Delayed biliary duct obstruction after orthotopic liver transplantation

Abstract

After orthotopic liver transplantation and biliary reconstruction by cholecystoduodenostomy, four of 40 patients developed delayed obstruction of the cystic duct. The recipients had the clinical syndrome of fulminating cholangitis with jaundice, fever, leukocytosis, toxemia, and bacteremia. All four patients died; of the four, two patients died despite late reoperation and re-establishment of bile drainage by choledochoenterostomy. In all four cases, a factor contributing to the biliary obstruction may have been infection of the extrahepatic biliary ducts with or without ulceration, and in three of the livers, there was evidence of infection of the ducts with CMV. If cholecystoduodenostomy is used in future cases, prompt re-exploration and conversion to choledochoenterostomy should be considered if the diagnosis of duct obstruction, cholangitis, and persistent bacteremia are made.

Fig. 1

Biliary duct reconstruction with cholecystoduodenostomy. A, Surgical technique. B, Operative cholangiogram in a patient who developed jaundice almost three months after orthotopic transplantation. In this case, obstruction was ruled out.

Fig. 2

The course of a 16-year-old recipient of a hepatic homograft (Patient 3). Although liver function was satisfactory initially, hyperbilirubinemia developed 15 days after operation, but receded slightly with intensification of immunosuppression. Systemic sepsis prompted re-exploration, at which time a cholangiogram (Fig. 3, C) was obtained and biliary diversion was converted to choledochoduodenostomy. However, the child died of uncontrolled sepsis 46 days after transplantation.

Fig. 3

Cholangiography of hepatic homograft. A and B, Technique of dye injection through a duodenotomy and the anastomosis. C, Obstructed duct system in Patient 3.

Fig. 4

Obstructed cystic ducts of hepatic allografts in Patients 2 (A) and 4 (B). The wall (W) of each duct is lined by swollen epithelial cells which contain cytomegaloviral inclusions. Some similar cells lie free in the lumen (L) of each duct. (Hematoxylin and eosin. ×900.)