LIVER TRANSPLANTATION 21:1107–1108, 2015
LETTERS TO THE EDITOR
Reply Received May 14, 2015; accepted May 14, 2015.
TO THE EDITOR: We appreciate the letter by Sepulveda et al.1 for its useful comments and interest in our reported case, “Pure laparoscopic management of early biliary leakage after liver transplantation: Abdominal lavage and T-tube placement.”2 The authors express their surprise for the use of a T-tube to treat the biliary leak and report a 5-case series successfully treated with a laparoscopic lavage and ulterior placement of a stent by endoscopic retrograde cholangiopancreatography (ERCP). We congratulate them for their totally endoscopic approach and would like to address some of their concerns and comments. Biliary reconstruction over a T-tube used to be the procedure of choice for biliary reconstruction after liver transplantation (LT) until 1990. Nevertheless, posterior meta-analyses3 did not recommend its routine use because of its inherent complications (displacement, cholangitis, biliary fistula, or peritonitis). Regarding this evidence, the placement of a stent by ERCP would become an optimal strategy to repair a biliary posttransplant leak because it can solve the problem and it can avoid the above-mentioned fearful circumstances. Currently, endoscopic management is widely used, but when diffuse peritonitis is present, it requires a previous lavage of the abdominal cavity (whether it is performed open or laparoscopic) to solve the peritonitis and drain the biliary ascites that would otherwise become infected during the ERCP. Additionally, ERCP is not exempt from complications, some of which are life-threatening such as duodenal perforations or severe pancreatitis.4 Sepulveda et al.1 report some of these adverse events in 3 patients of their series, including stent migration, stent obstruction, and liver abscess. At the present time, a renewed interest in T-tube usefulness has arisen. Recent studies advocate again for the benefits and safety of T-tube insertion in LT showing excellent outcomes.5,6 Undoubtedly, it remains an open question, and we consider that the correct tube at the right moment can prevent or solve a biliary leak satisfactorily. In our reported case, we treated the diffuse biliary peritonitis and solved the biliary leak by placing a T-tube during a single
laparoscopic procedure. The main difference between our reported case and the series by Sepulveda et al.1 is that all of their patients presented with late leakages (median, 16; range, 10-70 days). Both managements, totally laparoscopic and fully endoscopic, are feasible and safe, but we believe that the time of onset supposes an essential issue for choosing the most suitable therapy. In agreement with the authors’ opinion, redissecting the pedicle is certainly not recommended because it could lead to more critical consequences. However, we want to emphasize that we faced an early biliary leak (third postoperative day) when adhesions were still soft, and the defect was easily detected without performing risky maneuvers. Our case offered the favorable conditions to apply this novel technique.2 Because the gold standard management for early biliary leakages is still to be determined, we argue for tailoring it to the particular conditions of each case in order to give the patient the best option. We consider that the totally laparoscopic approach constitutes a safe and useful option to consider for selected patients who present with early post-LT complications. Patricia Martınez-Ortega, M.D. Fernando Rotellar, M.D., Ph.D. Pablo Martı-Cruchaga, M.D. Gabriel Zozaya, M.D. Carlos Sanchez-Justicia, M.D. Fernando Pardo, M.D. Hepatopancreatobiliary Surgery and Liver Transplantation Department of Surgery University Clinic Universidad de Navarra Pamplona, Spain
REFERENCES 1. Sepulveda A, Brustia R, Perdigao F, Soubrane O, Scatton O. Toward a fully endoscopic management of biliary leakage after liver transplantation. Liver Transpl. 2015 Jun 4. doi: 10.1002/lt.24186. 2. Martınez-Ortega P, Rotellar F, Martı-Cruchaga P, Zozaya G, S anchez-Justicia C, Pardo F. Pure laparoscopic management of early biliary leakage after liver transplantation: abdominal lavage and T-tube placement. Liver Transpl 2015;21:561-563.
Address reprint requests to Fernando Rotellar, Hepatopancreatobiliary Surgery and Liver Transplantation, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, 31008 Spain. Telephone: 0034 948 296797; FAX: 0034 948 296500; E-mail:
[email protected] DOI 10.1002/lt.24191 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases C 2015 American Association for the Study of Liver Diseases. V
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€ ller MW, Michalski CW, H u € ser N, 3. Riediger C, M u Schuster T, Kleeff J, Friess H. T -Tube or no T -tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010;16:705717. 4. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004;60:721-731.
LIVER TRANSPLANTATION, August 2015
5. L opez-And ujar R, Or on EM, Carregnato AF, Su arez FV, Herraiz AM, Rodrıguez FS, et al. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the eternal dilemma: results of a prospective and randomized clinical trial. Ann Surg 2013;258:21-29. 6. Gastaca M, Valdivieso A, Ruiz P, Ventoso A, de Urbina JO. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the type of tube really matters. Ann Surg 2013;258:21-29.
