Role of surgery in the management of biliary complications after liver transplantation

Lladó, Laura; Fabregat, Joan; Ramos, Emilio; Baliellas, Carme; Torras, Jaume; Julià, David; Berrozpe, Ana; Jorba, Rosa; Rafecas, Antoni

doi:10.1016/S2173-5077(10)70183-6

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Abstract

Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years.

The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS).

Results

The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications.

Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs radiological: 20 (32%); P=.2 and mortality: surgical: 0% vs radiological: 8 (11%); P=.23).

Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%).

Conclusions

Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.

Keywords:

Biliary complications

Endoscopy

Hepaticojejunostomy

Liver transplantation

Radiology

Resumen

El manejo de las complicaciones biliares (CB) postrasplante hepático ha evolucionado en los últimos años.

Los objetivos de este estudio fueron analizar la incidencia y el manejo de las CB en nuestro centro en 1.000 trasplantes hepáticos; y estudiar específicamente el manejo de las estenosis anastomóticas (EA).

Resultados

La incidencia de CB fue del 23%. Se dieron 76 casos de fístula biliar, 106 casos de estenosis anastomóticas, 46 casos de estenosis no-anastomóticas, 42 coledocolitiasis y 19 otras complicaciones.

De los 106 casos de estenosis anastomóticas, se indicó tratamiento radiológico (CPRE o CTPH) en 62 casos. En 38 casos (33%), la estenosis anastomótica se resolvió mediante tratamiento quirúrgico, en 18 tras previo tratamiento radiológico. La morbilidad y mortalidad relacionada con el tratamiento radiológico de las CB fue discretamente superior (morbilidad: Quir: 4 [18%] vs. Radiol: 20 (32%); p = 0,2 y mortalidad: Quir: 0% vs. Radiol: 8 [11%]; p = 0,23).

De los 46 pacientes con estenosis no anastomóticas, 29 (63%) fueron tratados mediante retrasplante.

Conclusión

El tratamiento quirúrgico tiene un papel relevante en el manejo de las CB postrasplante hepático, y es el tratamiento de elección en algunos casos de estenosis anastomóticas. El retrasplante, sin manipulación previa, es el tratamiento de elección en los pacientes con estenosis no anastomóticas.

Palabras clave:

Complicaciones biliares

Endoscopia

Hepaticoyeyunostomía

Trasplante hepático

Radiología

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