Objectives: Biliary complications are common after living-donor liver transplant. This retrospective study reviewed our experience with biliary complications in recipients of living-donor liver transplant.

Materials and Methods: Over our 9-year study period, 120 patients underwent living-donor liver transplant. Patients were divided into 2 groups, with group A having biliary complications and group B without biliary complications. Both groups were compared, and different treatment modalities for biliary complications were evaluated.

Results: Group A included 45 patients (37.5%), whereas group B included 75 patients (62.5%). Biliary com-plications included bile leak in 17 patients (14.2%), biliary stricture in 11 patients (9.2%), combined biliary stricture with bile leak in 15 patients (12.5%), and sphincter of Oddi dysfunction and cholangitis in 1 patient each (0.8%). Cold ischemia time was sig-nificantly longer in group A (P = .002). External biliary drainage was less frequently used in group A (P = .031). Technical success rates of endoscopic biliary drainage and percutaneous transhepatic biliary drainage were 68.3% and 41.7%. Survival rate following relaparotomy for biliary complications was 62.5%.

Conclusions: Graft ischemia is an important risk factor for biliary complications. Bile leaks can predispose to anastomotic strictures. The use of external biliary drainage seems to reduce the incidence of biliary complications. Endoscopic and percutaneous trans-hepatic approaches can successfully treat more than two-thirds of biliary complications. Relaparotomy can improve survival outcomes and is usually reserved for patients with intractable biliary complications.

Key words : Bile ducts, Biliary drainage, Hepatic transplantation, Living donors, Relaparotomy

Introduction

Liver transplantation is currently the only definitive treatment for end-stage liver disease, hepatocellular carcinoma, and some metabolic disorders. The dramatic improvement in posttransplant patient survival over the past few decades has been attributed to a variety of factors, including refined surgical and organ preservation techniques, better immuno-suppression protocols, more efficient treatment of infections, and improved perioperative care.^1-3 However, despite the recent advances in this field, liver transplant is still associated with many complications, including bleeding, vascular com-plications, biliary complications, primary graft nonfunction, small-for-size syndrome, graft rejection, and others.⁴

Biliary complications remain one of the most common and the most worrisome problems in liver transplant recipients. Biliary strictures and bile leaks account for most biliary complications after living-donor liver transplant (LDLT), and the outcomes are potentially lethal.⁵ The aim of this retrospective cohort study, which we conducted in 2014 and 2015, was to review our experiences with biliary complications in 120 patients who underwent LDLT over a 9-year period and to evaluate the efficacy of different treatment modalities in the management of different types of biliary complications.

Materials and Methods

Between October 2004 and October 2013, 120 patients underwent LDLT at Cairo University Hospitals and were included in this study. Medical records were retrospectively studied. Written informed consent was obtained from each patient (recipient) before LDLT. The study protocol was approved by the Institutional Ethical Committee before the study began and conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

All donors were subjected to a strict multistep evaluation protocol, including a precise study of the graft vascular and biliary anatomy by computed tomographic (CT) angiography, venography, and portography, as well as magnetic resonance cholangiopancreatography. Both CT volumetry and liver biopsy were performed preoperatively, and a 30% residual liver volume, together with a graft-to-recipient weight ratio of 0.8%, was set as a minimum cut-off for donation. In all donor operations, intraoperative transcystic cholangiography was performed as a routine to guide for proper intra-operative division of the bile ducts. For us to ensure good vascularity of graft bile ducts, hilar plate dissection was always kept to a minimum, skeletonization of the bile ducts was avoided, and a single sharp cut was used to divide the bile ducts in a direction perpendicular to their long axes. These precautions were consistent with the operative principles described in a recent study of LDLT.⁶ All liver grafts were perfused intraoperatively with at least 4 liters of cold histidine tryptophan ketog-lutarate solution (Custodiol, Essential Pharmaceuticals, LLC, Newtown, PA, USA).

