Biliary reconstruction without T tubes or stents in liver transplantation: Report of 502 consecutive cases

Abstract

Although T tubes and stents are widely used as part of the routine biliary reconstruction in liver transplantation, they have inherent complications and there is no proof that they are beneficial to healing. We do not use T tubes or anastomotic stents, and we reviewed our experience with 502 consecutive, whole-size liver grafts to determine the incidence and nature of biliary complications. Duct-to-duct (D-D) and Roux-en-Y loop-to-duct (RY-D) anastomoses were performed in 321 and 176 cases, respectively. In 62% of cases, the donor gallbladder was transplanted and an external catheter cholecystostomy was fashioned to provide for postoperative cholangiography. In the remaining cases the gallbladder was removed. Biliary complications of all types occurred after 13.5% of the transplants. Anastomotic complications (stricture, obstruction, or leak) occurred in 8.2% of the cases, and they were least frequent (4.0%) with RY-D reconstructions. Gallbladderrelated complications accounted for one quarter of all biliary complications, and they outweighed the advantage of convenient access to the biliary tree for cholangiography. Four patients (0.9%) died of biliary complications. We conclude that routine reconstruction of the biliary tract without T tubes or stents is a safe technique in liver transplantation. Retaining the donor gallbladder as a method of providing cholangiography is not necessary.

Diagnostic Value of Ultrasound in Detection of Biliary Tract Complications After Liver Transplantation

“…Biliary complications occur in 9-35 % of liver transplant recipients (1-8). It is reported as an uncommon cause of mortality, but represent a significant source of morbidity (9).…”

Biliary Tract Complications after Liver Transplantation: A Review

“…Biliary strictures complicate around 2–14% of OLT and are classified as anastomotic and non-anastomotic in site [5,6,7,8,9,10,11, 86, 119, 120]. They may be due to technical causes, ischemia of the biliary tree due to hepatic artery thrombosis or stenosis (fig.…”

“…An end-to-end duct-to-duct anastomosis is the procedure of choice in most institutions following whole-organ OLT in patients with healthy native bile ducts of suitable caliber [5, 6]. This technique yields a physiological bilioenteric continuity and allows biliary complications to be treated endoscopically.…”

“…originating from the T-tube exit site or from the cut surface of the graft in case of partial liver graft transplantation [5, 6, 8, 9, 107, 108]. As a general rule, the majority occur early in the postoperative period and mandate operative or endoscopic intervention to avoid sepsis [5].…”

“…With improvements in organ selection, retrieval, preservation, and implantation techniques such complications have been reduced dramatically. Biliary complications, however, still occur in 10–30% following whole-organ OLT resulting in mortality rates up to 10% of cases [5,6,7,8,9,10,11] (table 1). …”