Biliary Complications After Orthotopic Liver Transplantation: The Hungarian Experience G. Gámán, F. Gelley, A. Doros, G. Zádori, D. Görög, I. Fehérvári, L. Kóbori, and B. Nemes ABSTRACT Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the incidence and types of biliary complications after OLT in Hungary. We retrospectively analyzed data of 471 adult liver transplant recipients between 1995 and 2011. Biliary complications occurred in 28% of patients. The most frequent BCs were bile duct stricture, stenosis (19%), biliary leakage (12%), and necrosis (BN: 6.4%). Biliary complications were associated with the incidence of acute rejection (51% vs 31%; P ¼ .003), hepatic artery thrombosis (43% vs 11%; P < .001), and hepatic artery stenosis (26% vs 11%; P ¼ .002). When cold ischemic time was longer than 12 hours, leakage (10% vs 3%; P ¼ .043), ischemic type biliary lesion (20% vs 3.4%; P ¼ .05), and BN (12% vs 3%; P ¼ .067) were more often diagnosed post-OLT. Most of the biliary complications were treated by radiologic interventions (70%). Bile duct necrosis was associated with lower graft and patient survival. In conclusion, acute rejection, hepatic artery thrombosis/stenosis and cold ischemic time longer than 12 hours increase the incidence of BCs. Successful management of these risk factors can reduce the incidence of biliary complications and improve mortality.

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HE INCIDENCE OF BILIARY COMPLICATIONS (BC) is 5% to 30% after orthotopic liver transplantation (OLT).1,2 Biliary leakage (BL) occurs in 7.8% of cases,3 mainly in the early postoperative period.4 In the same review,3 which comprised a total of 11,547 cadaver liver transplantations, the incidence of biliary stenosis (BS) was 12%. Anastomotic strictures that appear in the early postoperative period are usually related to surgical technique, whereas BSs occuring in the long term are rather the consequences of fibrotic healing due to ischemia of the donor or recipient bile duct.5 Biliary necrosis (BN), ischemic type biliary lesion (ITBL),6 and vanishing bile duct syndrome (VBDS) can also occur as a postoperative complication. Many risk factors of BC have been evaluated, such as usage of University of Wisconsin perfusion solution, female donor, advanced donor and recipient age, macrovesicular steatosis, high Model for End-Stage Liver Disease score (above 25), international normalized ratio >2, high amount of perioperative fresh frozen plasma, and red blood cell transfusion, longer cold and warm ischemic time.3 MATERIALS AND METHODS Data of 471 adult liver transplant recipients were retrospectively analyzed from 1995 to 2011. Different groups were formed and the

following BC were evaluated: BL (N1 ¼ 57), BN (N2 ¼ 30), nonanastomotic BS (N3 ¼ 32), anastomotic BS (N4 ¼ 72), and ITBL (N5 ¼ 7). Control groups included those patients who did not have the examined BC (N1c ¼ 414; N2c ¼ 441; N3c ¼ 439; N4c ¼ 399; N5c ¼ 467). Risk factors of BCs, graft and patient survival, and intervention types were analyzed. Early BC was diagnosed within the first 3 postoperative months; late complication was diagnosed after 3 postoperative months.7 Statistical analysis was performed using SPSS 15.0 software. P < .05 was considered to be significant.

RESULTS

BC after OLT was found in 28% of patients (n ¼ 131). In 72 cases (16%) BC occured within 3 months. Leakage and necrosis were diagnosed only in the early postoperative period, while ITBL and VBDS were found as late complications. Bile duct strictures occured both within and after 3 postoperative months. Risk factors associated with BC are

From the Departure of Transplantation and Surgery Budapest, Hungary. Address reprint requests to György Gámán, Department of Transplantation and Surgery, Semmelweis University, Baross u. 23e25, H-1082 Budapest, Hungary. E-mail: [email protected] gmail.com

ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.10.009

Transplantation Proceedings, 45, 3695e3697 (2013)

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GÁMÁN, GELLEY, DOROS ET AL Table 1. Biliary Complications and Risk Factors BL (N1 ¼ 57)

CIT > 12 h (n ¼ 301) WIT > 65 min Bacterial infections Cholangitis Sepsis HAT or HAS Acute rejection PSC as OLT indication

3 18 26 16 14 15 29 10

(10%) (37%) (46%) (28%) (25%) (26%) (51%) (18%)

Non-AS (N3 ¼ 32)

Infections Cholangitis HAT or HAS Acute rejection BL BL within 3 mo AIH as OLT indication Chronic rejection Retransplantation

16 9 9 13 6 6 4 3 8

(50%) (28%) (28%) (41%) (18.8%) (18.8%) (12.5%) (10%) (25%)

Control (N1c ¼ 414)

8 73 109 29 46 47 126 34

(3%) (18%) (27%) (7%) (11%) (11%) (31%) (8%)

Control (N3c ¼ 439)

114 34 53 139 50

.043 .013

Biliary complications after orthotopic liver transplantation: the Hungarian experience.

Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to ana...
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