Diagnosis and treatment of biliary complications after liver transplantation

doi:10.3877/cma.j.issn.1674-3903.2025.06.016

Abstract

Abstract:

Liver transplantation remains the sole definitive therapy for end-stage liver disease, and biliary complications are among common postoperative issues following transplantation. This review summarizes relevant advances in biliary complications over recent years, and delineates the risk factors, classification, clinical presentation, diagnostic strategies and therapeutic approaches in biliary complications after liver transplantation. The aim is to provide valuable insights into addressing clinical challenges associated with biliary complications, ultimately enhancing the quality of life for liver transplant recipients.

Key words: Liver transplantation, Biliary complications, Surgical treatment

Xiaoyan Liu, Zhaoxu Yang. Diagnosis and treatment of biliary complications after liver transplantation[J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 475-481.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://zhyzzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1674-3903.2025.06.016

https://zhyzzz.cma-cmc.com.cn/EN/Y2025/V19/I06/475

Figures/Tables 4

References 64

1	郑树森，俞军，张武. 肝移植在中国的发展现状[J]. 临床肝胆病杂志，2014, 30(1): 2.
2	Kochhar G, Parungao JM, Hanouneh IA, et al. Biliary complications following liver transplantation[J]. World J Gastroenterol, 2013, 19(19): 2841-2846.
3	Fasullo M, Patel M, Khanna L, et al. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment[J]. BMJ Open Gastroenterol, 2022, 9(1): e000778.
4	古维立，庄思敏，东尚，等. 肝移植中胆总管重建的术式探讨[J]. 广东医学，2002, 23(8): 799-800.
5	陶一峰，李瑞东，沈丛欢，等. 不同吻合方法在肝移植胆道重建中应用研究[J]. 临床军医杂志，2018, 46(11): 1334-1336, 1339.
6	刘大群．缝线类型及吻合方式对肝移植术后胆道吻合口狭窄的影响[D]. 长春：吉林大学，2022.
7	López-Andújar R, Maupoey J, Escrig J, et al. Selective indication of T-tube in liver transplantation: prospective validation of the results of a randomized controlled trial[J]. Transplant Proc, 2019, 51(1): 44-49.
8	Senter-Zapata M, Khan AS, Subramanian T, et al. Patient and graft survival: biliary complications after liver transplantation[J]. J Am Coll Surg, 2018, 226(4): 484-494.
9	Li T, Chen ZS, Zeng FJ, et al. Impact of early biliary complications in liver transplantation in the presence or absence of a T-tube: a Chinese transplant centre experience[J]. Postgrad Med J, 2007, 83(976): 120-123.
10	Navez J, Mohkam K, Darnis B, et al. Biliary duct-to-duct reconstruction with a tunneled retroperitoneal T-tube during liver transplantation: a novel approach to decrease biliary leaks after T-tube removal[J]. J Gastrointest Surg, 2017, 21(4): 723-730.
11	卡地尔丁·艾海提，叶建荣，吐尔干艾力·阿吉. 离体肝脏冷缺血时间对自体肝移植术后早期肝脏功能及并发症影响研究[J]. 中国实用外科杂志，2023, 43(3): 315-318.
12	陈非凡，黄帆，王国斌，等. 肝移植术后胆道并发症单中心研究[J]. 肝胆外科杂志，2021, 29(5): 354-358, 384.
13	Castaing D． Surgical anatomy of the biliary tract[J]. HPB (Oxford), 2008, 10(2): 72-76.
14	Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies[J]. Liver Transpl, 2008, 14(6): 759-769.
15	Sanchez-Urdazpal L, Gores GJ, Ward EM, et al. Diagnostic features and clinical outcome of ischemic-type biliary complications after liver transplantation[J]. Hepatology, 1993, 17(4): 605-609.
16	张晓峰，朱震宇. ABO血型不相容肝移植策略[J]. 器官移植，2024, 15(1): 33-39.
17	Testa G, Vidanovic V, Chejfec G, et al. Adult living-donor liver transplantation with ABO-incompatible grafts[J]. Transplantation, 2008, 85(5): 681-686.
18	Egawa H, Oike F, Buhler L, et al. Impact of recipient age on outcome of ABO-incompatible living-donor liver transplantation[J]. Transplantation, 2004, 77(3): 403-411.
19	Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease[J]. Hepatology, 2001, 33(2): 464-470.
