Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases.

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Long-term ex situ normothermic machine perfusion allows regeneration of human livers with severe bile duct injury.

Bile duct regeneration is hypothesized to prevent biliary strictures, a leading cause of morbidity after liver transplantation. Assessing the capacity for biliary regeneration may identify grafts as suitable for transplantation that are currently declined, but this has been unfeasible until now. This study used long-term ex situ normothermic machine perfusion (LT-NMP) to assess biliary regeneration. Human livers that were declined for transplantation were perfused at 36 °C for up to 13.5 days. Bile duct biopsies, bile, and perfusate were collected throughout perfusion, which were examined for features of injury and regeneration. Biliary regeneration was defined as new Ki-67-positive biliary epithelium following severe injury. Ten livers were perfused for a median duration of 7.5 days. Severe bile duct injury occurred in all grafts, and biliary regeneration occurred in 70% of grafts. Traditional biomarkers of biliary viability such as bile glucose improved during perfusion but this was not associated with biliary regeneration (P > .05). In contrast, the maintenance of interleukin-6 and vascular endothelial growth factor-A levels in bile was associated with biliary regeneration (P = .017 for both cytokines). This is the first study to demonstrate biliary regeneration during LT-NMP and identify a cytokine signature in bile as a novel biomarker for biliary regeneration during LT-NMP.

Primary cilia as a targetable node between biliary injury, senescence and regeneration in liver transplantation.

BACKGROUND & AIMS: Biliary complications are a major cause of morbidity and mortality in liver transplantation. Up to 25% of patients that develop biliary complications require additional surgical procedures, re-transplantation or die in the absence of a suitable regraft. Here, we investigate the role of the primary cilium, a highly-specialised sensory organelle, in biliary injury leading to post-transplant biliary complications. METHODS: Human biopsies were used to study the structure and function of primary cilia in liver transplant recipients that develop biliary complications (N=7) in comparison with recipients without biliary complications (N=12). To study the biological effects of the primary cilia during transplantation, we generated murine models that recapitulate liver procurement and cold storage, and assessed the elimination of the primary cilia in biliary epithelial cells in the K19CreERTKif3aflox/flox mouse model. To explore the molecular mechanisms responsible for the observed phenotypes we used in vitro models of ischemia, cellular senescence and primary cilia ablation. Finally, we used pharmacological and genetic approaches to target cellular senescence and the primary cilia, both in mouse models and discarded human donor livers. RESULTS: Prolonged ischemic periods before transplantation result in ciliary shortening and cellular senescence, an irreversible cell cycle arrest that blocks regeneration. Our results indicate that primary cilia damage results in biliary injury and a loss of regenerative potential. Senescence negatively impacts primary cilia structure and triggers a negative feedback loop that further impairs regeneration. Finally, we explore how targeted interventions for cellular senescence and/or the stabilisation of the primary cilia improve biliary regeneration following ischemic injury. CONCLUSIONS: Primary cilia play an essential role in biliary regeneration and we demonstrate that senolytics and cilia-stabilising treatments provide a potential therapeutic opportunity to reduce the rate of biliary complications and improve clinical outcomes in liver transplantation. IMPACT AND IMPLICATIONS: Up to 25% of liver transplants result in biliary complications, leading to additional surgery, retransplants, or death. We found that the incidence of biliary complications is increased by damage to the primary cilium, an antenna that protrudes from the cell and is key to regeneration. Here, we show that treatments that preserve the primary cilia during the transplant process provide a potential solution to reduce the rates of biliary complications.

Early hepatic artery thrombosis treatments and outcomes: aorto-hepatic arterial conduit interposition or revision of anastomosis?

