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Original Investigation
Pacific Coast Surgical Association
February 13, 2019

Assessment of Anastomotic Biliary Complications in Adult Patients Undergoing High-Acuity Liver Transplant

Author Affiliations
  • 1Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, UCLA
  • 2Hepato-Pancreato-Biliary Surgery Unit, Department of Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
JAMA Surg. 2019;154(5):431-439. doi:10.1001/jamasurg.2018.5527
Key Points

Questions  What is the incidence of anastomotic biliary complications in patients undergoing liver transplant, and what risk factors predispose patients to their occurrence?

Findings  In this cohort study, adult recipients of 509 consecutive liver transplants underwent analysis, with a 20.2% incidence of anastomotic biliary complications and the following 7 independent risk factors for complications: recipient hepatic artery thrombosis, second liver transplant, recipient hepatic artery stenosis, donor hypertension, recipients with hepatocellular carcinoma, donor death due to anoxia, and use of nonabsorbable suture material for biliary reconstruction.

Meaning  Efforts to mitigate the incidence of anastomotic biliary complications should focus on reducing the number of risk factors through appropriate donor-recipient matching and suitable intraoperative technique.


Importance  Anastomotic biliary complications (ABCs) constitute the most common technical complications in liver transplant (LT). Given the ever-increasing acuity of LT, identification of factors contributing to ABCs is essential to minimize morbidity and optimize outcomes. A detailed analysis in a patient population undergoing high-acuity LT is lacking.

Objective  To evaluate the rate of, risk factors for, and outcomes of ABCs and acuity level in LT recipients.

Design, Setting, and Participants  This retrospective cohort study included adult LT recipients from January 1, 2013, through June 30, 2016, at a single large urban transplant center. Patients were followed up for at least 12 months after LT until June 30, 2017. Of 520 consecutive adult patients undergoing LT, 509 LTs in 503 patients were included. Data were analyzed from May 1 through September 13, 2017.

Exposure  Liver transplant.

Main Outcomes and Measures  Any complications occurring at the level of the biliary reconstruction.

Results  Among the 503 transplant recipients undergoing 509 LTs included in the analysis (62.3% male; median age, 58 years [interquartile range {IQR}, 50-63 years), median follow-up was 24 months (IQR, 16-34 months). Overall patient and graft survival at 1 year were 91.1% and 90.3%, respectively. The median Model for End-stage Liver Disease (MELD) score was 35 (IQR, 15-40) for the entire cohort. T tubes were used in 199 LTs (39.1%) during initial bile duct reconstruction. Overall incidence of ABCs included 103 LTs (20.2%). Anastomotic leak occurred in 25 LTs (4.9%) and stricture, 77 (15.1%). Exit-site leak in T tubes occurred in 36 (7.1%) and T tube obstruction in 16 (3.1%). Seventeen patients with ABCs required surgical revision of bile duct reconstruction. Multivariate analysis revealed the following 7 independent risk factors for ABCs: recipient hepatic artery thrombosis (odds ratio [OR], 12.41; 95% CI, 2.37-64.87; P = .003), second LT (OR, 4.05; 95% CI, 1.13-14.50; P = .03), recipient hepatic artery stenosis (OR, 3.81; 95% CI, 1.30-11.17; P = .02), donor hypertension (OR, 2.79; 95% CI, 1.27-6.11; P = .01), recipients with hepatocellular carcinoma (OR, 2.66; 95% CI, 1.23-5.74; P = .01), donor death due to anoxia (OR, 2.61; 95% CI, 1.13-6.03; P = .03), and use of nonabsorbable suture material for biliary reconstruction (OR, 2.45; 95% CI, 1.09-5.54; P = .03).

Conclusions and Relevance  This large, single-center series identified physiologic and anatomical independent risk factors contributing to ABCs after high-acuity LT. Careful consideration of these factors could guide perioperative management and mitigate potentially preventable ABCs.

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