Biliary complications following donation after brainstem death liver transplantation

Biliary complications are increasingly seen after liver transplantation. Different modalities are used to overcome these complications. In this study, we investigated the occurrence of biliary complications following donation after brainstem death (DBD) liver transplant and their management.

To investigate the occurrence and management of biliary complication in patients who underwent orthotopic liver transplant (OLT) with grafts from DBD donors between October 2014 and October 2020.

A retrospective review of patients who underwent DBD OLT from October 2014 to October 2020. The primary outcome was biliary stricture, and the secondary outcome was return to theatre.

A total of 366 patients underwent DBD whole OLT during the study period. There were 229 (62.6%) males and 137 (37.4%) females. Recipients median age was 55 years (range 16-73 years) and donors median age was 51 years (range 11-89 years). Mean cold ischemic time was 581 ± 218.7 minutes. Duct to duct anastomosis was performed in 240 (65.6%) patients, and 126 (34.4%) patients underwent Roux-en-Y hepaticojejunostomy (RYHJ). Eighteen (4.9%) patients experienced bile leak, 39 (10.7%) patients experienced anastomotic biliary stricture and 18 (4.9%) patients had ischemic cholangiopathy. Main and segmental hepatic artery thrombosis occurred in 27 (7.4%) patients, 29 (7.9%) patients had early allograft dysfunction, and six (1.6%) patients experienced primary non function. Among 39 patients who developed anastomotic biliary stricture, 21 (53.8%) were treated with RYHJ representing 5.7% of the total transplant group. Endoscopic retrograde cholangiopancreatography was performed in nine patients (23.1%), conservative management in six patients (15.4%), percutaneous transhepatic cholangiography in two patients (5.1%) and re-transplantation in one patient who had concomitant ischemic cholangiopathy (2.6%). Overall, 84 (22.9%) patients returned to theatre and 27 (7.4%) patients underwent retransplant over five years follow up period. Multivariate analysis confirmed that RYHJ reconstruction emerged as the only significant independent protective factor against biliary complications (odds ratio = 0.473, 95% confidence interval: 0.23-0.97, P = 0.041).

Biliary complications following DBD liver transplant are a frequent occurrence and careful monitoring and planning are required to improve patients' outcomes.