Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Dec 24, 2015; 5(4): 300-309
Published online Dec 24, 2015. doi: 10.5500/wjt.v5.i4.300
Biliary complications in liver transplantation: Impact of anastomotic technique and ischemic time on short- and long-term outcome
Stefan Kienlein, Wenzel Schoening, Anne Andert, Daniela Kroy, Ulf Peter Neumann, Maximilian Schmeding
Stefan Kienlein, Wenzel Schoening, Anne Andert, Ulf Peter Neumann, Maximilian Schmeding, Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, 52074 Aachen, Germany
Daniela Kroy, Department of Gastroenterology and Hepatology, University Hospital Aachen, 52074 Aachen, Germany
Author contributions: Kienlein S wrote the manuscript and collected data; Schoening W analysed data and revised manuscript; Andert A and Kroy D collected data; Neumann UP analysed data; Schmeding M designed study, analysed data and revised manuscript.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Aachen Medical University Hospital.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to the treatment by written consent. For full disclosure, the details of the study are published on the home page of Aachen Medical University.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Stefan Kienlein, MD, Department of General, Visceral and Transplantation Surgery, University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany. skienlein@ukaachen.de
Telephone: +49-241-8037356
Received: June 24, 2015
Peer-review started: June 24, 2015
First decision: September 17, 2015
Revised: September 29, 2015
Accepted: October 20, 2015
Article in press: October 27, 2015
Published online: December 24, 2015
Processing time: 182 Days and 5.8 Hours
Abstract

AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.

METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation (LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side (SS), end-to-end (EE) anastomosis or hepeaticojejunostomy (HJ). Biliary complications (BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion (ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography (ERCP)]. Laboratory results included alanine aminotransferase (ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional (e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.

RESULTS: A total of 200 patients [age: 56 (19-72), alcoholic cirrhosis: n = 64 (32%), hepatocellular carcinoma: n = 40 (20%), acute liver failure: n = 23 (11.5%), cryptogenic cirrhosis: n = 22 (11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13 (6.5%), primary sclerosing cholangitis: n = 13 (6.5%), others: n = 25 (12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5% (n = 75) with anastomotic strictures (AS): n = 38 (19%), bile leak (BL): n = 12 (6%), biliary drain complication: n = 12 (6%); papillary stenosis (PS): n = 7 (3.5%), ITBL: n = 6 (3%). Clinically relevant were only 19% (n = 38). We established a comprehensive classification for AS with four grades according to clinical relevance. The reconstruction techniques [SS: n = 164, EE: n = 18, HJ: n = 18] showed no significant impact on the development of BCs in general (all n < 0.05), whereas in the HJ group significantly less AS were found (P = 0.031). The length of donor intensive care unit stay over 6 d had a significant influence on BC development (P = 0.007, HR = 2.85; 95%CI: 1.33-6.08) in the binary logistic regression model, whereas other reviewed variables had not [warm ischemic time > 45 min (P = 0.543), cold ischemic time > 10 h (P = 0.114), ALT init > 1500 U/L (P = 0.631), bilirubin init > 5 mg/dL (P = 0.595), donor age > 65 (P = 0.244), donor sex (P = 0.068), rescue organ (P = 0.971)]. 13% (n = 10) of BCs had no therapeutic consequences, 36% (n = 27) resulted in repeated lab control, 40% (n = 30) received ERCP and 11% (n = 8) surgical therapy. Fifteen (7.5%) patients developed cholangitis [AS (n = 6), ITBL (n = 5), PS (n = 3), biliary lesion BL (n = 1)]. One patient developed ITBL twelve months after LT and subsequently needed retransplantation. Rehospitalisation rate was 10.5 % (n= 21) [AS (n = 11), ITBL (n = 5), PS (n = 3), BL (n = 1)] with intervention or reinterventional therapy as main reasons. Retransplantation was performed in 5 (2.5%) patients [ITBL (n = 1), acute liver injury (ALI) by organ rejection (n = 3), ALI by occlusion of hepatic artery (n = 1)]. In total 21 (10.5%) patients died within the follow-up period. Out of these, one patient with AS developed severe fatal chologenic sepsis after ERCP.

CONCLUSION: In our data biliary reconstruction technique and ischemic times seem to have little impact on the development of BCs.

Keywords: Liver transplantation; Biliary complications; Anastomotic stenosis; Ischemic type biliary lesion; Non-anastomotic strictures; Bile leak; Ischemic time; Biliary drain complications

Core tip: This study evaluates the impact of various factors on development of biliary complications (BC) after liver transplantation (LT). Biliary reconstruction technique and ischemic times, as well as other donor- and recipient- factors did not influence appearance of BC. However, length of donor-intensive care unit-stay over 6 d did. Furthermore we are the first to describe a comprehensive classification of anastomotic strictures after LT according to clinical relevance.