20	Dumortier J, Chambon-Augoyard C, Guillaud O, et al. Anastomotic bilio-biliary stricture after adult liver transplantation: a retrospective study over 20 years in a single center[J]. Clin Res Hepatol Gastroenterol, 2020, 44(4): 564-571.
21	Wang L, Yang B, Jiang H, et al. Individualized biliary reconstruction techniques in liver transplantation: five years' experience of a single institution[J]. J Gastrointest Surg, 2023, 27(6): 1188-1196.
22	胡旭，钟艺武，李建辉. 供肝脂肪变性治疗策略研究进展[J]. 中外医疗，2024, 43(11): 195-198.
23	Kaldas FM, Korayem IM, Russell TA, et al. Assessment of anastomotic biliary complications in adult patients undergoing high-acuity liver transplant[J]. JAMA Surg, 2019, 154(5): 431-439.
24	Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: current knowledge and therapeutic advances[J]. World J Hepatol, 2021, 13(1): 66-79.
25	Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery[J]. Surgery, 2011, 149(5): 680-688.
26	Wojcicki M, Milkiewicz P, Silva M. Biliary tract complications after liver transplantation: a review[J]. Dig Surg, 2008, 25(4): 245-257.
27	op den Dries S, Westerkamp AC, Karimian N, et al. Injury to peribiliary glands and vascular plexus before liver transplantation predicts formation of non-anastomotic biliary strictures[J]. J Hepatol, 2014, 60(6): 1172-1179.
28	de Jong IEM, Overi D, Carpino G, et al. Persistent biliary hypoxia and lack of regeneration are key mechanisms in the pathogenesis of posttransplant nonanastomotic strictures[J]. Hepatology, 2022, 75(4): 814-830.
29	张起帆，朱晨，林建华，等. 肝移植术后非吻合口胆管狭窄危险因素的Logistic分析[J]. 中国现代普通外科进展，2011, 14(6): 446-449，469.
30	Georges P, Clerc C, Turco C, et al. Post-Transplantation cytomegalovirus infection interplays with the development of anastomotic biliary strictures after liver transplantation[J]. Transpl Int, 2022, 35: 10292.
31	Buis CI, Geuken E, Visser DS, et al. Altered bile composition after liver transplantation is associated with the development of nonanastomotic biliary strictures[J]. J Hepatol, 2009, 50(1): 69-79.
32	张全保，沈丛欢，陶一峰，等. 肝移植术后胆道并发症的危险因素分析及分类治疗策略[J]. 中华器官移植杂志，2020, 41(10): 623-628.
33	史育仪，李森，李加起，等. 肝移植术后胆道非吻合口狭窄的诊断及治疗[J]. 中国现代普通外科进展，2016, 19(5): 385-389.
34	Karakoyun R, Romano A, Nordström J, et al. Type of preservation solution, UW or HTK, has an impact on the incidence of biliary stricture following liver transplantation: a retrospective study[J]. J Transplant, 2019, 2019: 8150736.
35	Khuroo MS, Al Ashgar H, Khuroo NS, et al. Biliary disease after liver transplantation: the experience of the King Faisal Specialist Hospital and Research Center, Riyadh[J]. J Gastroenterol Hepatol, 2005, 20(2): 217-228.
36	Rahbari NN, Elbers H, Koch M, et al. Bilirubin level in the drainage fluid is an early and independent predictor of clinically relevant bile leakage after hepatic resection[J]. Surgery, 2012, 152(5): 821-831.
37	Kono Y, Ishizawa T, Kokudo N, et al. On-site monitoring of postoperative bile leakage using bilirubin-inducible fluorescent protein[J]. World J Surg, 2020, 44(12): 4245-4253.
38	Saruwatari MS, Jawed K, Ali KM, et al. Assessment of a novel biliary-specific near-infrared fluorescent dye (BL-760) for intraoperative detection of bile ducts and biliary leaks during hepatectomy in a preclinical swine model[J]. Lasers Surg Med, 2023, 55(5): 480-489.
39	Wang HQ, Yang J, Yang JY, et al. Bile leakage test in liver resection: a systematic review and meta-analysis[J]. World J Gastroenterol, 2013, 19(45): 8420-8426.
40	Sanyal R, Lall CG, Lamba R, et al. Orthotopic liver transplantation: reversible Doppler US findings in the immediate postoperative period[J]. Radiographics, 2012, 32(1): 199-211.
