane Central Register of Controlled Trials. Studies and data were extracted and assessed independently. Dichotomous outcomes were reported as odds ratios (ORs) and weighted mean difference with 95% confidence intervals (CI).

RESULTS

Five RCTs and eight comparative studies with a total of 1 608 subjects were identified. The data showed that the operation with T-tube had better outcomes for duct stenosis (P=0.01, OR=0.45, 95% CI 0.24-0.85). The operations with or without T-tube had equivalent outcomes as follows: overall biliary complications (P=0.85, OR=1.15, 95% CI 0.28-4.72), bile leaks (P=0.38, OR=0.75, 95% CI 0.39-1.42), and cholangitis (P=0.24, OR=4.64, 95% CI 0.36-60.62). These results were strengthened by the analysis of all thirteen non-randomized and randomized studies.

CONCLUSIONS

Our systematic review and meta-analysis suggest that the insertion of a T-tube reduces the incidence of biliary stenosis without increasing the incidence of other biliary complications.

Biliary strictures after liver transplantation

Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.

Steatosis of the hepatic graft as a risk factor for post-transplant biliary complications

BACKGROUND

Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles' heel of liver transplantation. The aim of this study is to retrospectively analyze the incidence of biliary complications and identify risk factors that might predispose to the development of biliary problems.

METHODS

From January 2004 to December 2007, 117 consecutive liver transplantations were retrospectively analyzed for the development of biliary complications by the review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74).

RESULTS

The overall biliary complication rate was 36.8% (leakage 6% and stricture 30.8%). Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (p = 0.037) and macrovacuolar steatosis of the graft > 25% (p = 0.004). Stepwise logistic regression model demonstrated that a macrosteatosis of the graft > 25% (OR = 5.21 CI 95% [1.79-15.15], p = 0.002) was the only independent risk factor predicting biliary complications after liver transplantation. No differences in patient's and graft's survival were noted between the two groups.

CONCLUSION

According to our experience, transplanting a liver with > 25% of steatosis is a risk factor for the development of biliary complication.

Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome

Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.

Current management of biliary complications after liver transplantation: emphasis on endoscopic therapy

Biliary complications occur in 5-25% of patients after liver transplantation and represent a major source of morbidity in this group of individuals. The major risk factor for most of these complications is ischemia of the bile tree usually due to obstruction or vascular insufficiency of the hepatic artery. The most common complications include biliary strictures (anastomostic and nonanastomotic), bile leaks, and biliary filling defects. The initial diagnostic approach starts with a high index of suspicion along with an abdominal ultrasound and Doppler exam. Magnetic resonance imaging is highly sensitive and is usually reserved for confirmation. The vast majority of these complications can be successfully treated with endoscopic retrograde cholangiography, however if this procedure cannot be performed a percutaneous approach or surgery is recommended. Nonanastomotic strictures and living donor recipients present a less favorable response to endoscopic management. This review focuses on the current diagnostic and therapeutic approaches for the management of biliary complications after liver transplantation.

Biliary complications following liver transplantation

The aphorism that reconstruction of the biliary anastomosis is the "Achilles heel" of liver transplantation remains valid as biliary complications following liver transplantation remain a major source of morbidity with an incidence of 5-32%. Biliary complications include biliary strictures, biliary leaks, and stones. Biliary strictures can be divided into anastomotic and non-anastomotic. The management of biliary complications previously relied on surgical intervention. However, advances in endoscopic and radiological interventions have resulted in less-invasive options. The management of biliary complications post-liver transplantation requires a multidisciplinary approach and continues to evolve. Biliary complications also reflect the continued expansion of the donor pool with extended, live, and non-heart beating donors.

Endoscopic management of biliary complications after liver transplantation

Complications of the biliary tract are an important cause of morbidity and mortality after liver transplantation. The most frequent complications are anastomotic biliary tract strictures, bile leaks, and bile duct stones. The estimated incidence of these complications ranges between 5% and 25%, although rates have been decreasing in recent years. Most complications can be managed successfully with endoscopic retrograde cholangiography. This article reviews the various biliary complications after liver transplantation (both deceased donor and living-related donor) and their endoscopic management.

Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: a prospective randomized trial

OBJECTIVE

The biliary anastomosis is still one of the major causes for morbidity after orthotopic liver transplantation. The optimal method of reconstruction remains controversial. The aim of the study was to assess biliary complications after liver transplantation using a choledochocholedochostomy with or without a temporary T-tube.

