Biliary Complications in Liver Transplant Recipients

Despite numerous advancements in the management of patients who have undergone cadaveric liver transplantation, biliary complications continue to challenge clinicians. Biliary leaks in the early postoperative period and strictures in the late postoperative period represent the two major posttransplant biliary complications. Intrahepatic and hilar strictures are particularly difficult to manage and frequently require retransplantation, which should not be delayed. Choledocholithiasis and the biliary cast syndrome are frequently associated with underlying biliary strictures, and endoscopic attempts at removal should precede surgical interventions. Sphincter of Oddi dysfunction is increasingly recognized despite unclear pathophysiology. Hemobilia is most commonly iatrogenic and requires a high suspicion and prompt intervention. Although the number of diagnostic and therapeutic options have increased, there is no consensus as to which is superior. In recent years there has been a trend toward nonsurgical interventions, in particular endoscopic approaches.
Bile Duct Injury During Cholecystectomy and Survival in Medicare Beneficiaries
David R. Flum, MD, MPH; Allen Cheadle, PhD; Cecilia Prela, PharmD; E. Patchen Dellinger, MD; Leighton Chan, MD, MPH
JAMA. 2003;290:2168-2173.
Context Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear.
Objective To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries.
Design, Setting, and Patients Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury.
Main Outcome Measure Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics.
Results Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.8 for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon.
Conclusions The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

Author Affiliations: Departments of Surgery (Drs Flum and Dellinger), Health Services (Drs Flum and Cheadle), and Rehabilitation Medicine (Dr Chan), University of Washington, and the Division of Clinical Standards and Quality (Drs Chan and Prela), Centers for Medicare & Medicaid Services (CMS, formerly the Health Care Financing Administration), Region 10, Seattle, Washington. Dr Flum is formerly from the Robert Wood Johnson Clinical Scholars Program at the University of Washington.

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