Management of biliary complication after LT

Anatomy of biliary system

Variation of biliary system (extrahepatic)

Biliary AnastomosisThere is two types of anastomosis:1. Physiologic choledochocholedochostomy end to

end (duct to duct) anastomosis.2. Hepaticojejunostomy.

Biliary complication after liver transplantation

• Biliary complications occur in 5—25%. of patients after liver transplantation and represent a major source of morbidity and mortality after liver transplantation.

Incidence of biliary complications (Endoscopic and Liver unite, Barcelona, Spain, 2011)

Biliary complication Incidence

1. Anastomotic strictures a. Deceased donor 4-13% b. Living donor 18-40%

2. Bile leak 2-25% 3. Sphincter of Oddi dysfunction 2-7% 4. Biliary filling defects 5% 5. Non—anastomotic stricture 0.5-3% 6. Mucocele < 0.5% 7. Hemobilia < 0.5%

RISK FACTORS

The most common risk factors responsible for the development of biliary complications after LT are related to: (1)Graft- related factors.(2) Intra-operative factors.(3)Non-operative factors.

Diagnostic approach1. The clinical presentation of biliary complications.2. A biliary complication usually is first suspected in

asymptomatic LT recipients who have elevations liver functions.

Investigation1. Abdominal ultrasound (US) with a Doppler

evaluation of the hepatic vessels.2. MRCP.3. Liver biopsy.4. Endoscopic retro-grade cholangiography ERC to

confirm diagnosis and allows therapy. 5. A percutaneous trans-hepatic cholangiography

(PTC): for patients in whom ERC was unsuccessful or in patients with a Roux-en-Y hepaticojejunostomy.

ERC: endoscopic retrograde cholangiography. BS: biliary sphincterotomy, PTC: percutaneous transhepatic cholangiography

Biliary strictureIt is the most common biliary complication after LT and account for approximately 40% of complications.

Classification 1. According to time: a. Early.b. Late.2. According to the localizationc. Anastomotic (AS) account 80% of stricture.d. Nonanastomotic (NAS): 0.5 cm proximal to

anastomosis

Anastomotic stricturesA. Factors

1. Technical problems of the biliary anastomosis.2. Ischemia.

B. Management 3. ERC and biliary sphincterotomy. Patients usually

require several ERC sessions every 3 months and long-term stenting (for 12—24 months).

4. Percutaneous internal-external drainage placed with PTC if failed ERC.

Nonanastomotic strictureA. Factors

1. Hepatic artery complications leading to irreversible biliary injury.

2. Long cold ischemia time or ABO-blood type incompatibility.

B. Management3. ERC and PTC are more difficult and less successful

than that of AS. 4. Furthermore, up to 50% of patients undergo

retransplantation or die as a consequence of this complication.

Bile leakSite: the anastomotic site, the cystic duct remnant or cut surface of the liver.Classification: early or late.The clinical presentation: is variable and may be accidental discovered by US as a fluid collection.Management 1. ERC. 2. A percutaneous drainage.3. Surgery if signs of peritonitis.4. Roux-en-Y leak is less common. ERC is not standard. Management is per-cutaneous internal-external drainage or surgery.

BilomaIt occurs due to bile duct rupture and extravasation of bile into the hepatic parenchyma or the abdominal cavity. Sites: perihepatic area, outside of the liver.Management:1. Percutaneous drainage and antibiotics.2. Surgery is indicated when the patients have tense

ascites or failed percutaneous drainage to control.

Biliary filling defectsTypes: gall- stones (70%), debris, blood clots, and casts.Symptoms of CBD stone is vary from asymptomatic cholestasis, to abdominal pain, or recurrent attacks of cholangitis.ManagementERC like non-transplant patients (biliary sphincterotomy and balloon or stone extraction) with. Recurrence rate is 17% within a median of 6 months.

Prevention of biliary complicationsDonor surgery

1. Preoperative evaluation of the biliary anatomy like MRCP.2. Intraoperative cholangiography.3. Maintain sufficient blood supply for the graft bile duct by

the connective tissue around the duct should be left, with minimal dissection.

Recipient surgeryThere are two major technical considerations in duct to duct anastomosis:(1) Maintain a viable blood supply to the biliary tract.(2) Leave sufficient length of the bile duct for a tension-free

anastomosis.

Management of biliary complication after LDLT by AL-Azhar university team

• 72 patients underwent liver transplantation by Al-Azhar university team

• 25 pt. at the liver unite Al-Zahraa university hospital.

• 4 pt. Dar Elhekema hospital• 43 pt. El-Rahma hospital.

Types of anastomosis:

Duct to duct anastomosis 70 pt.

Hepaticojejunostomy anastomosis 2 pt.

70 Pt.

Number of orifices

Single orifice

45 Pt.

2 orifices 23 pt.

Convert to 1 orifice

13 Pt.

To separate orifices 10 pt.

Types of anastomosis

Right and cystic duct

7 Pt.

Right and left Hepatic duct

5 Pt.

3 orifices 2 pt.

End up 2 orifices

Biliary Complications12 patients

Bile leak5 patients

3 Pat with single duct

ERCP 2 pt.

Failed and died Success

hepaticojejunostomy

2 Pat with 2 orifices

ERCP

Success and Stenting of

right posterior

Failed and converted to

Hepaticojejunostomy

anastomosis

Stricture

4 Pat

3 Pat with single orifices

2 Pat with ERCP

Success in 2nd time and stenting

Failed and converted to

Hepaticojejunostomy

anastomosis

MRCP Hepaticojejun

ostomy

Surgery duct to duct

Hepaticojejunostomy

1 Pat with 2 orifices

ERCP

Failed and converted to

Hepaticojejunostomy

anastomosis

Biloma3 Pat

1 Pat ERCP

2 Pat percutaneous drainage by

US