In all cases, recipient factors (age, sex, Model for End-Stage Liver Disease score, ABO blood type) and indications for transplant were recorded. Total hepatectomy was performed in all recipients. The graft hepatic vein was anastomosed to the recipient inferior vena cava in an end-to-side fashion. Reconstruction of additional graft veins to the inferior vena cava was carried out if necessary. Portal venous reconstruction and graft reperfusion were then undertaken, followed by hepatic arterial reconstruction. Intraoperative Duplex ultrasono-graphy scanning was used to exclude any graft inflow/outflow problems. Finally, biliary recon-struction was carried out.

Although there is still no clear consensus regarding the preferred type of biliary reconstruction in LDLT, the use of duct-to-duct anastomosis has been increasingly reported in the literature.^7-13 This was the standard technique that we used for biliary reconstruction in our LDLT program. Several key points are known to be crucial for a safe duct-to-duct biliary anastomosis in LDLT, including size match of the donor and recipient bile ducts, good quality and blood supply of both ducts, and the ability to have a tension-free anastomosis.⁶ These key points were carefully targeted in all of our patients.

An absorbable 6/0 polydioxanone suture material was used for biliary reconstruction. Duct-to-duct anastomosis (duct-to-duct hepaticocholedochostomy) was performed by anastomosing the graft bile duct to the recipient right or left hepatic duct in an end-to-end fashion. If 2 bile ducts were present in the liver graft, the second duct was anastomosed either to the other recipient hepatic duct in an end-to-end fashion or to the common hepatic duct in an end-to-side fashion, whichever was more technically feasible. Occasionally, if the 2 graft ducts were too close to each other (ie, < 2 mm apart), a ductoplasty was undertaken by approximating both ducts together with a single suture and performing a single 2-in-1 anastomosis. If > 2 bile ducts were present in the graft, the remaining duct or ducts were anastomosed either to the common hepatic duct in an end-to-side fashion or, less frequently, to the cystic duct, whichever was more technically feasible. The anastomotic technique consisted of a running posterior wall suture and interrupted anterior wall sutures. However, in cases of having a too small graft duct, interrupted sutures were used. Occasionally, in patients with extrahepatic biliary disease (eg, primary sclerosing cholangitis [PSC]) and in some pediatric recipients, an end-to-side Roux-en-Y hepaticojejunostomy (RYHJ) was used for biliary reconstruction. The decision on whether to perform transanastomotic external biliary drainage (EBD) was made on a case-by-case basis, guided by the number and size of the bile ducts. This was achieved by inserting a biliary stent tube upward into the biliary anastomosis through the wall of the common hepatic duct (or the jejunum in cases of RYHJ). If ≥ 2 duct-to-duct anastomoses were needed, 2 or more stents were placed. Postoperatively, the stent was left unclamped to allow free biliary drainage. Once serum bilirubin levels were normalized, the stent was clamped. If serum bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl trans-ferase (GGT) levels were normal and there was no clinical or radiologic evidence of bile leak or biliary stricture, the stent was removed 3 months after LDLT.

Postoperatively, all patients were closely monitored in the intensive care unit and later in the surgical ward. The immunosuppression protocol consisted of tacrolimus and low-dose steroids. Mycophenolate mofetil was added if necessary. Basiliximab was used as induction therapy in patients with renal im-pairment. Repeated clinical examinations, laboratory investigations (including bilirubin in the drain effluent), ultrasonography, and Doppler scanning were daily performed. After the first week, some laboratory investigations were performed every other day, as necessary. After hospital discharge, all patients were followed up weekly for 1 month, monthly until the end of the first year, and then every 3 months thereafter. Failure to complete an 18-month follow-up was set as an exclusion criterion.

If a biliary complication was suspected, a thorough primary work-up was instituted, including complete liver function tests, tests for bilirubin levels in drains (if applicable), pelviabdominal ultrasonography, and Doppler scanning, mainly to check the hepatic arterial flow. If necessary, CT scans of the abdomen and pelvis were performed. In stable patients with suspected bile leak, conservative treatment was attempted first. A tube cholangiography was also done in patients with biliary stent tubes to delineate the presumed leak. The duration of conservative treatment was quite variable in these patients, depending on the amount of bilious drain output, bilirubin levels in drains, blood test findings (including complete blood count, C-reactive protein, and liver function tests), ultra-sonographic findings, tube cholangiography findings in patients who had biliary stent tubes, and time of development of the presumed leak. If conservative treatment failed, a therapeutic endos-copic retrograde cholangiography (ERC) was carried out (if feasible).

