ERCP in the management of early versus late biliary leaks after liver transplantation

The role of endoscopy in the management of bile leaks following liver transplantation has been controversial. Bile leak after liver transplantation has an incidence of ∼10% to 15%, and the choice of observation, laparotomy, or endoscopic retrograde pancreatography (ERCP), usually with sphincterotomy and/or placement of a bile duct stent, has depended on the transplant groups' experience and the availability of skilled endoscopists. We report our experience in the management of bile leaks following orthotopic liver transplantation. Between July 11, 1995, and January 22, 2003, there were 174 whole-liver-graft orthotopic liver transplant procedures performed at the University of Kentucky. In 158 of these, the initial bile duct management was by choledochocholedochostomy (duct-to-duct anastomosis) over a small-caliber T-tube. Bile leaks were diagnosed in 21 of 158 patients, with an incidence of 13.3%. Of the early leaks (<30 days post-transplantation), 2 were managed with observation alone, and 12 underwent ERCP. This revealed five anastomotic leaks requiring laparotomy. Of the seven leaks occurring later, six were managed by ERCP and one required laparotomy. With a median follow-up period of 18 months, 18 patients (85.7%) are alive with no further biliary tract problems. ERCP remains a useful adjunct in the management of post-liver transplant bile leaks. It is, however, less likely to be successful in the definitive management of early leaks.