Biliary Complications Following Orthotopic Liver Transplantation: the Place of Surgical Reconstruction in the Minimally-Invasive Era

Background: Biliary complications are the more frequent problem following liver transplantation (LT) and have been considered the “Achiles´s heel”of this procedure. The aim of this study was to evaluate the rates of biliary complications after LT, the different therapeutic modalities currently available and their outcomes. Methods: A total of 420 LTs performed up to 2020 were retrospectively analyzed. Evaluation factors included MELD score, images, surgical techniques, type of biliary reconstruction and type of complications. We also analyzed the different therapeutic options, and the short and long-term outcome. Results: 417 deceased donors and 3 living donor transplants were performed. Biliary complications occurred in 37 patients (8,8%) – 31 strictures (81%), four leaks (11%), one acute biliary peritonitis after T-tube removal (3%) and two patients biliary stones (5%). Biliary complications associated with vascular complications were seen in 10 patients (27%). In general, a minimally invasive management (percutaneous or endoscopic) was the first-line approach. Percutaneous interventional procedures were the treatment of choice in 32/37 patients (86,48%), with a success rate of 67.74% (21/31). Hepaticojejunostomy (HJ) was performed in 14 patients. Overall morbidity rate of surgical reconstruction was 14% (2/14 patients) and perioperative mortality was 7%. The median follow–up was 54,53 months. At follow-up, none of the patients in the HJ group had developed a new stricture. Conclusions: The majority of biliary complications must be treated by minimally invasive approach. However, when those fail,surgical reconstruction allows to avoid future consequences in the graft.