In unstable or critically ill patients and those with clinically evident (frank) bile leak, we proceeded directly to ERC for prompt diagnosis and treatment. Endoscopic treatment involved a sphincterotomy with insertion of a plastic stent, whenever possible. If this failed, either a repeat ERC or a percutaneous transhepatic cholangiography (PTC) with percu-taneous transhepatic biliary drainage (PTBD) was the next resort. A successful outcome of ERC or PTBD was defined as “continuous improvement in liver function tests after the procedure and persistent patency of the biliary anastomosis with no evidence of bile leak on cholangiography.” On the other hand, patients with suspected biliary strictures were ideally investigated by magnetic resonance cholangiography (MRC). Based on MRC, a decision was made regard-ing further intervention (ERC or PTC). Endoscopic treatment involved insertion of a plastic stent through the stricture. If this failed, either a repeat ERC or a PTC with PTBD was attempted. Ultrasonography/CT-guided drainage was per-formed in cases of uncontrolled bile leak with intra-abdominal biloma. Relaparotomy was always reserved as the last resort for patients with intractable biliary complications in whom ERC and/or inter-ventional radiologic procedures were not able to achieve satisfactory therapeutic results. In these patients, peritoneal lavage and drainage and/or redo biliary reconstruction via RYHJ was performed, depending on the type of biliary complication encountered.

Our study patients were divided into 2 groups: group A consisted of patients with biliary complications, and group B consisted of patients without biliary complications. Both groups were compared in terms of recipient factors, indications for transplant, graft/operative factors, postoperative laboratory data, and rates of hepatic arterial thrombosis (HAT), relaparotomy, and mortality (Table 1). Different types of biliary complications were analyzed in terms of incidence, risk factors, clinical presentations, and postoperative laboratory data. The different treatment modalities for biliary complications were finally evaluated.

Values in our study were expressed as means ± standard deviations or as numbers (%). Categorical variables were compared using chi-square test. According to normality test, mean values of different variables in patients without biliary complications were compared with those in other groups using either unpaired t test or Mann-Whitney U test, whichever was appropriate. A P value < .05 was considered statistically significant, whereas a value < .01 was considered highly significant. Data were analyzed using SPSS for Windows (SPSS: An IBM Company, version 16.0, IBM Corporation, Armonk, NY, USA).

Results

The study patients included 112 adults and 8 pediatric recipients. Patients ranged in age from 1 year to 65 years (44.89 ± 13.85 y). Male-to-female ratio was 103 to 17. The indications for LDLT were postviral cirrhosis in 106 patients (88.3%) (101 with viral hepatitis C, 2 with viral hepatitis B, and 3 with viral hepatitis B and C), with 30 patients having disease complicated by hepatocellular carcinoma and 2 patients having disease complicated by hepatorenal syndrome. Other indications included cryptogenic cirrhosis in 5 patients (4.2%), Crigler-Najjar syn-drome in 3 patients (2.5%), hepatocellular carcinoma in 2 patients (1.7%), and PSC, autoimmune hepatitis, familial intrahepatic cholestasis, and Wilson disease in 1 patient each (0.8%). Model for End-Stage Liver Disease score at the time of LDLT ranged from 11 to 40 (17.72 ± 4.207). The ABO blood types were compatible in all cases. Liver grafts consisted of right lobe without the middle hepatic vein in 110 cases (91.7%) and left lateral section in 10 cases (8.3%). The number of graft bile ducts was 1 in 64 grafts (53.33%), 2 in 48 grafts (40%), 3 in 7 grafts (5.83%), and 4 ducts in 1 graft (0.83%). Biliary reconstruction was carried out using duct-to-duct anastomosis in 118 patients (98.3%) and RYHJ in 2 patients (1.7%) (1 with Crigler-Najjar syndrome and 1 with PSC). Ductoplasty was used in 14 patients (11.7%), and transanastomotic EBD was used in 71 patients (59.2%). The follow-up period in our study ranged from 21 to 63 months (mean of 37 mo). All patients completed 18-month follow up, with none excluded from the study.