BACKGROUND DATA

Several reports have suggested that biliary reconstruction without T-tube is a safer method with a lower rate of biliary complications compared with T-tube insertion.

METHODS

A total of 194 recipients of deceased donor liver grafts were randomized. In group 1 the biliary reconstruction was performed by side-to-side choledochocholedochostomy with (n = 99) and in group 2 (n = 95) without a T-tube. The T-tube was removed after 6 weeks.

RESULTS

The overall biliary complication rate was significantly increased in group 2 (P < 0.0005). Biliary leaks occurred in 5 patients in group 1 and in 9 patients in group 2 (5.05% vs. 9.47%; P = 0.2756 ns). Anastomotic strictures of the bile duct were seen in 7 patients in group 1 and in 8 patients in group 2 (7.07% vs. 8.42%; P = 0.7923 ns). Two of the patients in group 1 and 5 patients in group 2 developed an ischemic type biliary lesion (2.02% vs. 5.26%; P = 0.2716 ns). The rate of reoperations was comparable in both groups. The rate of invasive interventions was higher in the group without T-tubes (9% vs. 18%, P = ns), as was the rate of cholangitis (5% vs. 11%. P = ns) and pancreatitis (4% vs. 14%, P = 0.0218). No complications after removal of the T-tube were observed.

CONCLUSION

This study is a large prospective randomized trial to assess biliary complications that occur following liver transplantation, after anatomizing the bile duct with or without T-tubes. A significant increased rate of complications in the group without T-tube insertion was observed. In summary, our results indicate that the usage of T-tubes is safe and an excellent tool for the quality control of biliary anastomoses.

Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results

BACKGROUND

The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation.

METHODS

We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models.

RESULTS

The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangitis," "fewer episodes of peritonitis," and showed a favorable trend for "overall biliary complications." Although the "with T-tube" group showed superior result for "anastomotic and nonanastomotic strictures," the incidence of interventions was not diminished.

CONCLUSIONS

Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.

Biliary complications after liver transplantation: A review

After liver transplantation, the prevalence of complications related to the biliary system is 6-35%. In recent years, the diagnosis and treatment of biliary problems has changed markedly. The two standard methods of biliary reconstruction in liver transplant recipients are the duct-to-duct choledochocholedochostomy and the Roux-en-Y-hepaticojejunostomy. Biliary leakage occurs in approximately 5-7% of transplant cases. Leakage from the site of anastomosis, the T-tube exit site and donor or recipient remnant cystic duct is well described. Symptomatic bile leakage should be treated by stenting of the duct by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTCD). Biliary strictures can occur at the site of the anastomosis (anastomotic stricture; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). AS occur in 5-10% of cases and are due to fibrotic healing. Treatment by ERCP or PTCD with dilatation and progressive stenting is successful in the majority of cases. NAS can occur in the context of a hepatic artery thrombosis, or with an open hepatic artery (ischaemic type biliary lesions or ITBL). The incidence is 5-10%. NAS has been associated with various types of injury, e.g. macrovascular, microvascular, immunological and cytotoxic injury by bile salts. Treatment can be attempted with multiple sessions of dilatation and stenting of stenotic areas by ERCP or PTCD. In cases of localized diseased and good graft function, biliary reconstructive surgery is useful. However, a significant number of patients will need a re-transplant. When biliary strictures or ischaemia of the graft are present, stones, casts and sludge can develop.

Biliary strictures following liver transplantation: past, present and preventive strategies

Biliary complications are still the major source of morbidity for liver transplant recipients. The reported incidence of biliary strictures is 5%-15% after deceased donor liver transplantation and 28%-32% after right-lobe live donor surgery. Presentation is usually within the first year, but the incidence is known to increase with longer follow-up. The anastomotic variant is due to technical factors, whereas the nonanastomotic form is due to immunological and ischemic events, which later may lead to graft loss. Endoscopic management of anastomotic strictures achieves a success rate of 70%-100%; it drops to 50%-75% for nonanastomotic strictures with a higher recurrence rate. Results of endoscopic maneuvers are disappointing for biliary strictures after live donor liver transplantation, and the success rate is 60%-75% for anastomotic strictures and 25%-33% for the nonanastomotic variant. Preventive strategies in the cadaveric donor include the standardization of the type of anastomosis and maintenance of a vascularized ductal stump. In right-lobe live donor livers, donor liver duct harvesting also involves a major risk. The concept of high hilar intrahepatic Glissonian dissection, dissecting the artery and the duct as one unit, use of microsurgical techniques for smaller ducts, use of ductoplasty, and flexibility in the performance of double ductal anastomosis are the critical components of the preventive strategies in the recipient. In the case of live donors, judicious use of intraoperative cholangiograms, minimal dissection of the hilar plate, and perpendicular transection of the duct constitute the underlying principals for obtaining a vascularized duct.

