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Bile duct reconstruction is known as the Achilles heel of liver transplantation (LT), as biliary complications remain a major source of morbidity, with an incidence of 5% to 32%.1 In living-donor liver transplantation (LDLT), which is characterized by its technical complexity, these are even more frequent.2–4

The most frequent biliary complications are bile leaks, strictures, and stones. Less frequent ones are mucoceles of the cystic duct, biliary sludge, and Oddi sphincter dysfunction.

The presentation varies, and could appear early or late, 4 weeks posttransplant. Some patients are asymptomatic with mild elevations of cholestatic liver function tests, while others may present with fever and acute abdominal pain (cholangitis).

Once a biliary complication is suspected, an imaging study must be performed to evaluate the biliary tree and the hepatic vessels. Abdominal Doppler ultrasound carries a high positive predictive value but only in the presence of dilated bile ducts; otherwise, the sensitivity is 38% to 68% for the detection of biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) has an excellent sensitivity of 93% to 100% in the detection of biliary strictures and is increasingly used to avoid the risks of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC), though these last 2 present with the possibility of therapeutic options. However, ERCP remains the gold standard in the diagnosis of strictures. Computed tomography (CT) is preferred when acute abdominal pain is present, evaluating the possibility of other causes of acute abdominal pain.

The management of these complications requires a multidisciplinary approach and is constantly evolving.


Bile leaks, with an incidence of 2% to 21%, usually occur in the immediate postoperative period within 2 months after LT.5 Most leaks occur at the anastomosis, especially with Roux-en-Y anastomoses than with duct-to-duct anastomoses. Also it may appear at the cystic remnant duct following removal of a T-tube if present (late bile leaks), ischemia related, Roux-en-Y rupture/dehiscence, or surface leak in reduced livers, either split or LDLT.

They may be present in asymptomatic patients as persistent postoperative bile drainage or can be incidentally discovered during ultrasound, CT, or ERCP performed for other reasons as a fluid collection (biloma).

When a patient develops abdominal pain or fever after LT, a bile leak should be the first differential diagnosis and images should be requested.

Treatment varies depending on the size of the bile leak and the clinical presentation (Fig. 85-1). In small leaks, treatment is often not required, as they usually heal spontaneously. Larger leaks can be managed with endoscopic treatment or percutaneous drainage as ways to decrease the biliary pressure and to help the healing. ERCP has now become the initial therapeutic option in the management of biliary leaks when a duct-to-duct anastomosis was performed and a communicating bile leak is diagnosed. A sphincterotomy ...

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