Group A included 45 patients (37.5%), and group B included 75 patients (62.5%). Biliary complications in group A included bile leak in 17 cases (14.2% of all patients/37.8% of those with biliary complications), biliary stricture in 11 cases (9.2% of all patients/24.4% of those with biliary complications), combined biliary stricture and bile leak in 15 cases (12.5% of all patients/33.3% of those with biliary complications), sphincter of Oddi dysfunction in 1 case (0.8% of all patients/2.2% of those with biliary complications), and cholangitis without leak/stricture in 1 case (0.8% of all patients/2.2% of those with biliary com-plications). Thus, the overall bile leak rate in our study was 26.7% (32 patients) (30 cases of anas-tomotic leaks and 2 cases of leaks from the graft cut-surface). Our overall biliary stricture rate was 21.7% (26 patients) (23 cases of anastomotic stricture and 3 cases of nonanastomotic stricture).

Analyses of graft and operative factors revealed that cold ischemia time of liver grafts was significantly longer in group A (80.67 ± 35.11 min) than in group B (64.13 ± 27.64 min; P = .002). However, we found no significant differences in warm ischemia time between the 2 groups (50.00 ± 27.41 min in group A vs 45.53 ± 15.59 min in group B; P = .539). Ductoplasty was performed in 8 patients in group A (17.8%) compared with 6 patients in group B (8%). Thus, overall, the rate of biliary complications was higher in patients who had a ductoplasty (57.1%; 8/14 cases) than in those who did not have a ductoplasty (34.9%; 37/106 cases; P = .106). Meanwhile, EBD was used in 21 patients in group A (46.7%) and in 50 patients in group B (66.7%). Thus, overall, the rate of biliary com-plications was significantly higher in patients who did not have EBD (49%; 24/49 cases) than in those who had EBD (29.6%; 21/71 cases), and the difference was statistically significant (P = .031).

Of all 45 cases with biliary complications, 31 (68.9%) manifested in the early postoperative period (ie, during month 1 after transplant), whereas 14 cases (31.1%) showed delayed presentation. All patients with bile leak manifested in the first 1 to 2 months after transplant, with clinical presentations ranging from asymptomatic elevation of drain bilirubin levels to frank peritonitis and sepsis. Meanwhile, delayed presentations were usually seen in patients with biliary strictures, ranging from asymptomatic derangement of liver biochemical markers to severe cholangitis and sepsis. Patients with combined biliary stricture and bile leak almost always presented with bile leak first, followed by a cholestatic picture weeks or months later. Sphincter of Oddi dysfunction presented with abnormal serum bilirubin and ALP levels, bile duct dilatation with poor contrast drainage, and smooth narrowing of the papilla at cholangiography.

In almost all patients with biliary complications, a correct preliminary diagnosis of the problem was established on the basis of both the clinical picture and the primary work-up (laboratory investigations and imaging) (see Tables 1 and 2). Serum total and direct bilirubin, ALP, and GGT levels in the first 18 months after LDLT and drain bilirubin levels were significantly higher in group A than in group B (P = .001, .001, .001, .004, and .001, respectively). In all cases, the diagnosis was confirmed and the bile leak/biliary stricture clearly outlined by cholan-giography, eg, tube cholangiography (Figure 1), MRC (Figure 2), ERC (Figure 3), and/or PTC (Figure 4).

