ENDOSCOPIC MANAGEMENT OF BILE LEAKS AFTER SILASTIC VERSUS LATEX T-TUBE REMOVAL IN LIVER TRANSPLANT RECIPIENTS
Justin Bilello, Divya M. Chalikonda*, Shuji Mitsuhashi, Brianna Shinn, Shruti Sirapu, Warren Maley, Adam Bodzin, Ashesh Shah, Adam Frank, Jaime Glorioso, Faisal Kamal, Austin Chiang, Alexander Schlachterman, Anand Kumar, Thomas E. Kowalski, David E. Loren
Gastroenterology, Thomas Jefferson University, Philadelphia, PA
Background:
Bile peritonitis due to bile leak after T-tube removal in liver transplant recipients is frequently managed with urgent endoscopic retrograde cholangiopancreatography (ERCP). ERCP with stenting across the biliary anastomosis is an effective treatment to halt leakage and redirect bile flow, though there is no consensus on optimal stent type. At our institution, latex T-tubes (LT) were used in most patients with a duct-to-duct anastomosis. However, a supply shortage led to use of silastic T-tubes (ST) for approximately 4 months. Biliary outcomes with silastic T-tubes have not previously been described. We aim to describe our institution's endoscopic approach to treating patients with bile leak after removal of ST compared to LT.
Methods:
A retrospective cohort study was performed evaluating patients who underwent liver transplantation with T-tube placement between 08/2021 and 04/2022. All reconstructions were performed using a continuous running technique with the T-tube brought out via a separate incision below the anastomosis in the common bile duct. The primary outcome was rate of bile leak in patients with LT compared to ST. Secondary outcomes included timing of ERCP, type of stent used and management at follow up ERCP. Fisher's exact test was used to determine differences in bile leak management between LT and ST. Predictors of bile leak were assessed with unadjusted and adjusted logistic regression models.
Results:
19 LT patients and 23 ST patients were evaluated (Table 1). 75% of the first 4 ST patients had bile leaks after T-tube removal compared to 15.8% of 19 LT patients in the preceding 4 months. Based on this finding, 17 of the remaining ST patients underwent ERCP with prophylactic stenting and simultaneous T-tube removal. 47.8% of all ST patients had a bile leak clinically or during ERCP with cholangiogram, compared to 15.8% of all LT patients (p=0.03). After adjusting for age and gender using logistic regression, ST use was an independent predictor of bile leak (OR: 5.43, 95% CI 1.19-24.87, p=0.03).
There was no difference in type of stent placed at index ERCP (p=0.85) or in persistence of bile leak after stent placement (p=0.99) between patients with ST compared to LT. There was no difference in frequency of plastic versus metal stent among patients with ST, although 2 patients had symptomatic persistent bile leak after stenting with plastic stents (on day 2 and 3 following ERCP). The plastic stents were exchanged for metal in both cases leading to resolution of the leak.
Conclusions:
Almost half of liver transplant recipients with ST develop bile leak with T-tube removal, far exceeding the leak rate with LT. For patients with ST we recommend prophylactic ERCP with stenting and simultaneous T-tube removal to prevent bile peritonitis. We have a preference for fully covered metal stent placement if technically feasible.
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