The experience of biliary tract complications after liver transplantation

AIM

To report the morbidity and mortality of patients who undergo liver transplantation with or without T-tube implantation after choledochocholedochostomy as well as to discuss management of biliary complications.

PATIENTS AND METHODS

We performed a retrospective review of 104 liver transplantations from August 2001 to February 2006, including 51 patients who underwent choledochocholedochostomy with a T-tube (group A) and 53, without a T-tube (group B). We compared the clinical characteristics, operative methods, biliary complications, morbidity, mortality, and management of complications.

RESULTS

Between the two groups, there were no significant differences in clinical characteristics, including sex, age, and indication for liver transplantation (hepatitis B virus, hepatitis C virus, alcoholic liver cirrhosis, or hepatocellular carcinoma), Child-Pugh classification, Model for End-stage Liver Disease score, and operative macroscopic/microscopic findings. Additionally, there was no significant difference in biliary complications. Among these 104 patients, 14 (13.5%) developed biliary complications: seven anastomotic strictures, two intrahepatic duct strictures, two anastomotic stricture combined intrahepatic duct stricture, one bile leakage, one bile leakage combined with anastomotic stricture, and one external biliary compression. Nine patients with anastomotic stricture underwent endoscopy with a stent, which was successful only in two patients. The other six patients underwent choledochojejunostomy with excellent results.

CONCLUSIONS

This study showed choledochocholedochostomy with or without a T-tube after liver transplantation did not influence the biliary complications. The biliary complications of anastomotic stricture after liver transplantation can be managed by endoscopy with a stent. If endoscopy fails, surgical intervention should be considered immediately.

Management of biliary complications following orthotopic liver transplantation

Biliary complications are a major cause of morbidity following orthotopic liver transplantation with an overall incidence between 11% and 25%. The most common complications are biliary leaks, strictures, and stones. These complications have an impact on graft survival, length of hospital stay, recovery, and overall cost of care. Therefore, knowledge of these complications and their management is important to the practicing gastroenterologist. Historically, biliary complications after liver transplantation have been managed surgically. However, with the growth of therapeutic endoscopic and percutaneous radiologic methods, most of these complications can now be managed less invasively. This article focuses on the incidence, timing, mechanism, and endoscopic management of biliary leak, strictures, stones, sludge, casts, and sphincter of Oddi dysfunction following liver transplantation.

Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.

METHODS: Patients who developed biliary complications were analysed in detail for the clinical information, laboratory tests, treatment offered, response to it, follow up and outcomes. The profile of liver enzymes was determined. The safety, efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed.

RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L, P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L, P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients.

CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early, non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.

Biliary complications after deceased-donor orthotopic liver transplantation

A wide range of potential biliary complications can occur after orthotopic liver transplantation (OLT). The most common biliary complications are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dyfunction, which may occur in up to 20%-40% of OLT recipients. Leaks predominate in the early posttransplant period; stricture formation typically develops gradually over time. However, with the advent of new techniques, such as split-liver, reduced-size, and living-donor liver transplantation, the spectrum of biliary complications has changed. Risk factors for biliary complications comprise technical failure; T-tube or stent-related complications; hepatic artery thrombosis; bleeding; ischemia/reperfusion injury; and other immunological, nonimmunological, and infectious complications. Noninvasive diagnostic methods have been established and treatment modalities have been modified towards a primarily nonoperative, endoscopy-based strategy. Besides, the management of biliary complications after OLT requires a multidisciplinary approach, in which interventional and endoscopic treatment options have to be weighed up against surgical treatment options. The etiology and spectrum of bile duct complications, their diagnosis, and their treatment will be reviewed in this article.