Treatment modalities that were attempted in the 45 group A patients included conservative treatment in 37 patients (82.2%), ultrasonography/CT-guided drainage of intra-abdominal biloma in 5 patients (11.1%), ERC and biliary drainage in 41 patients (91.1%) (once in 33 patients; > once in 8 patients), PTBD in 12 patients (26.7%; 11 with ERC failure, 1 with ERC not feasible because of a Roux-en-Y biliary reconstruction), and relaparotomy in 8 patients (17.8%) (Table 3). Conservative treatment was successful in only 3 cases (8.1%; 2 with bile leak and 1 with cholangitis), and ultrasonography/CT-guided drainage was successfully performed in 5 of 5 patients (100%). Endoscopic retrograde cholan-giography with biliary drainage (Figure 3) was technically successful in 28 patients (68.3%; 27 with sphincterotomy and stent insertion and 1 with sphincterotomy alone). Excellent clinical, biochem-ical, and radiologic responses to endoscopic sphincterotomy were noted in the only patient with sphincter of Oddi dysfunction. In the 13 patients in whom ERC did not diagnose or treat the problem, 11 patients underwent PTBD and 2 patients underwent immediate relaparotomy without attempting PTBD (1 with biliary peritonitis and 1 with combined biliary stricture with bile leak and sepsis).

The technical success rate of PTBD (Figure 4) was 41.7% (5/12 patients; 1 of those 5 patients died days later despite technical success). Relaparotomy was carried out in 13 patients (10.8%) in our study: in 9 patients in group A (8 with biliary complications and 1 with HAT) and in 4 patients in group B (2 with bleeding and 2 with HAT). Of the 8 patients in group A who underwent relaparotomy for biliary com-plications (after failure of ERC alone or ERC and PTBD), peritoneal lavage and drainage were per-formed in 3 patients (once in 2 patients, twice in 1 patient), a redo biliary reconstruction via RYHJ was performed in 1 patient, and combined peritoneal lavage and drainage with RYHJ was performed in 4 patients (Figure 5). In this group, 5/8 patients survived (62.5%). In the 17 patients with isolated bile leak, the overall biliary stricture rate after treatment of bile leak was 0% (ie, there was no difference in the biliary stricture rate between patients who underwent ERC or PTC and those who underwent relaparotomy). The retransplant rate was 0% in both of our study groups.

There was a higher proportion of patients who had HAT in group A (11.1% or 5 patients) than in group B (4% or 3 patients; P = .131). Of the 5 patients in group A, 2 (40%) had bile leak, 2 (40%) had biliary stricture, and 1 (20%) had combined biliary stricture with bile leak. The overall mortality rate in our study was 28.3% (34 patients). Of those patients, 5 patients died of biliary complications and sepsis (1 patient with bile leak who underwent ERC and relaparotomy twice, 1 patient with bile leak who underwent ERC twice and ultrasonography-guided drainage, 1 patient with biliary stricture who underwent ERC and PTC, and 2 patients with combined biliary stricture and bile leak who underwent ERC, PTC, and relaparotomy). In addition, 2 patients died of combined HAT and biliary complications. There was a higher proportion of dead patients in group B (23 patients or 30.7%, 19.2% of all patients, 67.65% of overall mortality) than in group A (11 patients or 24.4%, 9.2% of all patients, 32.35% of overall mortality), but the difference between the 2 groups was not statistically significant (P = .464).

Discussion

Biliary complications are an important cause of morbidity and mortality after orthotopic liver transplant. The overall incidence of biliary com-plications after orthotopic liver transplant ranges from 11% to 34%.^14-17 That is why biliary recon-struction in liver transplant recipients has been considered, for years, as the Achilles heel of liver transplant procedures.¹⁸ Although the incidence of biliary complications has declined in deceased-donor liver transplant (from 6%-34% in older literature to 5%-15% in more recent reviews), it has remained high in LDLT, ranging from 24% to 60%.^2,19-25 Several factors are thought to contribute to this higher incidence in LDLT. These include the much smaller size of the bile ducts, the multiplicity of the bile ducts in some grafts, the high incidence of variations in the donor biliary anatomy, the presence of a liver parenchymal cut surface, and the impaired vascularity of bile ducts secondary to the hilar dissection carried out in both donor and recipient operations.^8,19,26,27 Herein, we report a retrospective series of 120 LDLTs with an overall incidence of recipient biliary complications of 37.5%, a rate that almost coincides with rates shown in the literature.

