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

Abstract

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.)

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

“…The results of the endoscopic approach in the treatment of biliary fistulas reported in recent literature [15] are more favorable with 82.6% of success. Moreover, we must consider that cannulation of the bile ducts proximal to the origin of the fistula may be unsuccessful [16] in a relevant percentage of cases and that ERCP is not feasible in patients with hepatico-jejunostomy.…”

Biliary Tract Complications after Liver Transplantation: A Review

“…These include the use of rubber tubes instead of silicone ones [7], leaving a counter drain or the T-tube in the tract under fluoroscopic guidance [98, 99], or delayed removal of biliary drains until 4–6 months after OLT [100, 101]. Transcystic or internal endobiliary stents, as well as routine interventional radiologic procedures have also been proposed to overcome these problems [11, 100,102,103,104]. Many groups have abandoned the use of a T-tube at whole-organ OLT, which has been shown to be safe, efficacious, and cost-effective, as compared to biliary reconstruction over a T-tube [86, 87, 105, 106].…”

“…Endoscopic sphincterotomy and stenting or nasobiliary drainage, however, appear to emerge as the preferred treatment options in case of both leaks after T-tube removal and cut surface biliary leaks, restricting surgery to patients with frank peritonitis and/or large leaks [116,117,118]. Endoscopic placement of nasobiliary catheters may offer the advantage of access for cholangiography and easy removal [104]. In any case, associated intra-abdominal bile collection (biloma) should be treated by percutaneous ultrasound-guided or CT-guided drainage [101, 110].…”

Endoscopic management of post-liver transplant biliary complications

“…In case of T-tube associated bile leaks confirmed on Ttube cholangiogram, leaving the drain open might suffice, without need for any further interventions. Naso-biliary drainage can also be performed in place of biliary stenting and Saab et al [72] in fact suggested that it might be the preferred strategy for management of biliary leaks. Although naso-biliary tubes can be useful for cholangiographic follow-up without further endoscopies and confirmation of leak sealing, however are very poorly tolerated.…”