Biliary complications following adult right lobe ex vivo split liver transplantation

Biliary complications are common following split liver transplantation (SLT). We analyzed the incidence, treatment, and outcome of biliary complications following adult right lobe ex vivo SLT performed between November 1992 and January 2005. There were 72 patients, of which 70 were analyzed. Early postoperative deaths resulted in 2 being excluded from the analysis. There were 44 males (median age, 48 yr; range, 19-70 yr). Biliary reconstruction was by duct-to-duct (DD) anastomosis in 52 (74%) and Roux-en-Y hepaticojejunostomy (RYHJ) in 18 (26%) patients. Until mid-2001, no T-tube was used for DD anastomosis (DD/non-T-tube) in 26 (37%) patients; subsequent to this, DD over a T-tube (DD/T-tube) was performed in 26 (37%) patients. Eighteen (26%) biliary complications occurred in 16 patients. Two anastomotic leaks of RYHJ were associated with hepatic artery thrombosis. The most frequent biliary complication was parenchymal radical leak from the transected liver surface (11%; 8/70), with anastomotic leaks in 6% (4/70) and strictures in 4% (3/70). There were also 2 cases of biliary leaks from T-tube exit site following T-tube removal, and 1 leak from the donor cystic duct stump. DD anastomosis without a T-tube was associated with a higher rate of cut surface and anastomotic biliary leaks (7/26), compared to the DD/T-tube group (1/26; P = 0.05). Six patients (9%) died following biliary complications, including 3 due to cut surface leaks in the DD/non-T-tube group and 2 cases with fatal biliary peritonitis following T-tube removal. A patient in the RYHJ group died due to biliary sepsis associated with hepatic artery thrombosis. In conclusion, biliary complications following right lobe ex vivo SLT are associated with significant morbidity and mortality. Our results suggest that T-tube biliary drainage of DD anastomosis may reduce parenchymal cut surface and biliary anastomotic leaks. However, bile leak following T-tube removal could lead to potentially fatal biliary peritonitis, which should always be anticipated and treated promptly.

Cost/efficacy clinical trial about the use of T-tube in cadaveric donor liver transplant: preliminary results

Biliary reconstruction is the most common cause of morbidity associated with orthotopic liver transplantation. Our objective was to assess the complications and hospital resources related to the use of a T-tube.

MATERIAL AND METHODS

Among 95 liver transplants performed from October 2002 to November 2003, 84 patients were randomized to receive a T-tube or no T-tube. We analyzed all patients with a follow-up of at least of 3 months.

RESULTS

Fifty-five transplants were analyzed with 8 months mean follow-up, including twenty eight with T-tube and twenty seven without a T-tube. No patient died during the follow-up. The overall rate of biliary complications was 45.4% (25/55) including 21/28 (75%) in the T-tube group and 4/27(14.8%) in the non-T-tube group (P < .0001). Complications related to T-tube extraction occurred in 48.2% (13/27), including 3 cholangitis and 10 leaks. The costs of hospital resources due to radiological studies were 5329 capital JE, Ukrainian for the T-tube group vs 5785 capital JE, Ukrainian for the non-T-tube group. The costs of hospital resources due to treatment were 28,280 capital JE, Ukrainian for the T-tube group vs 10,088 capital JE, Ukrainian for the non-T-tube group.

CONCLUSIONS

Use of a T-tube during orthotopic liver transplantation does not seem justified. Biliary anastomosis stenting is followed by an increased incidence of complications, most of which are related to its use. Hospital stay, radiological studies, and cost of hospital resources are higher among the T-tube patients. Therefore its systematic use is not advisable.

Biliary complications in liver transplant recipients

Despite numerous advancements in the management of patients who have undergone cadaveric liver transplantation, biliary complications continue to challenge clinicians. Biliary leaks in the early postoperative period and strictures in the late postoperative period represent the two major posttransplant biliary complications. Intrahepatic and hilar strictures are particularly difficult to manage and frequently require retransplantation, which should not be delayed. Choledocholithiasis and the biliary cast syndrome are frequently associated with underlying biliary strictures, and endoscopic attempts at removal should precede surgical interventions. Sphincter of Oddi dysfunction is increasingly recognized despite unclear pathophysiology. Hemobilia is most commonly iatrogenic and requires a high suspicion and prompt intervention. Although the number of diagnostic and therapeutic options have increased, there is no consensus as to which is superior. In recent years there has been a trend toward nonsurgical interventions, in particular endoscopic approaches.