Biliary complications after LDLT include biliary strictures, bile leaks, cholangitis, choledocholithiasis, and others (eg, sphincter of Oddi dysfunction, hemobilia, and recurrence of biliary disease).⁵ Approximately one-third of biliary complications occur within the first month after transplant, two-thirds occur within the first 3 months, and nearly 80% occur within the first 6 months after liver transplant.¹⁹ In our study, biliary complications included bile leak (incidence of 14.2%), biliary stricture (incidence of 9.2%), combined biliary stricture and bile leak (incidence of 12.5%), sphincter of Oddi dysfunction (incidence of 0.8%), and cholangitis (incidence of 0.8%). Of all complications, nearly two-thirds (68.9%) manifested in the early postoperative period. Although the overall bile leak rate in our study (26.7%) exceeded the literature leak rates (ranging from 4.7% to 18.2%), our overall biliary stricture rate (21.7%) coincides with the stricture rates reported in previous studies of LDLT (ranging from 8.3% to 31.7%).^8,13,28

In fact, the most vulnerable point of the biliary system is the blood supply. Previous studies have suggested that the biliary epithelium is much more vulnerable to ischemic injury than hepatocytes.^23,29-31 This explains why prolonged graft ischemia time, ischemia of the bile duct stumps, and HAT have been recognized as potential risk factors for biliary complications, mainly strictures.^31-33 In our study, the cold ischemia time of liver grafts was significantly longer in group A than in group B patients (P = .002). There was also a relatively higher incidence of HAT in group A than in group B patients, but the difference was not statistically significant (P = .131). These findings further support the role of graft ischemia as an important risk factor for biliary complications. Other known risk factors include inadequate surgical technique, old donor age, marginal grafts, cytomegalovirus infection, ABO incompatibility, chronic rejection, recurrent PSC, and early hepatitis C virus recurrence.^{8,30,31,34-39} A preceding bile leak has also been described as an important risk factor for anastomotic biliary strictures,36-38 a finding that is consistent with our study in which 15 cases of biliary strictures were preceded by bile leaks.

Bile leaks usually occur in the early postoperative period due to bile duct necrosis and poor healing, with the anastomotic site being the most common. Other sources include cut surfaces of liver grafts, cystic duct, drainage tube exit sites, and sinus tracts.^5,31,40,41 Similarly, in our study, all bile leaks manifested in the first 1 to 2 months after transplant, with the majority being anastomotic leaks (30/32; 93.75%) and a minority being leaks from the graft cut surface (2/32; 6.25%). On the other hand, biliary strictures are generally classified into anastomotic and nonanastomotic strictures (ischemic-type biliary lesions), with anastomotic strictures being much more common.31 Agreeing with the literature,31 most biliary strictures encountered in our study were anastomotic strictures.

Although ductoplasty has been shown to increase the risk of bile duct ischemia, it was used by some surgeons to facilitate biliary reconstruction in the recipient if the graft had ≥ 2 bile ducts.^11,13 In our study, ductoplasty was used in a total of 14 patients, with the aim of performing less biliary anastomoses and to obtain a larger luminal diameter for an easier reconstruction. Overall, the rate of biliary com-plications was higher in patients who had ductoplasty (8/14 cases; 57.1%) than in those who did not have ductoplasty (37/106 cases; 34.9%), but the difference was not statistically significant (P = .106). Therefore, the use of ductoplasty did not seem to affect the outcomes so far. On the other hand, the use of EBD for stenting of the biliary anastomosis in LDLT is controversial. The rationale of EBD is to maintain bile flow despite swelling of the anas-tomotic site as well as to provide an easy access for postoperative cholangiography if a biliary com-plication is suspected.⁴² In a series of right-lobe LDLT,13 EBD seemed to reduce biliary complications in Roux-en-Y biliary reconstruction but was associated with a high overall incidence of biliary strictures (26.6%) in duct-to-duct reconstruction at long-term follow-up. In our study, EBD was performed in a total of 71 patients. Overall, the rate of biliary complications was significantly higher in patients who did not have EBD (24/49 cases; 49%) than in those who had EBD (21/71 cases; 29.6%) (P = .031). This suggests that the use of EBD can reduce the overall incidence of biliary complications, a finding that is consistent with some reports.43,44 However, because our decision on whether to perform EBD was made on a case-by-case basis, a selection bias might still exist. Also, lacking a comparison between the rates of biliary com-plications in patients who had a running posterior wall suture and those who had interrupted posterior wall sutures for duct-to-duct biliary reconstruction is another limitation of our study.