BACKGROUND: Hepatic artery thrombosis (HAT) is one of the critical conditions after an orthotopic liver transplant (OLT) and leads to severe problems if not corrected promptly. However, multiple treatments have been proposed for HAT, in which surgical revascularization with either auto-hepatic conduit interposition (AHCI) or revision of the anastomosis is more familiar indeed indicated for some patients and in specific situations. In this study, we want to evaluate the success and outcomes of treating early HAT (E-HAT), which defines HAT within 30 days after OLT with either of the surgical revascularization techniques. METHOD: In this retrospective study, we collected information from the medical records of patients who underwent either of the surgical revascularization procedures for E-HAT after OLT. Patients who needed early retransplantation (RT) or died without surgical intervention for E-HAT were excluded. Demographic data, OLT surgery information, and data regarding E-HAT were gathered. The study outcomes were secondary management for E-HAT in case of improper inflow, biliary complications (BC), RT, and death. RESULTS: A total of 37 adult patients with E-HAT after OLT included in this study. These E-HATs were diagnosed within a mean of 4.6 ± 3.6 days after OLT. Two patients had their HA revised for the initial management of E-HAT; however, it changed to AHCI intraoperatively and finally needed RT. Two and nine patients from the AHCI and revision groups had re-thrombosis (12.5% vs. 47.3%, respectively, p = 0.03). RT was used to manage rethrombosis in all patients of AHCI and two patients of the revision group (22.2%). In comparison to the AHCI, revision group had statistically insignificant higher rates of BC (47.4% vs. 31.2%); however, RT for nonvascular etiologies (12.5% vs. 5.3%) and death (12.5% vs. 10.5%) were nonsignificantly higher in AHCI group. All patients with more than one HA exploration who were in the revision group had BC; however, 28.5% of patients with just one HA exploration experienced BC (p < 0.001). CONCLUSION: Arterial conduit interposition seems a better approach for the initial management of E-HAT in comparison to revision of the HA anastomosis due to the lower risk of re-thrombosis and the number of HA explorations; indeed, BC, RT, and death remain because they are somewhat related to the ischemic event of E-HAT than to a surgical treatment itself.

Long-term outcome of combined radiologic and surgical strategy for the management of biliary complications after pediatric liver transplantation.

OBJECTIVES: We aimed to analyze the risk factors for management failure of BC after pediatric liver transplantation (pLT) by retrospectively analyzing primary pLT performed between 1997 and 2018 (n = 620 patients). RESULTS: In all, 117/620 patients (19%) developed BC. The median (range) follow-up was 9 (1.4-21) years. Patient survival at 1, 5 and 10 years was 88.9%, 85.7%, 84.4% and liver graft survival was 82.4%, 77.4%, and 74.3% respectively. Graft not patient survival was impaired by BC (p = 0.01). Multivariate analysis identified the number of dilatation courses > 2 (p = 0.008), prolonged cold ischemia time (p = 0.004), anastomosed multiple biliary ducts (p = 0.019) and hepatic artery thrombosis (p = 0.01) as factors associated with impaired graft survival. The number of dilatation courses > 2 (p < 0.001) and intrahepatic vs anastomotic stricture (p = 0.014) were associated with management failure. Thus, repeated (> 2) radiologic dilatation courses are associated with impaired graft survival and management failure. Overall, graft but not patient survival was impaired by BC.

Percutaneous Transhepatic Sphincterotome-Guided Management of Post-Living Donor Liver Transplant Biliary Anastomotic Stricture: An Innovative Approach.

Post-liver transplantation biliary complications remain a serious concern and are associated with reduced patient and graft survival. Among various biliary complications, anastomotic stricture (AS) is the most frequent and challenging one. The frequency of AS after living donor liver transplantation (LDLT) is higher as compared to deceased donor liver transplantation. The management involves endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage, but refractory cases necessitate surgical revision. We present a case of complex biliary AS in a 63-year-old man after LDLT. The conventional approaches including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and cholangioscope-guided interventions remained unsuccessful. An innovative approach using a wire-guided sphincterotome through percutaneous transhepatic route successfully managed the complex post-LDLT AS. This is perhaps the first reported case of novel utilization of sphincterotome through transhepatic route for the management of AS in LDLT, averting major surgical interventions with related morbidity and mortality.

The long-term follow-up of the living liver donors.

