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Management of biliary complication after LT

Author: moustafa-hegazy

Post on 03-Jun-2015

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محاضرات عين شمس

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  • 1. Management of biliary complication after LT

2. Anatomy of biliary system 3. Variation of biliary system (extrahepatic) 4. Biliary AnastomosisThere is two types of anastomosis:1. Physiologic choledochocholedochostomy end toend (duct to duct) anastomosis.2. Hepaticojejunostomy. 5. Biliary complication after livertransplantation Biliary complications occur in 525%. of patientsafter liver transplantation and represent a majorsource of morbidity and mortality after livertransplantation. 6. Incidence of biliary complications (Endoscopic and Liverunite, Barcelona, Spain, 2011)Biliary complication Incidence1. Anastomotic stricturesa. 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. Nonanastomotic stricture 0.5-3%6. Mucocele < 0.5%7. Hemobilia < 0.5% 7. RISK FACTORSThe most common risk factors responsible for thedevelopment of biliary complications after LT arerelated to:(1)Graft- related factors.(2) Intra-operative factors.(3)Non-operative factors. 8. Diagnostic approach1. The clinical presentation of biliary complications.2. A biliary complication usually is first suspected inasymptomatic LT recipients who have elevationsliver functions. 9. Investigation1. Abdominal ultrasound (US) with a Dopplerevaluation of the hepatic vessels.2. MRCP.3. Liver biopsy.4. Endoscopic retro-grade cholangiography ERC toconfirm diagnosis and allows therapy.5. A percutaneous trans-hepatic cholangiography(PTC): for patients in whom ERC was unsuccessfulor in patients with a Roux-en-Yhepaticojejunostomy. 10. ERC: endoscopic retrograde cholangiography. BS: biliary sphincterotomy,PTC: percutaneous transhepatic cholangiography 11. Biliary strictureIt is the most common biliary complication after LTand account for approximately 40% of complications.Classification1. According to time:a. Early.b. Late.2. According to the localizationa. Anastomotic (AS) account 80% of stricture.b. Nonanastomotic (NAS): 0.5 cm proximal toanastomosis 12. Anastomotic stricturesA. Factors1. Technical problems of the biliary anastomosis.2. Ischemia.B. Management1. ERC and biliary sphincterotomy. Patients usuallyrequire several ERC sessions every 3 months andlong-term stenting (for 1224 months).2. Percutaneous internal-external drainage placedwith PTC if failed ERC. 13. Nonanastomotic strictureA. Factors1. Hepatic artery complications leading to irreversiblebiliary injury.2. Long cold ischemia time or ABO-blood typeincompatibility.B. Management1. ERC and PTC are more difficult and less successfulthan that of AS.2. Furthermore, up to 50% of patients undergoretransplantation or die as a consequence of thiscomplication. 14. Bile leakSite: the anastomotic site, the cystic duct remnant orcut surface of the liver.Classification: early or late.The clinical presentation: is variable and may beaccidental discovered by US as a fluid collection.Management1. 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-externaldrainage or surgery. 15. BilomaIt occurs due to bile duct rupture and extravasation ofbile into the hepatic parenchyma or the abdominalcavity.Sites: perihepatic area, outside of the liver.Management:1. Percutaneous drainage and antibiotics.2. Surgery is indicated when the patients have tenseascites or failed percutaneous drainage to control. 16. Biliary filling defectsTypes: gall- stones (70%), debris, blood clots, andcasts.Symptoms of CBD stone is vary from asymptomaticcholestasis, to abdominal pain, or recurrent attacks ofcholangitis.ManagementERC like non-transplant patients (biliarysphincterotomy and balloon or stone extraction) with.Recurrence rate is 17% within a median of 6 months. 17. Prevention of biliary complicationsDonor surgery1. Preoperative evaluation of the biliary anatomy like MRCP.2. Intraoperative cholangiography.3. Maintain sufficient blood supply for the graft bile duct bythe connective tissue around the duct should be left, withminimal dissection.Recipient surgeryThere are two major technical considerations in duct to ductanastomosis:(1) Maintain a viable blood supply to the biliary tract.(2) Leave sufficient length of the bile duct for a tension-freeanastomosis. 18. Management of biliary complication afterLDLT by AL-Azhar university team 72 patients underwent liver transplantation by Al-Azhar university team 25 pt. at the liver unite Al-Zahraa universityhospital. 4 pt. Dar Elhekema hospital 43 pt. El-Rahma hospital.Types of anastomosis:Duct to ductanastomosis70 pt.Hepaticojejunostomyanastomosis2 pt. 19. 70 Pt.Number oforificesSingle orifice45 Pt.2 orifices 23pt.Convert to 1orifice13 Pt.To separateorifices 10 pt.Types ofanastomosisRight andcystic duct7 Pt.3 orifices 2 pt.End up 2orificesRight and leftHepatic duct5 Pt. 20. Biliary Complications12 patientsBile leak5 patients3 Pat withsingle ductERCP 2 pt.Failed anddiedhepaticojejunostomySuccess2 Pat with 2orificesERCPSuccess andStenting ofrightposteriorFailed andconverted toHepaticojejunostomyanastomosisStricture4 Pat3 Pat withsingle orifices2 Pat withERCPSuccess in 2ndtime andstentingFailed andconverted toHepaticojejunostomyanastomosisMRCPHepaticojejunostomySurgery ductto ductHepaticojejunostomyBiloma3 Pat1 Pat with 2orificesERCPFailed andconverted toHepaticojejunostomyanastomosis1 Pat ERCP2 Patpercutaneousdrainage byUS