LIVER TRANSPLANTATION 21:1105–1106, 2015
LETTERS TO THE EDITOR
Pure Laparoscopic Management of Early Biliary Leakage After Liver Transplantation: Abdominal Lavage and T-Tube Placement Received April 21, 2015; accepted May 13, 2015.
TO THE EDITOR: Martınez-Ortega et al.1 reported an innovative approach in the treatment of early biliary leakage (EBL) after liver transplantation (LT). We congratulate them and agree that laparoscopy is an efficient tool to achieve faster clinical recovery and diminish postoperative morbidity in immunosuppressed patients. We were, however, surprised by the decision of a T-tube insertion, given the potential risk of complications related to its use (eg, biliary peritonitis at removal and cholangitis). Recently, endoscopic management has been proven to be a safe and effective option to treat EBL after LT with good results.2 This endoscopic approach has become our standard approach for both anastomotic stricture and biliary leakage3 during the last 5 years. On this basis, we applied a totally endoscopic
approach (TEA) in 5 patients who were affected by EBL after LT between October 2013 and March 2015. Like the strategy described by Martınez-Ortega et al.,1 our approach included laparoscopic washout but differed by endoscopic insertion of a plastic or selfexpandable covered biliary metallic stent to treat the biliary leakage. Laparoscopy was feasible in all cases without conversion. We did not find any limitation due to intra-abdominal adhesions, probably because of postoperative ascites and immunosuppressive regimen. In this series, endoscopic management was always possible and efficient. The authors hypothesized that endoscopic retrograde cholangiopancreatography (ERCP) could worsen the clinical condition, leading to ascites infection. This latter reason was an argument to use T-tube drainage rather than endoscopic stenting. In our series, median delay between laparoscopy and ERCP
TABLE 1. Patient Characteristics
Sex Age, years Liver disease
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Male 44 Alcohol
Male 66 Alcohol
Male 52 Alcohol
Female 58 Alcohol
560 70 150 2 93 No —
450 16 105 20 44 Yes Stenosis recurrence 6 3 8.3 15.8
360 23 80 1 42 No —
Male 50 Acute alcoholic hepatitis 500 13 100 1 189 Yes Stent migration 2.1 1 2.1 9.7
Cold ischemia time, minutes Delay LT–bile leak, days Surgery duration, minutes Delay laparoscopy–ERCP, days Hospital stay, days Complications Description Delay, months Re-ERCP, n End of treatment, delay, months Follow-up, months
3.1 1 3.1 15.8
3.5 1 3.5 13.7
480 10 40 4 77 Yes Stent obstruction, liver abscess 1 1 5.4 5.8
^pital Pitie -Salpe ^trie`re, Address reprint requests to Olivier Scatton, M.D., Ph.D., Department of Hepatobiliary Surgery and Liver Transplantation, Ho ^pital, Paris 75013, France. Telephone: 1 33 (1) 42 17 56 90; FAX: 1 33 (1) 42 17 56 17; E-mail: [email protected] 47-83 Boulevard de l’Ho Potential conflict of interest: Nothing to report. DOI 10.1002/lt.24186 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases C 2015 American Association for the Study of Liver Diseases. V
1106 SEPULVEDA ET AL
LIVER TRANSPLANTATION, August 2015
was 2 days (range, 1-20 days). Bile leakage and ascites were completely drained by a suction drain close to the biliary anastomosis, and TEA was feasible and safe for all patients. No complications occurred and the 90-day mortality was nil (Table 1). Noteworthy, all 5 patients had clinical symptoms of localized or diffuse peritonitis. Laparoscopic washout and drainage allowed for rapid clinical improvement and early postoperative biliary stenting. On the contrary, T-tube placement requires pedicle redissection and biliary duct manipulation. These maneuvers can be hazardous leading to vascular complications such as hepatic artery thrombosis. Last, incomplete biliary drainage is prone to happen. We believe that a fully endoscopic management, including laparoscopic washout and endoscopic treatment of the biliary leak, allows for an efficient and physiological biliary drainage with minimal manipulation of hepatic pedicle, avoiding any T-tube insertion with its inherent risks. For all these reasons, we believe TEA to be accessible, safe, easy, and reproducible, in complete accordance with minimally invasive principles. Ailton Sepulveda, M.D.1 Raffaele Brustia, M.D.2,3 Fabiano Perdigao, M.D.2 Olivier Soubrane, M.D.1,4 Olivier Scatton, M.D., Ph.D.2,3
1
Department of Hepatobiliary Surgery and Liver Transplantation ^ pital Beaujon Ho AP-HP Clichy, France 2 Department of Hepatobiliary Surgery and Liver Transplantation ^ pital Pitie -Salpe ^trie`re Ho AP-HP Paris, France 3 Pierre et Marie Curie Universite Paris, France 4 Diderot Universite Paris, France
REFERENCES 1. Martınez-Ortega P, Rotellar F, Martı-Cruchaga P, Zozaya G, S anchez-Justicia C, Pardo F. Pure laparoscopic management of early biliary leakage after liver transplantation: abdominal lavage and T-tube placement. Liver Transpl 2015;21:561–563. 2. Scatton O, Meunier B, Cherqui D, Boillot O, Sauvanet A, Boudjema K, et al. Randomized trial of choledochocholedochostomy with or without a T-tube in orthotopic liver transplantation. Ann Surg 2001;233: 432–437. 3. Oh DW, Lee SK, Song TJ, Park do H, Lee SS, Seo DW, Kim MH. Endoscopic management of bile leakage after liver transplantation. Gut Liver 2015;9:417–423.
