Biliary complications secondary to late hepatic artery thrombosis in adult liver transplant patients

Abstract

Biliary complications (BC) are the usual presentation of late hepatic artery thrombosis (HAT) of the liver graft. Our aim was to study the clinical features and outcome of BC secondary to HAT compared to BC which occurred in liver transplant (LT) patients with patent vessels. We present a retrospective study of 224 LTs performed in 204 patients between 1988 and 1996. The mean recipient x s age was 51 years. A choledochocholedochostomy without T‐tube was used as biliary reconstruction in most cases (67%); in 12%, a choledochojejunostomy was performed. An iliac conduit was necessary in 15 % of cases and back‐table arterial reconstruction was performed in 10 % of cases of anatomic variants in graft arteries. Different donor, recipient and intraoperative variables, as well as treatment and outcome, were studied in the two groups of patients presenting BC with or without HAT. BC occurred in 38 cases (17%) whereas HAT was diagnosed in 11 cases (4.9%). Therefore, 23 % of BC encountered after LT were secondary to HAT. Nine cases of late HAT manifested as BC, septicaemia (88 %) and hepatic bilomas (8 cases). Percutaneous or surgical drainage of hepatic bilomas was performed in all cases, followed by retransplantation in six cases (66%). BC secondary to HAT appeared later than the rest of BC. Donor age was the only significant predisposing factor found in our study. Graft survival is significantly reduced as most patients needed re‐transplantation. In conclusion, BC secondary to HAT presented later in livers from older donors in the form of biliary sepsis and hepatic biloma. Retransplantation was ultimately required in most cases and graft survival was significantly diminished.

Infected Bilomas in Liver Transplant Recipients, Incidence, Risk Factors and Implications for Prevention

“…Understanding the pathogenesis of biloma formation in liver transplantation is essential to devising effective strategies for prevention (Figure 2). Previous studies that attempted to identify risk factors for biloma formation were limited by relatively few cases (13,14), lack of a control group (13,14,25,26) or restricting the study population to patients with HAT (10–12,27), precluding analysis of HAT as a risk factor for biloma formation.…”

“…However, infection, especially involving the biliary tract, remains one of the most challenging complications (6,7). Bilomas, infected intra or parahepatic bilious fluid collections (8), are associated with frequent graft loss and necessity for retransplantation, greatly increased medical costs and significant mortality (9–12).…”

Bile duct complications after liver transplantation

“…They are sometimes caused by recurrence or persistence of early complications or can be due to delayed removal of T‐tubes, transhepatic anastomotic stents or biliary stent migration and perforation. Leakages secondary to late HAT were also reported and correlated significantly with donor age [50].…”

“…Three prospective trials on the usefulness of T‐tubes did not support the hypothesis that patients without T‐tubes are at higher risk for stricture formation [40,48,50]. Biliary strictures can occur with either type of biliary reconstruction.…”

Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation

“…There are four different sources to obtain such a vascular conduit: recipients own vessels (e.g. the umbilical vein, portal vein, any collateral vein, saphenous vein, iliac veins); radial artery may also be used for arterial interposition vessels procured from the living donor besides the allograft (the ovarian vein, inferior mesenteric vein), cadaveric vessels (the iliac artery and veins or any other vessels procured from the cadaver) and synthetic vascular grafts [2,12–19]. Initially, saphenous veins were preferred as an interposition graft, but Lee et al.…”