Living donor liver transplantation (LDLT) has been proposed in many countries to reduce organ shortage. While the early postoperative outcomes have been well investigated, little is known about the long-term follow-up of the living donors. We, therefore, designed a systematic review of the literature to explore long-term complications and quality of life among living donors. We searched MEDLINE and EMBASE registries for studies published since 2013 that specifically addressed long-term follow-up following living-donor liver donation, concerning both physical and psychological aspects. Publications with a follow-up shorter than 1 year or that did not clearly state the timing of outcomes were excluded. A total of 2505 papers were initially identified. After a thorough selection, 17 articles were identified as meeting the eligibility criteria. The selected articles were mostly from North America and Eastern countries. Follow-up periods ranged from 1 to 11.5 years. The most common complications were incision site discomfort (13.2-38.8%) and psychiatric disorders (1-22%). Biliary strictures occurred in 1-14% of cases. Minimally invasive donor hepatectomy could improve quality of life, but long-term data are limited. About 30 years after the first reported LDLT, little has been published about the long-term follow-up of the living donors. Different factors may contribute to this gap, including the fact that, as healthy individuals, living donors are frequently lost during mid-term follow-up. Although the reported studies seem to confirm long-term donor safety, further research is needed to address the real-life long-term impact of this procedure.

Harnessing Metabolites as Serum Biomarkers for Liver Graft Pathology Prediction Using Machine Learning.

Graft injury affects over 50% of liver transplant (LT) recipients, but non-invasive biomarkers to diagnose and guide treatment are currently limited. We aimed to develop a biomarker of graft injury by integrating serum metabolomic profiles with clinical variables. Serum from 55 LT recipients with biopsy confirmed metabolic dysfunction-associated steatohepatitis (MASH), T-cell mediated rejection (TCMR) and biliary complications was collected and processed using a combination of LC-MS/MS assay. The metabolomic profiles were integrated with clinical information using a multi-class Machine Learning (ML) classifier. The model's efficacy was assessed through the Out-of-Bag (OOB) error estimate evaluation. Our ML model yielded an overall accuracy of 79.66% with an OOB estimate of the error rate at 19.75%. The model exhibited a maximum ability to distinguish MASH, with an OOB error estimate of 7.4% compared to 22.2% for biliary and 29.6% for TCMR. The metabolites serine and serotonin emerged as the topmost predictors. When predicting binary outcomes using three models: Biliary (biliary vs. rest), MASH (MASH vs. rest) and TCMR (TCMR vs. rest); the AUCs were 0.882, 0.972 and 0.896, respectively. Our ML tool integrating serum metabolites with clinical variables shows promise as a non-invasive, multi-class serum biomarker of graft pathology.

Applying LASSO logistic regression for the prediction of biliary complications after ex vivo liver resection and autotransplantation in patients with end-stage hepatic alveolar echinococcosis.

BACKGROUND: The purpose of this study was to explore the relevant risk factors associated with biliary complications (BCs) in patients with end-stage hepatic alveolar echinococcosis (HAE) following ex vivo liver resection and autotransplantation (ELRA) and to establish and visualize a nomogram model. METHODS: This study retrospectively analysed patients with end-stage HAE who received ELRA treatment at the First Affiliated Hospital of Xinjiang Medical University between August 1, 2010 and May 10, 2023. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize the feature variables for predicting the incidence of BCs following ELRA. Multivariate logistic regression analysis was used to develop a prognostic model by incorporating the selected feature variables from the LASSO regression model. The predictive ability, discrimination, consistency with the actual risk, and clinical utility of the candidate prediction model were evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Internal validation was performed by the bootstrapping method. RESULTS: The candidate prediction nomogram included predictors such as age, hepatic bile duct dilation, portal hypertension, and regular resection based on hepatic segments. The model demonstrated good discrimination ability and a satisfactory calibration curve, with an area under the ROC curve (AUC) of 0.818 (95% CI 0.7417-0.8958). According to DCA, this prediction model can predict the risk of BCs occurrence within a probability threshold range of 9% to 85% to achieve clinical net benefit. CONCLUSIONS: A prognostic nomogram with good discriminative ability and high accuracy was developed and validated to predict BCs after ELRA in patients with end-stage HAE.

Erratum: Advantages and limitations of clinical scores for donation after circulatory death liver transplantation.

[This corrects the article DOI: 10.3389/fsurg.2021.808733.].

