Pancreaticobiliary complications after composite visceral transplantation: incidence, risk, and management strategies

BackgroundCombined liver/small-bowel (L/SB) and multivisceral (MV) transplantation has been increasingly used with significant improvement in outcome.ObjectiveTo report our experience with pancreaticobiliary (PB) complications in this unique population.Design and SettingSingle-center cohort study using a prospectively completed database.Patients and InterventionsFrom May 1990 to November 2008, records of 271 consecutive patients who received 289 composite visceral grafts were retrospectively reviewed; 151 of the allografts were L/SB (52%) and the remaining 138 were MV.Main Outcome MeasurementsType, incidence, risk factors, clinical features, and management of PB complications.ResultsPB complications were diagnosed in 44 patients with an incidence of 16%. Biliary complications developed in 20 patients (ampullary stenosis in 9, bile duct casts/stones in 6, and bile duct leaks in 5), pancreatic complications occurred in 19 patients (necrotizing pancreatitis in 7, edematous pancreatitis in 6, and pancreatic duct fistulae in 6), and combined biliary and pancreatic complications occurred in 5 patients. The risk of PB complications was significantly higher in MV graft recipients compared with L/SB recipients with a rate of 25% compared with 9%, respectively. ERCP was instrumental in the diagnosis and/or treatment of ampullary stenosis, bile duct casts and stones, bile duct leaks, and recurrent acute pancreatitis. Combined endoscopic and surgical intervention was required in most cases of pancreatic duct fistulae. Surgical intervention was performed in patients with pancreatic allograft necrosis and complex anastomotic biliary leaks.LimitationsSingle-center study.ConclusionsPB complications are common after composite visceral transplantation. Awareness of these complications is important to the transplantation team to ensure early diagnosis and appropriate intervention in an attempt to minimize morbidity and mortality.