Management of biliary complications after adult-to-adult living donor liver transplantation. Initial experience in a latin american center

Abstract

Presenter: Sergio Riveros MD | Pontificia Universidad Católica de Chile Background: Living donor liver transplantation (LDLT) is a complex therapeutic alternative that requires a specialized multidisciplinary team with the capacity to resolve complications. The number of anastomosed ducts has an impact on the rate of postoperative biliary complications, but the literature is still scarce. The objective of this study was to describe early and late postoperative biliary complications with a focus on therapeutic management in the initial experience of a LDLT program. Methods: Non-concurrent cohort study at a Pontificia Universidad Católica de Chile. All patients who underwent adult-to-adult LDLT were included from 2016 to 2020. Patients were divided into two groups according to the number of bile duct anastomoses (single duct, group A; and two or three ducts, group B). Demographic, perioperative, postoperative outcomes regarding early and late biliary complications (>2 months), treatment, major complications (Clavien-Dindo III-IV), mortality, and survival were evaluated and compared between groups. Results: single bile duct was anastomosed in 63.3% (n = 19), two bile ducts in 33.3% (n = 10) and three bile ducts in 3.3% (n = 1). Duct-to-duct (DD) anastomosis was performed in 56.7% (n = 17), hepaticojejunostomy (HJ) in 33.3% (n = 10) and combined in 10% (n = 3). Major complications were reported in 46.7% (n = 14), median length of postoperative stay was 15.5 days (7-46) and median follow-up 17 months (0.4-53.5). Overall graft and patient survival was 87% at 24 months. Group A (n = 19) had major complications in 21% (n = 4), early biliary complications in 15.8% (n = 3) and late biliary strictures in 26.7% (n = 4). None required percutaneous drainage, 5.3% surgical drainage (n = 1) and 10.5% re-anastomosis to a Roux-en-Y HJ (n = 2). They underwent ERCP in 26.7% (n = 4) and percutaneous transhepatic internal-external drainage in 6.7% (n = 1). Four patients (21.1%) had early mortality and one patient (6.7%) late mortality, all unrelated to biliary complications. Group B (n = 11) had major complications in 90.9% (n = 10), early biliary complications in 81.8% (n = 9) and late biliary strictures in 54.5% (n = 6). They required percutaneous drainage in 27.3% (n = 3), surgical drainage in 9.1% (n = 1), endoscopic transgastric drainage in 9.1% (n = 1), duct-to-duct reinforcement (n = 1) and re-anastomosis to Roux-en-Y HJ (n = 4). They underwent ERCP in 27.3% (n = 3) and percutaneous transhepatic internal-external drainage in 18.2% (n = 2). All patients are alive with 100% graft and patient survival. Conclusion: Living donor liver transplantation is a challenging treatment that requires a specialized high-volume center with the ability to rescue postoperative complications. The number of reconstructed ducts affects the rate of early biliary complications, without an impact on graft and patient survival. In our experience, patients with 2-3 graft bile ducts had a high rate of biliary complications, but with adequate management, all patients are alive with functioning grafts. Expertise in advanced endoscopy, interventional radiology, and complex reoperations are crucial to achieve excellent outcomes.