TREATMENT OF BILE FISTULAS FOLLOWING T-TU BE REMOVAL AFTER ORTHOTOPICLIVER-TRANSPLANTATION

Biliary tract complications are a major source of morbidity after live r transplantation. From October 1990 to September 1992, 77 patients, i ncluding 13 children and 64 adults, received 80 liver transplants. Bil iary reconstruction was performed using a choledochocholedochostomy wi th a T-tube in 40 recipients. We report the management of bile leaks f ollowing T tube removal in 6 patients. In all cases, bile leak was dia gnose by utrsound examination requested for abdominal pain. In the fir st 2 patients, a surgical treatment was applied : Roux-en-Y choledocho jejunostomy was performed on the first patient and simple suture of th e fistula in the second patient. Two patients were managed nonoperativ ely using endoscopic and radiological procedures allowing placement of bile duct prosthesis and abdominal drainage. In 2 patients with small localized sub-hepatic collection, no surgical or radio-endoscopic tre atment was attempted ; spontaneous resolution of the collections was a chieved in 2 months on ultrasound examination. All patients are alive, although, the patient who was operated on with a roux-en-Y choledocho jejunostomy developed thrombosis of the right hepatic artery and bilia iry anastomotic stenosis which required further operations. We advocat e endoscopic placement of endobiliary prosthesis and percutaneous bili ary drainage as first-line therapy for significant fistula after T-tub e removal. The use of choledochocholedochostomy without a T-tube when possible for biliary reconstruction in liver transplantation could be an effective procedure, but requires further evaluation.