41	吴晓冬，刘松，王峰，等. 经T管超声胆管造影评估肝移植术后早期肝内外胆管[J]. 中国医学影像技术，2022, 38(8): 1203-1207.
42	吴晓冬．经T管超声造影在肝移植术后早期应用价值[D]. 青岛：青岛大学，2022.
43	Wang CK, Cheng YF, Chen CL, et al. Imaging diagnosis of biliary complications of ABO incompatibility in living donor liver transplantation[J]. Transplant Proc, 2020, 52(6): 1833-1837.
44	Laghi A, Pavone P, Panebianco V, et al. Biliary complications of liver transplant. Role of cholangiography with magnetic resonance[J]. Radiol Med, 1998, 95(1-2): 66-71.
45	Pavone P, Laghi A, Catalano C, et al. Biliary-enteric anastomosis: role of cholangiography with magnetic resonance[J]. Radiol Med, 1996, 92(3): 247-251.
46	Heinemann M, Tafrishi B, Pischke S, et al. Endoscopic retrograde cholangiography and percutaneous transhepatic cholangiodrainage in biliary strictures after liver transplantation: long-term outcome predictors and influence on patient survival[J]. Liver Int, 2019, 39(6): 1155-1164.
47	张晖，黄备建，王文平，等. 超声引导下经皮经肝穿刺胆管置管引流的技术应用[J]. 中国临床医学，2006, 13(6): 1002-1003.
48	姜静华，陈静婉. 超声引导经皮经肝穿刺胆管引流术的应用及预后分析[J]. 中国超声医学杂志，2019, 35(4): 335-338.
49	Pedersen MR, Greenan G, Arora S, et al. Ursodeoxycholic acid decreases incidence of primary biliary cholangitis and biliary complications after liver transplantation: a meta-analysis[J]. Liver Transpl, 2021, 27(6): 866-875.
50	张章，陈肖佳，曹婷婷，等. ERCP治疗肝移植术后胆道并发症的研究[J]. 现代消化及介入诊疗，2022, 27(8): 947-950.
51	Ranjan P, Bansal RK, Mehta N, et al. Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India[J]. Indian J Gastroenterol, 2016, 35(1): 48-54.
52	Johnson G, Webster G, Papaefthymiou A, et al. Quality standards and curriculum for training in cholangiopancreatoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement[J]. Endoscopy, 2025, 57(9): 1056-1069.
53	Lee HW, Shah NH, Lee SK. An update on endoscopic management of post-liver transplant biliary complications[J]. Clin Endosc, 2017, 50(5): 451-463.
54	Eminler AT, Parlak E, Koksal AS, et al. Endoscopic treatment of biliary stones in patients with liver transplantation[J]. Surg Endosc, 2017, 31(3): 1327-1335.
55	Lladó L, Fabregat J, Baliellas C, et al. Surgical treatment of biliary tract complications after liver transplantation[J]. Transplant Proc, 2012, 44(6): 1557-1559.
56	杨俊，王善佩. 1例肝移植术后胆道狭窄行磁压榨胆道疏通术的围术期护理[J]. 全科护理，2018, 16(31): 3967-3968.
57	Langer FB, Györi GP, Pokorny H, et al. Outcome of hepaticojejunostomy for biliary tract obstruction following liver transplantation[J]. Clin Transplant, 2009, 23(3): 361-367.
58	李传云，刘源，赖威，等. 肝移植术后胆道并发症的处理(附40例次报道)[J]. 器官移植，2010, 1(3): 166-169.
59	Hawksworth J, Radkani P, Nguyen B, et al. Robotic hepaticojejunostomy for late anastomotic biliary stricture after liver transplantation: technical description and case series[J]. Ann Surg, 2022, 275(6): e801-e803.
60	傅志仁，倪之嘉. 再次肝移植的指征[J]. 肝胆外科杂志，2011, 19(5): 331-333.
61	Takao S, Matsuo Y, Shinchi H, et al. Magnetic compression anastomosis for benign obstruction of the common bile duct[J]. Endoscopy, 2001, 33(11): 988-990.
62	Jang SI, Kim JH, Won JY, et al. Magnetic compression anastomosis is useful in biliary anastomotic strictures after living donor liver transplantation[J]. Gastrointest Endosc, 2011, 74(5): 1040-1048.
63	Itoi T, Kasuya K. A small magnet with a large potential to replace surgery in repairing a disconnected bile duct after living-donor liver transplantation[J]. Endoscopy, 2016, 48(7): 607-608.
64	Parlak E, Küçükay F, Köksal A, et al. Recanalization of complete anastomotic biliary obstruction after living donor related liver transplantation with a novel through-the-scope magnet[J]. Liver Transpl, 2015, 21(5): 711-712.

