7237 Bile leaks after t-tube removal in orthotopic liver transplantation patients: the role of ercp.

Abstract

Background: End-to-end choledochocholedochostomy (CCS) over a T-tube has been the standard method of biliary reconstruction following orthotopic liver transplantation (OLT). Bile leaks following T-tube removal in these patients (pts) have been reported with a frequency of 8-12% in published series. Hypotheses: (1) T-tube removal in OLT pts with CCS have an unusually high incidence of post-procedure bile leaks. (2) Patients with bile leaks following Ttube extraction can be successfully treated with endoscopic therapy. Methods: The records of all pts having OLT at our center between 8/93 and 6/99 were reviewed for endoscopic management of bile leaks following T-tube removal. Pt records and a computerized database of ERCP procedures were searched. Indications for ERCP were noted, as well as the number of stent placements, the size of the stents, and length of treatment required for leak resolution. Results: 216 OLT procedures were performed in the study period. 26 (12%) pts required ERCP to assess and treat a bile leak after T-tube extraction. Most developed pain immediately after T-tube extraction; only 1 patient developed pain after 24 hours. Two patients were lost to follow-up after their index ERCP. Of the remaining 24, 20(83%) underwent 1 stent insertion and 4(17%) underwent 2 stent insertions. Initial stent sizes were 7FR (n=9; 38%); 8.5FR (n=1; 4%) and 10FR (n=14; 58%). All patients requiring two stent placements (n=4), initially received a 7FR stent. Treatment lasted an average of 49 days (ranging 21-82 days) following the initial ERCP. No pt required percutaneous biliary drainage or surgery for this type of leak. Cholangitis (n=1) was the only complication noted. Discussion: In our center, the incidence of bile leaks following T-tube extraction in OLT pts was similar to that of previously reported series. In every case endoscopic stenting resulted in resolution of the leak. Delayed closure of leaks was associated with initial use of a 7FR stent, suggesting that larger (e.g. 10FR) diameter stents should be used whenever possible. ERCP with biliary stent placement appears to be an effective way to manage bile leaks following T-tube extraction in this pt group. Recognizing that urgent ERCP may be required when T-tubes are removed, we have established a policy of fasting these patients overnight and doing the T-tube extraction early in the day.