Biliary Complications After Liver Transplantation: A Single-center Experience

Background:Liver transplantation has become the standard treatment for patients with liver decompensation,but the occurrence of postoperative biliary complications（BC）is an important influencing factor leading to reduced recipient survival time and decreased quality of life.Early studies reported that the incidence of BC is as high as 50%.With the development of organ preservation techniques,immunosuppressive agents and continuous advancement of surgical techniques,the incidence of BC after liver transplantation has dropped to 5% ～ 25%.However,due to its complex treatment and high mortality,it is also known by industry scholars as the "Achilles’ heel" of liver transplantation.The risk factors of BC formation after liver transplantation have been the focus of research in the international transplant community,and the current research angels have run through all aspects of the perioperative period,such as preoperative donor-recipient matching,donor liver source,intraoperative bile duct anastomosis methods,biliary reconstruction techniques,ischemic time,postoperative cytomegalovirus infection,vascular complications,immune rejection,etc.With the continuous updating and improvement of liver transplantation devices and the improvement of surgical techniques,the incidence of surgery-related bile leakage and biliary anastomotic stricture gradually decreased,while other types of BC showed an upward trend.There is no consensus in academia on the intrinsic mechanism of BC formation,therefore,to enhance the understanding of BC after orthotopic liver transplantation and explore its risk factors are beneficial to improve the efficacy of liver transplantation and the quality of life of patients.Objective:Through retrospective analysis,statistics and summary of liver transplantation cases in the Organ Transplantation Center of the First Affiliated Hospital of An Medical University,the incidence,diagnostic methods,treatment experience and prognosis results of BC in our center were summarized,and the factors leading to BC after liver transplantation were screened out,so as to provide reference and intervention methods for the prevention and treatment of BC in clinical practice.Methods:The clinical data of 123 cases of orthotopic liver transplantation performed in the First Affiliated Hospital of Anhui Medical University from February 2015 to August2021 were retrospectively analyzed,and all cases were divided into BC group（22 cases）and non-BC group（101 cases）according to the presence or absence of biliary complications after transplantation.The donor data and recipient data of each group were collected,and the following factors were statistically analyzed: donor and recipient gender,age,body mass index（BMI）,cause of donor death,donation type,cold/warm ischemia time,preoperative bilirubin,history of recipient biliary tract surgery,history of transcatheter arterial chemoembolization（TACE）,Child-Pugh classification,model for end-stage liver disease（MELD）score,surgical methods,biliary anastomosis methods,operation time,anhepatic phase,intraoperative blood loss,blood transfusion volume,arterial bypass,T-tube use,and postoperative vascular complications;and the diagnosis,treatment methods and prognosis of 22 recipients in the occurrence group were summarized,all results were statistically significant at P <0.05.Results:1.There were 123 orthotopic liver transplants and 22 patients in the group with biliary complications,with an incidence of 17.89%.There were 14 cases（63.64%）of anastomosis-related complications,including 11 cases of biliary anastomotic stricture,3cases of biliary anastomotic leakage（1 case of bile leakage after retransplantation）;7cases（31.82%）of non-anastomosis-related complications,including 4 cases of ischemic biliary tract injury,1 case of non-ischemic biliary stricture,1 case of hemobilia,1 case of bile duct lengthening;1 case（4.54%）of T-tube related complications,bile leakage after removal of the T-tube.Fourteen patients（63.64%）with BC were simple type and 8patients（36.36%）were compound type,including bile leakage or biliary stricture with biliary calculi,bile sludge formation and hemobilia.In terms of diagnosis,endoscopic retrograde cholangiopancreatography（ERCP）confirmed 7 cases,magnetic resonance cholangiopancreatography（MRCP）confirmed 12 cases,and color Doppler ultrasound（B ultrasound）combined with paracentesis confirmed 3 cases.In terms of treatment,endoscopic and interventional treatments such as ERCP and percutaneous transhepatic cholangiography（PTC）were performed in 16 cases,11 cases were cured and improved,5 cases had poor effect after treatment with the above methods,and all died of multiple organ dysfunction syndrome（MODS）;3 cases underwent paracentesis drainage,only 1case was improved,2 cases had poor effect and were discharged automatically;1 case was improved after drug treatment only;2 cases recovered after reoperation.2.Compared with the non-BC group,univariate analysis showed that MELD score≥ 25（P = 0.029）,donor age≥ 60 years（P = 0.043）,anhepatic phase≥ 60 min（P =0.042）,intraoperative red blood cell transfusion ≥ 8U（P = 0.02）and postoperative vascular complications（P = 0.037）were risk factors for biliary complications after liver transplantation.Logistic regression model analysis suggested that donor age≥60 years[OR = 4.489,95% Cl（1.210 ～ 16.657）,P = 0.025)],preoperative MELD/PELD score≥25 points [OR = 11.551,95% Cl（2.248 ～59.362）,P = 0.003)],intraoperative red blood cell transfusion≥8 U [OR = 6.519,95% Cl（1.752 ～24.256）,P = 0.005)] and postoperative vascular complications [OR = 10.210,95% Cl（1.638～63.652）,P = 0.013)]were independent risk factors for biliary complications after liver transplantation.Conclusions:1.The mortality rate of BC patients after liver transplantation is significantly higher than that of non-BC patients.2.MELD score≥25,donor age≥60 years,intraoperative red blood cell transfusion≥8 U and postoperative vascular complications are independent risk factors for biliary complications after liver transplantation.3.After the occurrence of biliary complications,MRCP has a high detection rate in the first imaging diagnosis and can be used as a preferential choice.Most patients with BC may improve with endoscopic or interventional therapy,but patients with persistent aggravation should undergo surgical intervention as soon as possible and require retransplantation if necessary,and patients with multiple organ failure have an overall poor prognosis.