并发症类型	临床表现	诊断要点
胆漏	(1)腹腔引流管引出胆汁样液体(最具特征性)；(2)引流液胆红素水平远高于血清水平	(1)超声/CT：肝周、膈下局限性积液；(2)胆道造影(金标准)：可见造影剂外泄
吻合口狭窄	(1)间歇性或进行性梗阻性黄疸；(2)肝功能：γ-谷氨酰转肽酶、碱性磷酸酶显著升高	(1)超声/MRCP：肝内外胆管普遍扩张，在吻合口处突然截断或狭窄；(2)胆道造影示吻合口局限性狭窄，近端胆管扩张
非吻合口狭窄	临床表现多样且无特异性，与吻合口狭窄、慢性排斥反应表现相似	(1)超声/CT：肝内胆管可能不扩张或仅轻度扩张；(2)MRCP/胆道造影(金标准)：肝内/外胆管多发性、节段性狭窄与扩张，呈"串珠样"改变，狭窄位于吻合口以外区域
胆道结石	腹痛、胆道梗阻症状/肝功能异常	超声/CT：肝内胆管可见充盈缺损或强回声后伴声影

并发症类型	临床表现	诊断要点
胆漏	(1)腹腔引流管引出胆汁样液体(最具特征性)；(2)引流液胆红素水平远高于血清水平	(1)超声/CT：肝周、膈下局限性积液；(2)胆道造影(金标准)：可见造影剂外泄
吻合口狭窄	(1)间歇性或进行性梗阻性黄疸；(2)肝功能：γ-谷氨酰转肽酶、碱性磷酸酶显著升高	(1)超声/MRCP：肝内外胆管普遍扩张，在吻合口处突然截断或狭窄；(2)胆道造影示吻合口局限性狭窄，近端胆管扩张
非吻合口狭窄	临床表现多样且无特异性，与吻合口狭窄、慢性排斥反应表现相似	(1)超声/CT：肝内胆管可能不扩张或仅轻度扩张；(2)MRCP/胆道造影(金标准)：肝内/外胆管多发性、节段性狭窄与扩张，呈"串珠样"改变，狭窄位于吻合口以外区域
胆道结石	腹痛、胆道梗阻症状/肝功能异常	超声/CT：肝内胆管可见充盈缺损或强回声后伴声影

患者编号	年龄(岁)	并发症类型	发病时间	手术类型	住院时长(d)	随访时间
1	32	胆总管结石伴急性胆囊炎，原发性硬化性胆管炎	术后3年	LCBDE＋胆肠吻合术	27	1年
2	50	胆管结石伴胆囊炎	术后4年	LCBDE＋胆肠吻合术	23	3年
3	45	胆管狭窄	术后14年	LCBDE＋T管引流	9	2年
4	66	肝内胆管结石	术后6年	LCBDE＋T管引流	18	2年
5	65	胆管狭窄	术后5年	LCBDE＋T管引流	17	1年
6	45	胆管狭窄	术后3个月	LCBDE＋T管引流	12	1年
7	42	肝内外胆管扩张	术后2年	腹腔镜下胆肠吻合术	25	3年
8	63	肝脏肿瘤(胆汁瘤)	术后6个月	LCBDE＋PHX＋T管引流	13	半年

患者编号	年龄(岁)	并发症类型	发病时间	手术类型	住院时长(d)	随访时间
1	32	胆总管结石伴急性胆囊炎，原发性硬化性胆管炎	术后3年	LCBDE＋胆肠吻合术	27	1年
2	50	胆管结石伴胆囊炎	术后4年	LCBDE＋胆肠吻合术	23	3年
3	45	胆管狭窄	术后14年	LCBDE＋T管引流	9	2年
4	66	肝内胆管结石	术后6年	LCBDE＋T管引流	18	2年
5	65	胆管狭窄	术后5年	LCBDE＋T管引流	17	1年
6	45	胆管狭窄	术后3个月	LCBDE＋T管引流	12	1年
7	42	肝内外胆管扩张	术后2年	腹腔镜下胆肠吻合术	25	3年
8	63	肝脏肿瘤(胆汁瘤)	术后6个月	LCBDE＋PHX＋T管引流	13	半年

[1]	Rui Jiao, Gang Xu, Huibin Lian, Zhimin Yin, Hui Han, Jie Zhou. Discussion on the treatment of gluteal muscle and skin necrosis caused by arterial embolization for massive hemorrhage due to pelvic fracture [J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2026, 21(01): 7-11.
[2]	Ling Li, Yan Xu, Li Pan, Xin Zhou, