ENDOSCOPIC MANAGEMENT OF BILIARY FISTULAS COMPLICATING LIVER-TRANSPLANTATION AND OTHER HEPATOBILIARY OPERATIONS

Objective This study was undertaken to prospectively evaluate the effi cacy and safety of endoscopic management of biliary fistulas complicat ing liver transplantation and other hepatobiliary operations. Summary Background Data Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantati on. Although endoscopic management is rapidly becoming an acceptable a lternative to surgery tor the treatment of biliary fistulas complicati ng non liver transplant hepatobiliary operations, it has received limi ted attention in the liver transplant setting Methods During a 15-mont h period, 146 adults underwent liver transplantation with biliary reco nstruction by end-to-end choledochocholedochostomy over a T-tube. Inad vertent T-tube migration or intentional T-tube removal resulted in bil e peritonitis in 18 patients. The patients were treated with a nasobil iary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincteroto my with removal of obstructing stones when present (n = 6). Twelve pat ients also had stents placed. All patients were prospectively followed after hospital discharge and assessed tor recurrent symptoms suggesti ve of biliary tract disease and procedure-related complications. Resul ts Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of th eir symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two g roups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group a nd 0% in the other hepatobiliary operation group (p > 0.05). The 30-da y mortality rate was 0% Conclusions The results of this study support the application of endoscopic management of biliary fistulas complicat ing orthotopic liver transplantation and other hepatobiliary operation s This approach was relatively safe and obviated the need for surgical intervention.