Diagnosing biliary complications of orthotopic liver transplantation with mangafodipir trisodium-enhanced MR cholangiography: comparison with conventional MR cholangiography

OBJECTIVE

This study was designed to determine whether the addition of mangafodipir trisodium-enhanced MRI could improve the image quality, visualization of ductal structures, and diagnostic confidence provided by conventional T2-based MR cholangiography (MRC) in patients with suspected biliary complications after orthotopic liver transplantation. SUBJECTS AND METHODS. Our study group consisted of 25 consecutive patients who were referred for MR evaluation of clinically suspected biliary complications after orthotopic liver transplantation. Conventional MRC in the axial and coronal planes was performed in each patient, followed by fat-suppressed volumetric gradient-echo imaging in the same planes both before and after the IV administration of mangafodipir trisodium. Imaging was performed in all patients until the contrast agent was seen in the bowel. Images were then graded for quality, visualization of bile ducts and anastomoses, presence of significant stricture or leak, and level of diagnostic confidence.

RESULTS

Mangafodipir trisodium-enhanced MRC tended to outperform conventional MRC in overall image quality and extrahepatic duct visualization; it was also more effective in delineating biliary anastomoses, and the difference was statistically significant (p < 0.001). All 25 enhanced examinations were considered diagnostic. Diagnostic confidence was scored as poor or lacking in 14 of the conventional MRC examinations for biliary stenosis and in 12 examinations for biliary leak.

CONCLUSION

Enhancement with mangafodipir trisodium improves the performance of MRC for the detection and exclusion of biliary abnormalities after orthotopic liver transplantation. Future investigations should compare the performance of mangafodipir trisodium-enhanced MRC with the performance of more invasive techniques.

Long-term follow-up of percutaneous transhepatic balloon cholangioplasty in the management of biliary strictures after liver transplantation

BACKGROUND

This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation.

METHODS

Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years.

RESULTS

PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures.

CONCLUSIONS

PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.

US of liver transplants: normal and abnormal

Whole-liver transplantation is an accepted and successful method of treating end-stage liver disease. As a result of the shortage of cadaveric livers, split-liver transplantation and living donor liver transplantation are becoming more commonplace. Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. Biliary complications include leaks, strictures, stones or sludge, dysfunction of the sphincter of Oddi, and recurrent disease. Neoplastic disease in the transplanted liver may represent recurrent neoplasia or posttransplantation lymphoproliferative disorder. Parenchymal disease may take the form of a focal mass or a diffuse parenchymal abnormality. Perihepatic fluid collections and ascites are common after liver transplantation. Knowledge of the surgical technique of liver transplantation and awareness of the normal US appearance of the transplanted liver permit early detection of complications and prevent misdiagnosis.

A cost-effectiveness analysis of biliary anastomosis with or without T-tube after orthotopic liver transplantation

Biliary reconstruction continues to be a major source of morbidity following orthotopic liver transplantation. We wished to determine if choledochocholedochostomy without a T-tube was associated with fewer biliary complications and was less costly than choledochocholedochostomy with a T-tube. A retrospective cohort study of patients who underwent liver transplantation was performed. Patients were stratified into two groups: group I had bile duct reconstruction with T-tube and group II did not have a T-tube. The results were interpreted on an intention-to-treat analysis. We identified 147 adult patients who underwent initial liver transplantation. There were 76 patients in group I and 71 patients in group II. There were no statistical differences between the two groups regarding underlying cause of liver disease, patient age, gender or United Network for Organ Sharing status. As the decision to use a T-tube was made at the time of surgery, the two groups may not be strictly comparable. The mean hospital stay was longer in group I (31.1 +/- 27.9d) than in group II (18.8 +/- 15.5d) (p = 0.001). Biliary complications were statistically more frequent in patients from group I patients (25/76, 32.9%) than in patients from group II (11/71, 15.5%) (p = 0.01). There was a trend for the costs associated with diagnostic and therapeutic procedures for the management of biliary complications to be greater for group I than for group II, although this was not statistically significant (p = 0.235). Our study suggests choledochocholedochostomy without T-tube reconstruction is the preferred strategy for biliary reconstruction in orthotopic liver transplantation. It is not only associated with fewer biliary complications, but also less costly than using choledochocholedochostomy over a T-tube. Randomized prospective studies are needed to confirm our results.