LETTERS TO THE EDITOR
Pure Laparoscopic Management of Early Biliary Leakage After Liver Transplantation: Abdominal Lavage and T-Tube Placement Received April 21, 2015; accepted May 13, 2015.
TO THE EDITOR: Martınez-Ortega et al.1 reported an innovative approach in the treatment of early biliary leakage (EBL) after liver transplantation (LT). We congratulate them and agree that laparoscopy is an efficient tool to achieve faster clinical recovery and diminish postoperative morbidity in immunosuppressed patients. We were, however, surprised by the decision of a T-tube insertion, given the potential risk of complications related to its use (eg, biliary peritonitis at removal and cholangitis). Recently, endoscopic management has been proven to be a safe and effective option to treat EBL after LT with good results.2 This endoscopic approach has become our standard approach for both anastomotic stricture and biliary leakage3 during the last 5 years. On this basis, we applied a totally endoscopic
approach (TEA) in 5 patients who were affected by EBL after LT between October 2013 and March 2015. Like the strategy described by Martınez-Ortega et al.,1 our approach included laparoscopic washout but differed by endoscopic insertion of a plastic or selfexpandable covered biliary metallic stent to treat the biliary leakage. Laparoscopy was feasible in all cases without conversion. We did not find any limitation due to intra-abdominal adhesions, probably because of postoperative ascites and immunosuppressive regimen. In this series, endoscopic management was always possible and efficient. The authors hypothesized that endoscopic retrograde cholangiopancreatography (ERCP) could worsen the clinical condition, leading to ascites infection. This latter reason was an argument to use T-tube drainage rather than endoscopic stenting. In our series, median delay between laparoscopy and ERCP
TABLE 1. Patient Characteristics
Sex Age, years Liver disease
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Male 44 Alcohol
Male 66 Alcohol
Male 52 Alcohol
Female 58 Alcohol
560 70 150 2 93 No —
450 16 105 20 44 Yes Stenosis recurrence 6 3 8.3 15.8
360 23 80 1 42 No —
Male 50 Acute alcoholic hepatitis 500 13 100 1 189 Yes Stent migration 2.1 1 2.1 9.7
Cold ischemia time, minutes Delay LT–bile leak, days Surgery duration, minutes Delay laparoscopy–ERCP, days Hospital stay, days Complications Description Delay, months Re-ERCP, n End of treatment, delay, months Follow-up, months
3.1 1 3.1 15.8
3.5 1 3.5 13.7
480 10 40 4 77 Yes Stent obstruction, liver abscess 1 1 5.4 5.8
^pital Pitie -Salpe ^trie`re, Address reprint requests to Olivier Scatton, M.D., Ph.D., Department of Hepatobiliary Surgery and Liver Transplantation, Ho ^pital, Paris 75013, France. Telephone: 1 33 (1) 42 17 56 90; FAX: 1 33 (1) 42 17 56 17; E-mail: [email protected] 47-83 Boulevard de l’Ho Potential conflict of interest: Nothing to report. DOI 10.1002/lt.24186 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases C 2015 American Association for the Study of Liver Diseases. V
1106 SEPULVEDA ET AL
LIVER TRANSPLANTATION, August 2015
was 2 days (range, 1-20 days). Bile leakage and ascites were completely drained by a suction drain close to the biliary anastomosis, and TEA was feasible and safe for all patients. No complications occurred and the 90-day mortality was nil (Table 1). Noteworthy, all 5 patients had clinical symptoms of localized or diffuse peritonitis. Laparoscopic washout and drainage allowed for rapid clinical improvement and early postoperative biliary stenting. On the contrary, T-tube placement requires pedicle redissection and biliary duct manipulation. These maneuvers can be hazardous leading to vascular complications such as hepatic artery thrombosis. Last, incomplete biliary drainage is prone to happen. We believe that a fully endoscopic management, including laparoscopic washout and endoscopic treatment of the biliary leak, allows for an efficient and physiological biliary drainage with minimal manipulation of hepatic pedicle, avoiding any T-tube insertion with its inherent risks. For all these reasons, we believe TEA to be accessible, safe, easy, and reproducible, in complete accordance with minimally invasive principles. Ailton Sepulveda, M.D.1 Raffaele Brustia, M.D.2,3 Fabiano Perdigao, M.D.2 Olivier Soubrane, M.D.1,4 Olivier Scatton, M.D., Ph.D.2,3
1
Department of Hepatobiliary Surgery and Liver Transplantation ^ pital Beaujon Ho AP-HP Clichy, France 2 Department of Hepatobiliary Surgery and Liver Transplantation ^ pital Pitie -Salpe ^trie`re Ho AP-HP Paris, France 3 Pierre et Marie Curie Universite Paris, France 4 Diderot Universite Paris, France
REFERENCES 1. Martınez-Ortega P, Rotellar F, Martı-Cruchaga P, Zozaya G, S anchez-Justicia C, Pardo F. Pure laparoscopic management of early biliary leakage after liver transplantation: abdominal lavage and T-tube placement. Liver Transpl 2015;21:561–563. 2. Scatton O, Meunier B, Cherqui D, Boillot O, Sauvanet A, Boudjema K, et al. Randomized trial of choledochocholedochostomy with or without a T-tube in orthotopic liver transplantation. Ann Surg 2001;233: 432–437. 3. Oh DW, Lee SK, Song TJ, Park do H, Lee SS, Seo DW, Kim MH. Endoscopic management of bile leakage after liver transplantation. Gut Liver 2015;9:417–423.