Immune Responses to Anti-Hepatitis C Virus Antibodies during Pre-Liver Transplantation Direct-Acting Antiviral Therapy in Hepatitis C Virus-Infected Recipients Associated with Post-Liver Transplantation Allograft Injury.

BACKGROUND AND AIMS: The impact of antibody responses following direct-acting antiviral (DAA) therapy in hepatitis C virus (HCV)-infected recipients before and after liver transplantation (LT) is still undetermined. METHODS: In this observational cohort study, we aimed to explore the association between changes in anti-HCV antibody titers following pre-LT DAA therapy and allograft injury, including biliary complications (BCs) and acute cellular rejection (ACR). RESULTS: A total of 153 cases were enrolled from January 2015 to February 2021. Serum anti-HCV antibody titers were assessed before and after (day 30) LT. Among all recipients, 31/153 (20.3%) had pre-LT DAA therapy (the DAA group) and 122/153 (79.7%) did not undergo pre-LT DAA therapy (the DAA-naïve group). A higher incidence of post-LT BCs was observed in the DAA group (p = 0.028). Compared with the DAA-naïve group, the DAA group had a significantly higher mean level of anti-HCV titer upregulation (p = 0.0024); furthermore, among the recipients with BCs (n = 28) and ACR (n = 41), those in the DAA group exhibited significantly higher mean levels of anti-HCV antibody titer upregulation (p < 0.005). CONCLUSIONS: In conclusion, we speculate that the upregulation of anti-HCV antibody titers, which might have been induced via the restoration of HCV-specific immune responses through pre-LT DAA therapy, was associated with post-LT allograft injury.

Biliary complications after liver transplantation / Complicações biliares pós-transplante hepático

ABSTRACT Background: Biliary reconstitution has been considered the Achilles's heel of liver transplantations due to its high rate of postoperative complications. Aim: To evaluate the risk factors for occurrence of biliary strictures and leakages, and the most efficient methods for their treatment. Method: Of 310 patients who underwent liver transplantation between 2001 and 2015, 182 medical records were retrospectively analyzed. Evaluated factors included demographic profile, type of transplantation and biliary reconstitution, presence of vascular and biliary complications, their treatment and results. Results: 153 (84.07%) deceased donor and 29 (15.93%) living donor transplantations were performed. Biliary complications occurred in 49 patients (26.92%): 28 strictures (15.38%), 14 leakages (7.7%) and seven leakages followed by strictures (3.85%). Hepatic artery thrombosis was present in 10 patients with biliary complications (20.4%; p=0,003). Percutaneous and endoscopic interventional procedures (including balloon dilation and stent insertion) were the treatment of choice for biliary complications. In case of radiological or endoscopic treatment failure, surgical intervention was performed (biliodigestive derivation or retransplantation (32.65%). Complications occurred in 25% of patients treated with endoscopic or percutaneous procedures and in 42.86% of patients reoperated. Success was achieved in 45% of patients who underwent endoscopic or percutaneous procedures and in 61.9% of those who underwent surgery. Conclusion: Biliary complications are frequent events after liver transplantation. They often require new interventions: endoscopic and percutaneous procedures at first and surgical treatment when needed. Hepatic artery thrombosis increases the number of biliary complications.

RESUMO Racional: A reconstituição biliar é considerada o calcanhar-de-Aquiles do transplante hepático devido à sua elevada taxa de complicações pós-operatórias. Objetivo: Analisar os fatores de risco para ocorrência de estenoses e fístulas biliares e os métodos terapêuticos mais eficientes para seu tratamento. Método: De 310 pacientes transplantados entre 2001 e 2015, 182 prontuários foram analisados retrospectivamente. Foram avaliados o perfil demográfico dos pacientes, tipo de transplante e reconstituição biliar, presença de complicações biliares e vasculares, tratamento utilizado e seus resultados. Resultados: Foram realizados 153 (84,07%) transplantes hepáticos cadavéricos e 29 intervivos (15,93%). Complicações biliares ocorreram em 49 pacientes (26,92%): 28 estenoses (15,38%), 14 fístulas (7,7%) e sete fístulas seguidas de estenose (3,85%). Trombose de artéria hepática esteve presente em 10 pacientes com complicações biliares (20,4%, p=0,003). Os tratamentos de escolha foram os procedimentos endoscópicos ou percutâneos (incluindo dilatação por balão e colocação de próteses (40,82%). No insucesso deles, foi realizado tratamento cirúrgico (derivação biliodigestiva ou retransplante (32,65%). Complicações ocorreram em 25% dos pacientes que fizeram procedimentos endoscópicos ou percutâneos e em 42,86% dos submetidos ao tratamento cirúrgico. A resolução das complicações biliares foi de 45% com os procedimentos endoscópicos ou percutâneos e de 61,9% com o cirúrgico. Conclusão: Complicações biliares são frequentes após transplante hepático. Comumente requerem novas intervenções. Os procedimentos endoscópicos e percutâneos são a primeira escolha e os cirúrgicos, empregados na falha destes. Trombose de artéria hepática aumenta a incidência de complicações biliares.

