A Study For Biliary Complications After Orthotopic Liver Transplantation

Background:In 1963,the pioneer of organ transplantation,Starzl,finished an orthotopic liver transplantation firstly and successfully in USA.Liver transplantation has been developed for more than 50 years,and the long-term survival of liver transplant patients has been improved significantly.In most of liver transplantation centers inland,the surgical success rate is more than 90%,while the 5-year survival rate is over 70%,which showed that our transplantation effect had reached an international advanced level.However,biliary complications(BC)have been one kind of the major complications which effects recipients' quality of life and long-term survival after liver transplantation.It was called "Achilles' heel" by Calnc,because it calls for a long-term and repeated treatment,and has some potential undetermined adverse effects on graft.Biliary complications after liver transplantation could affect the normal function of both bile tract and liver graft.The incidence of biliary complications reported abroad is around 10%,and the mortality rate is nearly 10%,which is one of the major reasons that cause recipients' death after liver transplantation.The occurrence rate inland is about 20%,in living donor liver transplant recipients is about 15-64%,and the fatality rate is as high as 19%.Because of its complex mechanisms and difficult clinical treatments,biliary complications affect the recipients' quality of life and long-term survival after liver transplantation,indeed.Thus,biliary complications had caught much attention in area of transplant.The reasons for biliary complications various a lot,in summary,these opinions might be possible:matching for donor and recipient,source of donor liver,surgical procedures,reconstruction technique,arteries and veins thrombosis,acute/chronic rejection,autoimmune diseases,cytomegalovirus infection,hepatitis virus infection and so on.With the development of liver transplantation surgical techniques and instruments,the incidence of bile anastomotic stricture and leakage is decreasing,while other complications increase gradually.Because the bile duct epithelial cell regenerative capacity is relatively week after being injured,deepening the understanding of the biliary complications after OLT further,filtrating the risk factors that related to postoperative biliary complications,and figuring out the characteristics between different types of biliary complications,would obviously make sense to clinical precaution,diagnosis and treatment for biliary complications,which could also improve the efficacy of operation and the quality of life for recipient.Objective:This research will screen the main factors that trigger the biliary complications after orthotopic liver transplantation,summarize the experience of the prevention,diagnosis,treatment and prognosis of biliary complications,in order to improve the efficacy of liver transplantation and the patients' quality of life.Methods:A total of 216 patients undergoing liver transplantation during Jan 1st 2015 to May 31st 2016 in the First Affiliated Hospital,Zhejiang University were enrolled,and divided into two groups according to the occurrence of biliary complications or not.Preoperative relevant factors such as MELD score,etc.surgery relevant factors such as the opening time between portal vein and hepatic artery,etc.and postoperative relevant factors such as vascular complications were analyzed.The experience of the diagnosis,treatment and prognosis of the 27 patients with biliary complications were summarized.Results:1.27 receptors got postoperative biliary complications(12.5%),including simple biliary stricture 10 cases,biliary stricture + biliary stone 7 cases,biliary stricture + bile leakage 2 cases,biliary stricture + biliary infection 2 case,biliary stricture + bile leakage + biliary infection 2 cases,biliary stricture + bile leakage + biliary stone 1 cases,biliary stricture + bile leakage + biliary infection + biliary stone 2 cases,biliary stricture+ bile leakage + biliary infection + biliary stone+ biliary carcinoma 1 cases.Clinical features:8 cases only had abnormal liver function,7 cases had jaundice,4 cases had fever,6 cases had jaundice with fever,1 case had bile like liquid through drainage tube with fever,and 1 case had no obvious abnormal symptom.The first diagnosis method:MRCP 16 cases,ERCP 6 cases,and type-B ultrasonic 5 cases.Treatment:4 cases only took medicine and recovered,20 cases got interventional therapy such as ENBD,etc.(including 13 cases recovered,3 cases left hospital voluntarily without thoroughly cured,and 4 cases didn't get better),2 cases got interventional therapy and artificial liver therapy,but left hospital voluntarily without thoroughly cured,too,and 1 case had another operation,however got septic shock and multiple organ dysfunction syndyome.2.Biliary complications group(BC)and none biliary complications group(N-BC),single factor comparative analysis of incidence between these two groups showed:preoperative Child-Pugh Grade C(p=0.009),MELD score over 25(p=0.038),high serum total bilirubin(p<0.001),perfusion with HTK(p=0.016),not opening portal vein and hepatic artery together would significant increase in the incidence of biliary complications.Receptor age,carcinoma,donor liver type(DBD/DCD/DBCD),cold/warm ischemia time,hepatic artery suture method,bile duct suture had no significant correlation.Conclusions:1.In the First Affiliated Hospital,Zhejiang University,UW perfusate,modified piggyback liver transplantation,duct-to-duct biliary anastomosis,without T tube drainage were used mostly.The occurrence rate of biliary complications is not high.2.Receptor with bad preoperative liver function,donor liver perfusion using HTK(compared with UW),portal vein and hepatic artery not opening at the same time would significant increase in the incidence of biliary complications.DBD donor liver type or cold warm ischemia time showed no significant correlation with the occurrence of biliary complications in this study.3.Noninvasion examine such as MRCP,etc.were priority selection for the diagnosis of biliary complications.Most of the biliary complications patients had good prognosis by medicine or interventional therapy,critical patients needed re-transplantation,patients with multiple organ dysfunction syndyome got bad prognosis..