Cholangiography and interventional biliary radiology in adult liver transplantation

Zajko, Albert B.; Campbell, William L.; Bron, Klaus M.; Lecky, James W.; Iwatsuki, Shunzaburo; Shaw, Byers W.; Starzl, Thomas E.

doi:10.2214/ajr.144.1.127

Cited by 61 publications

(40 citation statements)

References 6 publications

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“…Hepatic artery thrombosis or stenosis often presents as a hiliary tract complication. 9 We found 17% of the leaks and 10.7% of the strictures were associated with hepatic artery abnormalities. The coexistence of arterial pathologic conditions with a biliary problem must be recognized before a surgical procedure is undertaken.…”

Section: Discussionmentioning

confidence: 65%

See 1 more Smart Citation

The Incidence, Timing, and Management of Biliary Tract Complications After Orthotopic Liver Transplantation

Greif

Bronsther²,

Thiel³

et al. 1994

Annals of Surgery

470

377

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ObjectiveThis study analyzed the incidence and timing of biliary tract complications after orthotopIc liver transplantation (OL Tx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. Summary Background DataTechnical complications after OL Tx have a significant Impact on patient and graft survival. One of the principle technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless. biliary complications stili occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications In 13.2% of transplants. MethodsThe medical records of all patients who underwent liver transplantation and were hospitalized between January 1,1988 and July 31.1991 were revieWed. The case matenal conSisted of the medical records of 217 patients treated for 245 biliary complICations. Results Primary biliary continuity was established by either choledochocholedochostomy over a T·tube(C-C, n = 129) or a Roux-en-Y choledochoJeJunostomy With an internal stent (C-RY, n = 85). The overall Incidence for biliary complication in this large senes was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most biliary complications (n = 143, 66%) occurred Within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent In both C-C and CoRY (27.1 % and 25.9%, respectively): strictures were more common after a CoRY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an InCidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejectIOn before the recognition of biliary tract pathologiC findings. 40

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Section: Discussionmentioning

confidence: 65%

“…it must be emphasized that primary biliary tract complications must be differentiated from those secondary to arterial insufficiency. 9 From January I. 1988 to July 31.…”

mentioning

confidence: 99%

The Incidence, Timing, and Management of Biliary Tract Complications After Orthotopic Liver Transplantation

Greif

Bronsther²,

Thiel³

et al. 1994

Annals of Surgery

470

377

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“…[5][6][7] Although the clinical picture prompts the diagnosis of biliary leakage in most patients, the diagnosis is also suggested in a minority of patients based on fluctuating cyclosporine levels, pneumoperitoneum, or increased leakage through the Ttube tract. 8 The management of biliary leakage after elective Ttube removal has evolved with increased experience from surgery, 4,9-11 watchful waiting and/or supportive care, 12,13 interventional radiology, [14][15][16] and endoscopy. 5,17,18 Results of percutaneous transhepatic cholangiograpy and endoscopic intervention were initially discouraging because of poor results compared with surgery 19 and concerns of damage to the donor liver.…”

mentioning

confidence: 99%

Endoscopic Management of Biliary Leaks After T-Tube Removal in Liver Transplant Recipients: Nasobiliary Drainage Versus Biliary Stenting

Saab

Martin

Soliman

et al. 2000

Liver Transplantation

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This study presents the long-term sequelae of endoscopic retrograde cholangiopancreatography (ERCP)-managed biliary leakage in patients who underwent orthotopic liver transplantation (OLT) and compares the relative efficacy, safety, and charges of nasobiliary drainage (NBD) versus biliary stenting (BS). We identified all orthotopic liver transplant recipients from January 1, 1993, to December 31, 1997, who had undergone ERCP for biliary leakage. Clinical outcome and charges were calculated on an intention-to-treat basis according to initial endoscopic therapy. Of the 1,166 adult OLTs performed during the study period, 442 patients underwent elective T-tube removal. ERCP was attempted in 69 patients (16%) who developed biliary leakage after T-tube removal. Three patients (5%) in whom initial ERCP was unsuccessful underwent surgery. NBD and BS were used as primary therapy in 45 (68%) and 21 patients (32%), respectively. Three patients initially treated with NBD required reendoscopy or surgery compared with 6 patients initially treated with BS (P < .05). Although not statistically significant, there was a trend toward greater expense in the BS group compared with the NBD group. ERCP is a safe and effective method of managing biliary leakage after T-tube removal in orthotopic liver transplant recipients. However, our results suggest NBD is the preferred method because recurrent leaks were more common in patients treated initially with BS. With prompt use of ERCP, surgery is rarely needed for this complication of OLT. (Liver Transpl 2000;6: 627-632.)

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“…[7][8][9] Our habit of avoiding T tubes arose from the practical difficulties of inserting them, with the risk of damaging the ductal blood supply and potentially compromising the vascularity of the anastomosis. 21 The problems of migration, obstruction, and leakage related to the tubes and stents, which occur in up to 10% of patients, 3,11,12 were additional reasons to avoid them. Our experience has shown that T tubes are unnecessary, and routine biliary reconstruction without stenting is a safe technique with a complication rate that compares favorably to other series.…”

Section: Discussionmentioning

confidence: 99%

“…10 Although T tubes allow postoperative cholangiography, they have inherent disadvantages, and problems related to their migration, obstruction, and leakage are common. 3,[11][12][13] We have never been convinced that stenting is advantageous or beneficial to the healing of biliary anastomoses. The routine method of biliary drainage in our center has been either a D-D or RY-D reconstruction without a T tube or stent.…”

mentioning

confidence: 99%

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

et al. 1997

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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.

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Cholangiography and interventional biliary radiology in adult liver transplantation

Cited by 61 publications

References 6 publications

The Incidence, Timing, and Management of Biliary Tract Complications After Orthotopic Liver Transplantation

The Incidence, Timing, and Management of Biliary Tract Complications After Orthotopic Liver Transplantation

Endoscopic Management of Biliary Leaks After T-Tube Removal in Liver Transplant Recipients: Nasobiliary Drainage Versus Biliary Stenting

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

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