Prospective randomized trial of end-to-end versus side-to-side biliary reconstruction after orthotopic liver transplantation

BACKGROUND

Biliary reconstruction is the Achilles heel of liver transplantation. Side-to-side anastomosis of donor and recipient bile duct has been claimed to be superior to end-to-end anastomosis in uncontrolled studies.

METHODS

A total of 100 consecutive patients undergoing orthotopic liver transplantation were randomized after commencement of the transplant procedure to end-to-end or side-to-side anastomosis. No T tube drainage was employed. Endoscopic retrograde cholangiography was performed 2 weeks after transplantation and findings were reported by an experienced endoscopist as normal, leak or stricture. Median follow-up was 53 (range 35-63) months.

RESULTS

Patient age, sex, the graft preservation time and indication for transplantation were similar in both groups. Sixty patients received end-to-end and 40 side-to-side anastomosis. Ten patients randomized to side-to-side anastomosis had an end-to-end procedure. The total number of biliary complications was similar in both groups (end-to-end 32 per cent versus side-to-side 30 per cent) as were the number of leaks (17 versus 18 per cent) and biliary strictures (15 versus 12 per cent). There was no difference in the number of biliary complications that required interventional treatment (22 per cent in both groups).

CONCLUSION

Side-to-side and end-to-end biliary anastomosis at liver transplantation are equally effective.

Prospective study of hepatobiliary scintigraphy and endoscopic cholangiography for the detection of early biliary complications after orthotopic liver transplantation

BACKGROUND

Biliary complications are a significant cause of morbidity and death after orthotopic liver transplantation (OLT). This study was a prospective evaluation of endoscopic retrograde cholangiography (ERC) and hepatobiliary scintigraphy (HBS), using 99mTc Mebrofenin, to detect early biliary complications following OLT.

METHODS

One hundred consecutive patients who had OLT with a biliary duct-to-duct anastomosis were studied. Of these, 67 had both ERC and HBS performed within 30 days of OLT. Sensitivity, specificity and diagnostic accuracy of HBS in identifying biliary leak or stricture was calculated.

RESULTS

Of the 67 cholangiographies performed 45 were normal. In 22 patients there was radiological evidence of a leak (n = 14) or stricture (n = 8) which required further intervention in nine and four patients respectively. The sensitivity and specificity of scintigraphy for the detection of biliary leak after transplantation was 50 and 79 per cent and for biliary stricture 62 and 64 per cent respectively. No patient with normal scintigraphy required biliary intervention. Only six of 14 patients with biliary leaks and two of 20 with strictures suggested by scintigraphy required intervention. If both ERC and HBS reported leak or stricture, the intervention rate was considerably higher at five of seven leaks and two of five strictures.

CONCLUSION

This study suggests that scintigraphy is a useful screening test for biliary complications after OLT, ERC is only necessary if HBS is abnormal.

Prospective study of hepatobiliary scintigraphy and endoscopic cholangiography for the detection of early biliary complications after orthotopic liver transplantation

BACKGROUND

Biliary complications are a significant cause of morbidity and death after orthotopic liver transplantation (OLT). This study was a prospective evaluation of endoscopic retrograde cholangiography (ERC) and hepatobiliary scintigraphy (HBS), using 99mTc Mebrofenin, to detect early biliary complications following OLT.

METHODS

One hundred consecutive patients who had OLT with a biliary duct-to-duct anastomosis were studied. Of these, 67 had both ERC and HBS performed within 30 days of OLT. Sensitivity, specificity and diagnostic accuracy of HBS in identifying biliary leak or stricture was calculated.

RESULTS

Of the 67 cholangiographies performed 45 were normal. In 22 patients there was radiological evidence of a leak (n = 14) or stricture (n = 8) which required further intervention in nine and four patients respectively. The sensitivity and specificity of scintigraphy for the detection of biliary leak after transplantation was 50 and 79 per cent and for biliary stricture 62 and 64 per cent respectively. No patient with normal scintigraphy required biliary intervention. Only six of 14 patients with biliary leaks and two of 20 with strictures suggested by scintigraphy required intervention. If both ERC and HBS reported leak or stricture, the intervention rate was considerably higher at five of seven leaks and two of five strictures.

CONCLUSION

This study suggests that scintigraphy is a useful screening test for biliary complications after OLT, ERC is only necessary if HBS is abnormal.