[Treatments of biliary fistulas following the removal of a Kehr tube after orthotopic liver transplantation].

Biliary tract complications are a major source of morbidity after liver transplantation. From October 1990 to September 1992, 77 patients, including 13 children and 64 adults, received 80 liver transplants. Biliary reconstruction was performed using a choledochocholedochostomy with a T-tube in 40 recipients. We report the management of bile leaks following T tube removal in 6 patients. In all cases, bile leak was diagnose by ultrasound examination requested for abdominal pain. In the first 2 patients, a surgical treatment was applied: Roux-en-Y choledochojejunostomy was performed on the first patient and simple suture of the fistula in the second patient. Two patients were managed nonoperatively using endoscopic and radiological procedures allowing placement of bile duct prosthesis and abdominal drainage. In 2 patients with small localized sub-hepatic collection, no surgical or radio-endoscopic treatment was attempted; spontaneous resolution of the collections was achieved in 2 months on ultrasound examination. All patients are alive, although, the patient who was operated on with a roux-en-Y choledochojejunostomy developed thrombosis of the right hepatic artery and biliary anastomotic stenosis which required further operations. We advocate endoscopic placement of endobiliary prosthesis and percutaneous biliary drainage as first-line therapy for significant fistula after T-tube removal. The use of choledochocholedochostomy without a T-tube when possible for biliary reconstruction in liver transplantation could be an effective procedure, but requires further evaluation.