Association between indocyanine green clearance test and ischemic type biliary lesions within one year after orthotopic liver transplantation / Asociación entre la prueba de clearance verde de indocianina y las lesiones biliares de tipo isquémico dentro de un año después del trasplante ortotópico de hígado

Background: Ischemic type biliary lesions (ITBLs), a particular subset of non-anastomotic biliary strictures (NAS), are characterized by intra and extrahepatic strictures that occur in the absence of either hepatic artery thrombosis or stenosis. When they occur within the first year after liver transplantation their development is mostly related to ischemia–reperfusion injury (IRI). The indocyanine green plasma disappearance rate (ICG-PDR) might be able to predict the probability of IRI-induced graft damage after liver transplantation. Objective: Our aim was to evaluate the association between ICG-PDR and the occurrence of ITBLs. Secondly, we searched for evidence of IRI in patients presenting ITBLs. Methods: This retrospective single-center observational study assessed a cohort of 60 liver transplant patients. Each patient underwent ICG-PDR on the 1st postoperative day. ITBLs were identified by means of either cholangiography or magnetic resonance imaging evidence of a deformity and narrowing of the biliary tree in the absence of hepatic artery thrombosis/stenosis. Results: ITBLs were discovered in 10 patients out of 60 liver recipients (16.67%) within one year after transplantation. A low ICG-PDR value was found to be a significant predictive factor for ITBL development, with an OR of 0.87 and a 95% CI of 0.77–0.97. Liver biopsies were performed in 56 patients presenting unexplained abnormal liver function test results. A statistically significant association was found between the development of ITBLs and anatomopathological evidence of IRI. Limitations: Retrospective, single-center study. Conclusions: The findings from this study show a relationship between low ICG-PDR values on first post-operative-day and the occurrence of ITBLs within 1 year after transplantation.(AU)

Antecedentes: Las lesiones biliares de tipo isquémico (ITBL) representan un subconjunto de estenosis biliares no anastomóticas, caracterizadas por estenosis intra y extrahepáticas, que ocurren en ausencia de trombosis o estenosis de la arteria hepática. Cuando ocurren dentro del primer año después del trasplante de hígado, están relacionadas principalmente con la lesión por isquemia-reperfusión (IRI). La tasa de desaparición del plasma con verde de indocianina (ICG-PDR) podría estimar el daño del injerto inducido por IRI después de un trasplante. Objetivo: Nuestro objetivo es evaluar la asociación entre ICG-PDR y la aparición de ITBL. También investigamos la evidencia de IRI entre los pacientes que presentaron ITBL. Métodos: Estudio observacional, retrospectivo, unicéntrico, realizado en una cohorte de 60 receptores trasplantados con determinacion del ICG-PDR el primer día posoperatorio. Las ITBL se definieron mediante colangiografía o evidencia por resonancia magnética de deformidad del árbol biliar en ausencia de trombosis/estenosis de la arteria hepática. Resultados: De 60 receptores, se descubrieron ITBL en 10 pacientes (16,67%) en el primer año. El valor bajo de ICG-PDR es un factor predictivo significativo para ITBL, con OR=0,87 y un IC (95%)=0,77-0,97. Se analizaron 56 biopsias hepáticas para la presencia de IRI, si los receptores presentaban una prueba de función hepática anormal inexplicable, encontrando asociación significativa entre ITBL y evidencia anatomopatológica de IRI. Limitaciones: Estudio retrospectivo, unicéntrico.(AU)

