title: Endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.
abstract: OBJECTIVE
  This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.
  
  
  BACKGROUND
  Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting.
  
  
  METHODS
  During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications.
  
  
  RESULTS
  Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%.
  
  
  CONCLUSIONS
  The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.
authors.affiliation: Department of Medicine, UCLA School of Medicine.
authors.forename: S
authors.initials: S
authors.lastname: Sherman
authors.forename: A
authors.initials: A
authors.lastname: Shaked
authors.forename: H M
authors.initials: HM
authors.lastname: Cryer
authors.forename: L I
authors.initials: LI
authors.lastname: Goldstein
authors.forename: R W
authors.initials: RW
authors.lastname: Busuttil
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001658:Biliary Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002763:Cholecystectomy / Q000009:adverse effects; D002768:Choledochostomy; D016145:Endoscopy, Digestive System; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects; D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D016717:Sphincterotomy, Endoscopic; D015607:Stents / Q000009:adverse effects