Results of choledochojejunostomy in the treatment of biliary complicationsafter liver transplantation in the era of nonsurgical therapies

Advances in radiological and endoscopic techniques have allowed many biliar y complications after orthotopic liver transplantation (OLT) to be managed without surgery. The influence of nonsurgical management on the outcome of patients requiring surgical revision has not been addressed. We reviewed ou r 10-year experience (October 1988 to January 1998) of Roux-en-Y choledocho jejunostomy (CDJ) to treat biliary complications after OLT. Forty-six patie nts underwent CDJ for biliary complications (32 men, 14 women; age, 22 to 6 5 years; median, 60 years). Biliary reconstruction at the time of OLT was d uct to duct in 41 patients, primary CDJ in 3 patients, and gall bladder con duit in 2 patients. T-tubes were used only in patients with gallbladder con duit. The indication for CDJ was biliary leak (23 patients), stricture (20 patients), biliary stones (2 patients), and biliary sludge (1 patient). Two patients (4.3%) had associated hepatic artery thrombosis. The bile leaks w ere diagnosed at a median of 29 days post-OLT (range, 2 to 65 days) and str ictures at a median of 2 years (range, 33 days to 6.5 years) post-OLT. Befo re surgery, 25 patients (54%) underwent an attempt at radiological or endos copic therapeutic intervention that failed, Median follow-up was 5 years (r ange, 9 months to 10 years), Early complications occurred in 12 patients (2 6%); the most common was chest infection (4 patients). There were 3 periope rative deaths (6%); 1 death was directly related to surgery. Late complicat ions, mainly anastomotic strictures, occurred in 10 patients (22%), half of which were successfully treated by biliary balloon dilatation. The complic ation rate post-CDJ was less in those who underwent a failed nonsurgical ap proach than those proceeding straight to surgery (3 of 25 patients; 36% v 1 3 of 21 patients; 62%; P =.21, not significant). The procedure-related mort ality for surgical revision of biliary complications after OLT is low, but early and late complications are common. A failed attempt at nonsurgical ma nagement does not increase the complications of reconstructive surgery. Str ictures after CDJ should be considered for biliary balloon dilatation. Copy right (C) 2000 by the American Association fbr the Study of Liver Diseases.