Incidence and management of biliary complications after 291 liver transplants following the introduction of transcystic stenting

Background. Biliary complications occur frequently after liver transplantation, and many are historically related to T tubes. Stents placed through the donor cystic duct have been used to attempt to reduce tube-related complications yet maintain access to the biliary tree. Methods. The outcomes of all liver transplant procedures performed at the University of Michigan between December 7, 1990 (when transcystic stenting was first used), and April 6, 1995, were analyzed retrospectively. Preoperative, perioperative, and postoperative variables were studied in relationship to biliary complications. The management of complications was also reviewed. Results. A total of 291 transplants qualified fbr study. The overall biliary complication rate was 25%, with no difference between the 237 patients who received transcystic stents, the 28 who received T tubes, I;nd the 26 who received no tube. Among the complications patients experienced, 65% had stricture(s), 44% had stone or sludge formation, and 40% had a leak. Complications attributable solely to transcystic stents occurred in 4% of cases. Advanced age was the only preoperative variable associated with complications. Primary sclerosing cholangitis was associated with intrahepatic strictures, and prolonged cold ischemia time and rejection were associated with stone or sludge formation. Nonoperative management had the highest success rate for anastomotic stricture (76%) and the lowest for intrahepatic strictures (65%), Only one death was directly attributable to a biliary complication. Conclusion. Transcystic stenting reduces the incidence of significant tube-related complications, but not the frequency of other biliary complications. Biliary complications can usually be managed percutaneously or endoscopically, although intrahepatic strictures and large, early leaks frequently require reoperation. Aggressive, early management of these complications can reduce excess mortality to less than 2%.