THE INCIDENCE, TIMING, AND MANAGEMENT OF BILIARY-TRACT COMPLICATIONS AFTER ORTHOTOPIC LIVER-TRANSPLANTATION

Objective This study analyzed the incidence and timing of biliary trac t complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of p reviously reported series. Finally, recommendations were made on appro priate management strategies. Summary Background Data Technical compli cations after OLTx have a significant impact on patient and graft surv ival. One of the principle technical advances has been the standardiza tion of techniques for biliary reconstruction. Nonetheless, biliary co mplications still occur. A 1983 report from the University of Pittsbur gh reported biliary complications in 19% of all transplants, and an up date in 1987 reported biliary complications in 13.2% of transplants. M ethods The medical records of all patients who underwent liver transpl ant on and were hospitalized between January 1, 1988 and July 31, 1991 were reviewed. The case material consisted of the medical records of 217 patients treated for 245 biliary complications. Results Primary bi liary continuity was established by either choledochocholedpchostomy o ver a T-tube (C-C, n = 129) or a Roux-en-Y choledochojejunostomy with an internal stent (C-RY, n = 85). The overall incidence for biliary co mplication in this large series was 11.5%. Strictures (n = 93) and bil e leak (n = 58) were the most common complications (69.6%). Most bilia ry complications (n = 143, 66%) occurred within the first 3 months aft er surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent in both C-C and C-RY (27.1% a nd 25.9%, respectively); strictures were more common after a C-RY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patient s died, an incidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejection before the recognition of b iliary tract pathologic findings. Conclusions Progress has been made o n improving the results of biliary reconstruction after OLTx. Nonethel ess, patients continue to experience biliary complications after OLTx, and these complications cause considerable loss of grafts and life. I f significant additional improvement in patient and graft survival are to be obtained, the technical performance of OLTx must continue to im prove.