Biliary complications that occur after several months often have more serious causes. Liver tests are studied on a regular basis in post-transplant patients and are often the first indication that there is a problem. An ultrasound and Doppler examination of the hepatic vasculature (hepatic artery and portal vein), accompanied by a percutaneous liver biopsy, often comprise the next step. When coagulopathy is present, a transjugular biopsy is often performed. If the cause is suspected to be leakage or ductal obstruction, ERCP or PTC is performed.
Leaks are less common as late complications unless associated with severe vascular insufficiency and stricturing.37-39
Anastomotic strictures that occur late are usually vascular in origin. Other causes of obstruction that can occur later, particularly when nonanastomotic, are related to HAT (with intrahepatic strictures), ABO incompatibility, prolonged preservation, opportunistic infections, recurrent hepatitis B or C, ductopenic rejection, recurrent primary sclerosing cholangitis, stones or casts, post-transplant lymphoproliferative disorder or other tumors, and sphincter dysfunction or stenosis.31,40
Ductopenic rejection, post-transplant lymphoproliferative disorder, and opportunistic infections can often respond to medical management, though these patients may need transient endoscopic or percutaneous intervention to relieve large duct obstruction. Recurrent hepatitis B and C can occasionally be managed by medical treatment, though endoscopic or percutaneous interventions usually have little effect here.
Recurrent primary sclerosing cholangitis can often respond to endoscopic management with stricture dilation and, occasionally, stent placement. However, this disease appears to be different from the original disease, in that there are usually associated casts and stones. In this sense, the disease is likely related to vascular insufficiency and resembles recurrent pyogenic cholangitis. This situation can be managed with endoscopic and percutaneous therapy, though a durable cure is unlikely. The disadvantage to stent placement is that if the stent occludes, there is a risk of cholangitis and hepatic micro-abscesses (behind strictures) in an immunocompromised host, making cure difficult and retransplantation dangerous ().
Figure 12 Vascular insult resulting in bilateral strictures at the bifurcation (A). Initially, the jaundice was treated with bilateral stenting (two 7 Fr 10-cm double pigtail stents; B). The patient was maintained with periodic balloon dilation of the right duct (more ...)
Late strictures are usually not self-limiting with endoscopic or percutaneous therapy; they usually persist unless medically reversible. With this assumption in mind, a reasonable algorithm for late-appearing nonanastomotic strictures is not to perform endoscopic or percutaneous therapy on patients with minimal symptoms and preserved synthetic function. Balloon dilation should be the primary treatment for symptomatic patients, and stents should be reserved for failures of endoscopic or percutaneous dilations and used as a rebridge to retransplantation ().
From a practical standpoint, as the practitioner wonders about the causes of late complications, it would be naive to ignore the possibility of compliance with antirejection drugs and the return of a patient to alcohol use. It is also necessary to accept endoscopic or percutaneous long-term management as a successful outcome because resources for performing repeat transplantation are markedly limited, surgery may be too hazardous, and portal vein or hepatic artery thrombosis may make retransplantation impossible.41-43
It is likely that endoscopic and percutaneous therapy have minimized the need for post-transplant biliary surgery. According to a 10-year experience at the University of California, San Francisco, there were 1,061 cases of adult liver transplants, of which 959 were orthotopic liver transplants and 102 were living donor procedures. Of these patients, 947 underwent CDCD reconstruction and 114 had a hepaticojejunostomy. The study also noted that 232 (22%) of the adults experienced biliary complications: 140 bile duct strictures, 59 bile duct leaks, 18 cases of papillary stenosis, 16 cases of diffuse bile duct injury (usually ischemic), 7 cases of choledocholithiasis, and 2 cases of extrinsic compression from post-transplant lymphoproliferative disorder.44
The study also noted a trend toward increased complications in patients undergoing a surgical take-back procedure for hemorrhage, sepsis, and obstruction, patients with a choledochoenteric anastomosis, and those undergoing a living donor transplant ().
Frequency of Various Adult Biliary Complications Over 10 Years at the University of California, San Francisco
Of the 114 patients who had choledochoenteric anastomosis, 33 underwent percutaneous management for a complication and 21 of the 33 (64%) required surgical revision.
In addition, 166 individuals underwent ERCP with a CDCD anastomosis and 101 of 132 (77%) had endo-scopically manageable pathology and required no surgical revision. This figure included 64 of 100 cases (64%) of strictures, 16 of 31 cases (52%) of leaks, 16 of 16 cases (100%) of papillary stenosis or choledochocoele, and 4 of 14 cases (29%) of diffuse biliary injuries.
It is thus fair to conclude that endoscopic management and therapy can minimize the need for post-transplant biliary surgery in the cases of biliary tract complications of strictures and papillary stenosis. These techniques are generally safe and nearly always effective in the short term and can serve as a bridge to surgical therapy. Further endoscopic therapy may be the preferred therapy for chronic management of strictures and stones if definitive curative surgery (retransplant or reconstruction) is not possible.