Non-operative management of biliary anastomotic leaks and strictures following orthotopic liver transplantation

Historically, strictures (ST) and anastomotic leaks (AL) following orthotopic liver transplantation (OLT) have been treated surgically. However, a paucity of data exists regarding their non-operative management and outcome. AIM: 1) to evaluate the success of non-operative management of ST and AL. 2) to identify predictors of failure of non-operative management. METHOD: Among 128 OLTs performed from 7/94 to 11/96, 15 patients with ST and 14 different patients with AL were consecutively identified. All were evaluated with cholangiogram, Doppler ultrasound, abdominal CT and liver biopsies. Successful therapy was defined as normalization of liver function tests and normal follow up cholangiogram. RESULTS: Non-op F/U (mo.) Resolved Roux Y Died ST 14 11 10(71%) 3 1 Stent * 10 6(60%) 3 1 Observation 4 4 0 0 AL 9 10 4(44%) 3 2 Stent * 8 3 (38%) 3 2 T-tube opened 1 0 0 * Endoscopic or percutaneous AL or ST that presented with hepatic artery thrombosis (2), common bile duct dehiscence (2), or acute abdomen (1) were treated operatively. Minimally obstructive strictures were observed. In both groups, patients who had Stent placement, and eventually required surgery had associated extensive biliary debris including bile casts. None of the deaths were directly related to non-operative intervention. CONCLUSIONS: 1) In those OLT patients who develop AL or ST without hepatic artery thrombosis or biliary dehiscence, non-operative management is successful the majority of the time and should be the initial mode of intervention. 2) Those who undergo non-operative management and subsequently operative correction do well. 3) Failure of stent therapy is associated with extensive biliary debris that cannot be cleared.