Long-term management of biliary tract complications

Biliary tract complications represent an important problem after transplantation. They are not only important in the immediate posttransplantation period, but perhaps of even greater importance in the long-term management of transplant recipients. One of the major changes that has occurred over the past several years is an increasing use of nonoperative therapy, either via endoscopic or percutaneous routes. In many cases of biliary leak, stones, and T-tube malposition, nonoperative management may be curative. The exact role they play in the management of strictures, particularly diffuse stricturing and isolated hepatic duct strictures, remains to be determined. At the least, it provides temporary drainage before initiating surgical therapy. In addition to being efficacious, nonsurgical management is quite safe. In 64 cases of biliary complications managed nonoperatively, complications occurred at UCSF in only four patients. One patient developed bleeding along the percutaneous catheter tract and required replacement with a larger diameter catheter to tamponade the bleeding. Two patients developed hemobilia secondary to intrahepatic pseudoaneurysms caused by the percutaneous drainage catheter. One patient developed an osteomyelitis of a rib related to an indwelling percutaneous biliary catheter that responded to antibiotics and rib resection. Finally, understanding several of the biliary complications that occur after transplantation (ie, sphincter of Oddi dysfunction) will require additional research and hopefully will determine the pathophysiology of these complications. This should lead to more rational therapy.