Biliary complications following adult right lobe ex vivo split liver transplantation

Biliary complications are common following split liver transplantation (SLT). We analyzed the incidence, treatment, and outcome of biliary complications following adult right lobe ex vivo SLT performed between November 1992 and January 2005. There were 72 patients, of which 70 were analyzed. Early postoperative deaths resulted in 2 being excluded from the analysis. There were 44 males (median age, 48 yr; range, 19-70 yr). Biliary reconstruction was by duct-to-duct (DD) anastomosis in 52 (74%) and Roux-en-Y hepaticojejunostomy (RYHJ) in 18 (26%) patients. Until mid-2001, no T-tube was used for DD anastomosis (DD/non-T-tube) in 26 (37%) patients; subsequent to this, DD over a T-tube (DD/T-tube) was performed in 26 (37%) patients. Eighteen (26%) biliary complications occurred in 16 patients. Two anastomotic leaks of RYHJ were associated with hepatic artery thrombosis. The most frequent biliary complication was parenchymal radical leak from the transected liver surface (11%; 8/70), with anastomotic leaks in 6% (4/70) and strictures in 4% (3/70). There were also 2 cases of biliary leaks from T-tube exit site following T-tube removal, and 1 leak from the donor cystic duct stump. DD anastomosis without a T-tube was associated with a higher rate of cut surface and anastomotic biliary leaks (7/26), compared to the DD/T-tube group (1/26; P = 0.05). Six patients (9%) died following biliary complications, including 3 due to cut surface leaks in the DD/non-T-tube group and 2 cases with fatal biliary peritonitis following T-tube removal. A patient in the RYHJ group died due to biliary sepsis associated with hepatic artery thrombosis. In conclusion, biliary complications following right lobe ex vivo SLT are associated with significant morbidity and mortality. Our results suggest that T-tube biliary drainage of DD anastomosis may reduce parenchymal cut surface and biliary anastomotic leaks. However, bile leak following T-tube removal could lead to potentially fatal biliary peritonitis, which should always be anticipated and treated promptly.