1. Nalaka Gunawansa, John McCall, Stephen Munn, Peter Johnston
BILIARY COMPLICATIONS FOLLOWING ORTHOTOPIC LIVER TRANSPLANTATION – THE NEW ZEALAND LIVER TRANSPLANT UNIT (NZLTU) EXPERIENCE
Nalaka Gunawansa, John McCall, Stephen Munn, Peter Johnston

2. Biliary complications
A major source of morbidity and graft loss
Overall Incidence – 11-25% *
Biliary strictures / bile leaks
Strictures
- Deceased donor (DDLT) – 5-15%*
- Live donor (LDLT) – 28-32%*
* Starzl et al. Biliary complications after liver transplantation. Surgery 1977;81:
* Greif et al. The incidence, timing and management of biliary complications after OLT. Ann Surg 1994;219:40-45
* Thetyy et al. Management of biliary tract complications after OLT. Clin Transplant 2004;18:

3. Post-OLT biliary strictures -Risk Factors
Anastomotic
Surgical technique
Bile leaks
Ischaemia – hepatic artery thrombosis / stenosis
Non-anastomotic
HAS/HAT
Preservation injury
Prolonged cold/warm ischaemia
Increased donor age
Chronic ductopaenic rejection
DCD
ABO incompatible
Prolonged use of vasopressors in donor

4. NZLTU 1998 – 2008 (n=348) 338 patients, 348 transplants
Adult
(14 & above)
Paediatric
(<14 yrs)
DWL
292 04
296
(85.06%)
Partial (Split) 10 22 32
Partial
(Live donor) 07 13 20
(14.94%)
309 (88.8)
39 (11.2%)
Mean follow up – 57 months (5-132)

5. NZLTU –

6. Results 80 biliary complications, 70 transplants
Bile Leaks (n= 17)
Cut surface - 04
Anastomotic - 11
CD leak
Strictures (n = 63),18.1%
Anastomotic - 46 (73%)
Non-anas
Mixed
8 of the 11 anastomotic leaks went on to develop strictures

7. Variables Total transplants Biliary strictures Recipient age; <14y
(Overall – 18.1%)
Recipient age; <14y
=>14y 39
309
09 – 23.1%
54 – 17.5%
Donor age; <50y
=>50y
235
113
41 – 17.4%
22 – 19.5%
Graft ; whole liver
Partial
296 52
47 – 15.9%
16 – 30.8%
Cold ischaemia; <10hrs
=>10hrs
226
122
40 – 17.7%
23 – 18.9%
Preservation; UW
UW + arterial flush
HTK
128
174 46
17 – 13.3%
33 – 19.0%
13 – 28.2%
Biliary anastomosis; D-D
Roux
273 75
40 – 14.7%
23 – 30.7%
HA disease ; HAS/HAT +
HAS/HAT - 16
332
06 – 37.5%
57 – 17.2%

8. Biliary anastomosis; D-D, Roux HA complications; HAS/HAT
Odds ratio
(95% CI)
Univariate
P value
Multivariate
Recipient age;
<14, >=14
0.768
( )
0.52
0.011
Donor age;
<50, >=50
1.074
( )
0.81
Graft;
whole, partial
2.672
( )
0.0036
0.0069
Isch time;
<10hrs, >=10hrs
1.116
( )
0.70
Preservation;
HTK, UW based
0.912
( )
0.048
0.053
Biliary anastomosis; D-D, Roux
2.716
( )
0.0009
0.0018
HA complications; HAS/HAT
3.483
( )
0.026
0.069

9. Outcome Direct Mortality – 0
Graft loss due to biliary complications– 04 (5.7%)
Successful Non-operative Mx – 32 (45.7%)
Re-operations – 38 (54.3%)
- 04, re transplants
- 01, awaiting re-transplant
- 03, segmental resections
- 31 biliary reconstructions

10. Conclusions
Overall biliary complication rate – 23%, stricture rate of 18.1%
The complication rates were twice as common with partial grafts (31% vs 16%)
Paediatric recipients, partial grafts, associated arterial ischaemia and roux anastomoses were associated with significantly increased risk of strictures
Donor age, cold ischaemia time and preservation technique did not appear to be significant
Even though there was no direct mortality, 5.7% of the biliary complications resulted in graft loss
Approx. 50% required surgical intervention.
The remaining 50% were successfully managed with endoscopic / radiological means