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

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;81:212-221 * 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;18:647-653

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

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)

NZLTU – 1998 - 2008

Results 80 biliary complications, 70 transplants Bile Leaks (n= 17) Cut surface - 04 Anastomotic - 11 CD leak - 02 Strictures (n = 63),18.1% Anastomotic - 46 (73%) Non-anas - 09 Mixed - 08 8 of the 11 anastomotic leaks went on to develop strictures

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%

Biliary anastomosis; D-D, Roux HA complications; HAS/HAT Odds ratio (95% CI) Univariate P value Multivariate Recipient age; <14, >=14 0.768 (.346 - 1.704) 0.52 0.011 Donor age; <50, >=50 1.074 (.607-1.901) 0.81 Graft; whole, partial 2.672 (1.379-5.179) 0.0036 0.0069 Isch time; <10hrs, >=10hrs 1.116 (.637-1.955) 0.70 Preservation; HTK, UW based 0.912 (.633-1.192) 0.048 0.053 Biliary anastomosis; D-D, Roux 2.716 (1.507-4.896) 0.0009 0.0018 HA complications; HAS/HAT 3.483 (1.165-9.414) 0.026 0.069

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

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