Endoscopic Management of Biliary Complications after Adult Living Donor Liver Transplantation

Abstract

Background: Biliary complications and their treatment in adult cadaveric liver transplantation (CLT) are well described. However, biliary complications and their management in adult living donor liver transplantation (LDLT) are not well characterized. Recently, duct-to-duct anastomoses have been popularized as method for reconstruction of biliary continuity following adult LDLT. Endoscopic management has been highly successful in biliary complications post-CLT. However, limited data are available in reference to adult LDLT. Aim: To assess the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary complications following adult LDLT and compare it with the adult CLT recipient cohort. Patients and Methods: We performed a retrospective cohort analysis of all adult LDLT recipients with duct-to-duct anastomoses without T-tube. Comparisons were made with an adult CLT recipient cohort. The endoscopic procedure was considered successful if there was no need of other type of intervention for biliary complication and clinical picture resolved. Results: A total of 322 adult patients received 340 grafts from January 1988 to September 2004. The frequency of biliary complications after CLT was 16.5% (51/310) and after LDLT was 37 % (11/30) (p=0.006). Greater percentage of LDLT recipients underwent ERCP (8/30, 27%) compared to CLT recipients (21/310, 7%; p<0.001). Five LDLT patients had conventional duct-to-duct anastomosis and 3 patients had more complex biliary reconstruction. Biliary complications diagnosed by ERCP in LDLT recipients consisted of bile leaks and strictures, and were more frequent than in CLT recipients (leaks: 3/30, 10% vs. 4/310 1%; p<0.001; strictures: 3/30, 23% vs. 15/310, 5%; p<0.001). Bile leaks were successfully treated endoscopically in 100 % and 75 % of LDLT and CLT recipients, respectively (p= NS). The endoscopic resolutions for strictures were 28% and 80% in LDLT and CLT groups, respectively. Although the difference in the resolutions of biliary strictures among LDLT and CLT did not reach statistical significance (p=0.052), there was a trend to a higher success rate in the second group. Conclusions: Adult LDLT is associated with increased biliary complications as compared to CLT. In patients with duct-to-duct anastomosis without T-tube, ERCP can successful treat LDLT related biliary leaks. However, in LDLT related biliary strictures the endoscopic managenent may be associated with a low success rate. Background: Biliary complications and their treatment in adult cadaveric liver transplantation (CLT) are well described. However, biliary complications and their management in adult living donor liver transplantation (LDLT) are not well characterized. Recently, duct-to-duct anastomoses have been popularized as method for reconstruction of biliary continuity following adult LDLT. Endoscopic management has been highly successful in biliary complications post-CLT. However, limited data are available in reference to adult LDLT. Aim: To assess the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary complications following adult LDLT and compare it with the adult CLT recipient cohort. Patients and Methods: We performed a retrospective cohort analysis of all adult LDLT recipients with duct-to-duct anastomoses without T-tube. Comparisons were made with an adult CLT recipient cohort. The endoscopic procedure was considered successful if there was no need of other type of intervention for biliary complication and clinical picture resolved. Results: A total of 322 adult patients received 340 grafts from January 1988 to September 2004. The frequency of biliary complications after CLT was 16.5% (51/310) and after LDLT was 37 % (11/30) (p=0.006). Greater percentage of LDLT recipients underwent ERCP (8/30, 27%) compared to CLT recipients (21/310, 7%; p<0.001). Five LDLT patients had conventional duct-to-duct anastomosis and 3 patients had more complex biliary reconstruction. Biliary complications diagnosed by ERCP in LDLT recipients consisted of bile leaks and strictures, and were more frequent than in CLT recipients (leaks: 3/30, 10% vs. 4/310 1%; p<0.001; strictures: 3/30, 23% vs. 15/310, 5%; p<0.001). Bile leaks were successfully treated endoscopically in 100 % and 75 % of LDLT and CLT recipients, respectively (p= NS). The endoscopic resolutions for strictures were 28% and 80% in LDLT and CLT groups, respectively. Although the difference in the resolutions of biliary strictures among LDLT and CLT did not reach statistical significance (p=0.052), there was a trend to a higher success rate in the second group. Conclusions: Adult LDLT is associated with increased biliary complications as compared to CLT. In patients with duct-to-duct anastomosis without T-tube, ERCP can successful treat LDLT related biliary leaks. However, in LDLT related biliary strictures the endoscopic managenent may be associated with a low success rate.