No doubt, a high index of suspicion is needed for diagnosis of posttransplant biliary complications. Early and aggressive diagnostic investigations should be initiated without hesitation once a biliary complication is suspected.⁴⁵ In our study, a combination of close clinical surveillance, laboratory investigations (serum total and direct bilirubin, ALP, GGT, and drain bilirubin levels) and imaging were sufficient to establish a correct preliminary diagnosis in almost all patients with biliary complications in the first 18 months after LDLT.

Nonoperative treatment of biliary complications after LDLT has become very popular in recent years.⁴⁶ With the growing experience in endoscopic and interventional radiologic procedures, ERC and PTBD have superseded surgery for the management of almost all biliary strictures.⁴⁷ In our study, conservative management was attempted in 37 patients with biliary complications (82.2%), aiming for spontaneous normalization of liver function tests and/or drain bilirubin levels. This was successful in only 3 cases (8.1%). Ultrasonography/CT-guided drainage of intra-abdominal bilomas was performed in 5 patients (11.1%) with a 100% technical success rate. Endoscopic retrograde cholangiography with biliary drainage was attempted in 41 patients (91.1%) with an overall technical success rate of 68.3% (28/41 cases) and with the highest success rate being reported in patients with isolated bile leaks (12/15 cases; 80%), whereas PTBD was performed in 12 cases (26.7%) with a technical success rate of 41.7% (5/12 cases). The overall technical success rates of ERC (68.3%), PTBD (41.7%), and both together (33/42 cases; 78.6%) in our study were found to be somehow lower than those reported in recent reviews, which range from 75% to 100% for endoscopic management and from 55% to 100% for percutaneous management of biliary com-plications.46,48 These differences have been attributed to the growing experiences of endoscopists and interventional radiologists in our team and the steep learning curve that had to be overcome after the introduction of our LDLT program in 2004. Relaparotomy was resorted to in 8 patients with biliary complications (17.8% of group A patients/6.7% of all patients). This rate is slightly lower than that reported in a previous study of LDLT with duct-to-duct biliary reconstruction (7.7%).6 The survival rate after relaparotomy was 62.5% (5/8 cases).

In conclusion, biliary complications are common in recipients of LDLT. The most commonly en-countered complications are bile leak, biliary stricture, and combined biliary stricture with bile leak. Most of these complications manifest in the early postoperative period and most tend to occur at the site of the biliary anastomosis. Graft ischemia is an important risk factor for biliary complications, whereas bile leaks can predispose to anastomotic biliary strictures. The use of EBD seems to reduce the overall incidence of biliary complications. A combination of close clinical surveillance, laboratory investigations, and imaging is crucial for establishing a correct preliminary diagnosis in patients with biliary complications in the first 18 months after LDLT. Conservative treatment for biliary com-plications may be sufficient in a very limited number of stable patients. Endoscopic retrograde cholan-giography with biliary drainage should be attempted before more invasive interventions. Endoscopic and percutaneous transhepatic approaches can suc-cessfully treat more than two-thirds of biliary complications, with the highest success rate for the endoscopic approach being seen in patients with isolated bile leaks. Relaparotomy can improve survival outcomes and is usually reserved for patients with intractable biliary complications, in whom ERC and/or interventional radiologic procedures are not able to achieve satisfactory therapeutic results.

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