Diagnóstico y tratamiento de las complicaciones biliares asociadas al trasplante hepático / Diagnosis and treatment of biliary complications associated with liver transplantation

Las complicaciones biliares se presentan en 10 - 25% de los pacientes que reciben un trasplante hepático y pueden causar una importante morbilidad e incluso la pérdida del injerto. Las complicaciones más comunes son la estenosis biliar (anastomótica y no anastomótica), fuga biliar y litiasis biliar. La gran mayoría de estas complicaciones puede tratarse con éxito mediante colangiopancreatografía retrógrada endoscópica. Esta revisión se centra en el diagnóstico, factores de riego y tratamiento endoscópico de las complicaciones biliares asociadas al trasplante hepático

Biliary complications ocurr in 10 - 25% of liver transplant recipients and are associated to a significant morbidity and the possibility of graft failure. The most common biliary complications are strictures (both anastomotic and non-anastomotic), bile leaks and stones. Most of these complications can be appropriately managed with endoscopic retrograde cholangiopancreatography. This article will review the diagnosis, risk factors, and endoscopic management of biliary complications related to liver transplantation

Incidencia, factores de riesgo y tratamiento de las complicaciones biliares del trasplante hepático / Biliary tract complications after liver transplantation

Biliary tract complications (BC) are cause of mortality after liver transplantation (LT). There are different treatment alternatives for this complication. Aim: to determ¨ªnate incidence, risk factors and treatment of biliary complications after LT. Materials and Methods: A retrospective descriptive cohort of patients undergoing LT between March 1994 and March 2009. Risk factors and incidence for BC were ex-plored. Also the BC impact on overall survival on LT patients was assessed. We used SPSS 15.0 for statistical analysis and considered a significant p value less than 0.05. Results: 107 LT were performed in 102 patients. In 30 (28 percent) there was some biliary complication. Ten (33.3 percent) were early complications (< 3 months) and 20 (66.7 percent) were late ( > 3 month). Anastomotic stricture was the more frequent BC. The gender male recipient, the cold ischemic time and biliary reconstruction technique without tutor were associated with an increased risk for BC. Endoscopic treatment of biliary stricture was successful in 91 percent of cases at one year follow up. Three (10 percent) patients died due to BC or their long-term treatment. Conclusions: Biliary Complications after Liver Transplantation are frequent and are cause of mortality. Decrease cold ischemic time and improve te-chniques for biliary reconstruction could reduce the high incidence of this complication.

Introducción: Las complicaciones biliares (CB) en el trasplante hepático (TH) son causa de mortalidad post-trasplante. Existen diferentes alternativas terapéuticas para su tratamiento. Objetivo: Determinar la incidencia, factores de riesgo y evaluar los resultados del tratamiento de las CB posterior al TH. Materiales y Método: Estudio retrospectivo, descriptivo de una cohorte de pacientes sometidos a un TH entre marzo-1994 y marzo-2009. Se analizó los factores de riesgo para CB, su incidencia en el tiempo, su tratamiento y se determinó su impacto en la sobrevida global de los pacientes. Se utilizó el programa SPSS 15.0 para cálculos estadísticos y se consideró significativo un p < 0,05. Resultados: Se realizaron 107 TH en 102 pacientes. En 30 (28 por ciento), se consignó una o más CB. En 10 (33,3 por ciento), la CB fue precoz y en 20 (66,7 por ciento) tardía. La estenosis de la anastomosis fue la CB más frecuente. El sexo masculino del receptor, el tiempo de isquemia fría y la técnica de reconstrucción biliar sin tutor, se asociaron significativamente a un mayor riesgo de CB. El tratamiento endoscópico de la estenosis biliar fue exitoso en el 91 por ciento de los casos a un año de seguimiento. Tres (10 por ciento) pacientes fallecieron por una CB o su tratamiento a largo plazo. Conclusiones: Las CB del TH son frecuentes y son causa de mortalidad. Disminuir el tiempo de isquemia fría y mejorar las técnicas de reconstrucción biliar podrían disminuir su incidencia.

Diagnóstico y manejo endoscópico de las complicaciones biliares postoperatorias / Diagnosis and endoscopic management of postoperative biliary complications

El manejo exitoso de las complicaciones biliares requiere la intervención de un equipo multidisciplinario, que incorpore a endoscopistas, radiólogos intervencionistas y cirujanos. El abordaje del paciente depende de la naturaleza y extensión de la complicación, la presencia o no de colecciones biliares y el momento del diagnóstico de la lesión. El trauma durante la colecistectomía da cuenta de más de 65% de las estenosis biliares postoperatorias de pacientes derivados para terapéutica endoscópica, y la combinación de colecistectomía y exploración del conducto biliar común adiciona 24%. El daño biliar que ocurre durante otros procedimientos (anastomosis biliodigestiva, gastrectomía, resección hepática parcial y colecistostomía) contribuye con relativamente pocos casos. Los resultados de la terapéutica endoscópica para las lesiones del tracto biliar mayor en pacientes seleccionados, son por lo menos comparables con los de la cirugía. En muchos de estos pacientes, el tratamiento endoscópico puede ser la única intervención terapéutica necesaria.

The successful management of post operative biliary complications requires a multidisciplinary team including endoscopists, interventional radiologists and surgeons. The patient approach depends on the type and length of the lesion, the presence of bile collections and the time of the diagnosis. The post cholecystectomy lesions involve more than 65% of biliary stenosis sent to endoscopic therapy, and the combination of cholecystectomy and common bile duct exploration adds another 24%. The biliary injuries related to other procedures (biliodigestive anastomosis, gastrectomy, partial hepatic resection and cholecystostomy) add a few more cases. The outcome of endoscopic therapy for main biliary tract lesions in selected patients is at least comparable with surgery. For many patients, the endoscopic therapy might be the only procedure required.

Fatores de risco e conduta nas complicações do trato biliar no transplante hepático / Risk factors and management of biliary tract complications in liver transplantation

A reconstrução biliar é um dos pontos vulneráveis do transplante hepático apresentando incidência de complicações biliares, variando de 10 a 35%, nos diversos estudos da literatura. Esse trabalho tem por objetivo apresentar a experiência do nosso serviço em relação à incidência e ao manejo das complicações biliares notransplante de fígado. Foram incluídos no estudo 147 transplantes hepáticos ortotópicos, com idade média de 37,3 anos, correspondendo a 88 procedimentos em pacientes do sexo masculino e 59 do sexo feminino. Complicações biliares ocorreram em 27 transplantes (18,36%) em 25 pacientes (dois retransplantes). A presença derejeição celular e de complicações vasculares foi identificada como fator de risco para as complicações biliares.A idade, o sexo, a etiologia da cirrose e a técnica utilizada na reconstrução biliar não foram fatores de risco. No total, foram empregados 52 cursos terapêuticos: tratamento cirúrgico em 23 vezes; tratamento endoscópico em15 vezes; retransplante em sete vezes; drenagem biliar transparieto-hepática em seis vezes e um paciente está emlista de espera para retransplante. Conclui-se deste estudo que as complicações biliares são freqüentes após o transplante hepático e que as vasculares e a rejeição celular são fatores de risco.

Biliary reconstruction is a vulnerable step of liver transplantation, presenting an incidence of biliary complicationsbetween 10 to 35% in many studies. Our aim is to present our incidence and treatment of biliary complications, in atotal of 147 orthotopic liver transplantations, 88 males and 59 females, with an mean age of 37 years. Biliary complications occurred in 27 transplants (18,36%) performed in 25 patients (two retransplants). Cellular rejection and vascular complications were identified as risk factors for biliary complications. Age, sex, etiology of cirrhosis and biliary reconstruction technique were not risk factors. Fifty-two therapeutic courses were performed: 23 surgical treatments, 15 endoscopic treatments, seven retransplants, six external biliary drainage and one patient is waitingretransplantation. In conclusion, biliary complications are frequent after liver transplantation and vascular complications and cellular rejection are risk factors for them.