Nonoperative management of bile leaks following liver transplantation

The biliary anastomosis has been called 'the Achilles heel' of liver transplantation (RABKIN JM, ORLOFF SL, REED MH. Transplantation 1998: 65 [2]: 193; DAVIDSON BR, RAI R, KURZAWINSKI TR. Br J Surg 1999. 86 [4]: 447). Biliary complications after liver transplantation reportedly occur at an incidence of 20-30%, 10-15% as bile leaks. The management of bile leaks, especially early bile leaks, is controversial. In the present study, we report our experience with the management of bile leaks after liver transplantation. In this retrospective study, we reviewed 85 liver transplants over a 3-yr period. In 79, the biliary anastomosis was choledocho choledochostomy (CDCD) over a small-caliber T-tube, while choledochojejunostomy (CDJ) was used in 7. Over a mean follow up period of 13.5 months (median 10 months), 10 patients (12%) experienced a clinically significant bile leak within the first 3 months after liver transplantation. The early leaks, occurring within 1 month of transplant, were successfully managed by observation (DAVIDSON BR, RAI R, KURZAWINSKI TR. Br J Surg 1999: 86 [4]: 447) or endoscopic retrograde cholangiopancreatography (ERCP) and the placement of a biliary stent for a duration of 6-12 wk (RANDALL HB, WACHS ME, SOMBERG KA. Transplantation 1996: 61 [2]: 258). One of these resulted from accidental dislodgement of the T-tube on postoperative day 1; one resulted from necrosis at the CDCD anastomosis and required CDJ; the remaining four resulted from leaks along the T-tube track. One of the late leaks occurred following the planned removal of the T-tube at 3 months after liver transplantation; the other two were leaks along the T-tube track. All were successfully treated by ERCP and stent placement, though in one case, ERCP was initially unsuccessful because of the inability to advance a guidewire, necessitating a fluoroscopically aided guide wire placement during a mini laparotomy. ERCP was then successfully performed with the placement of a stent.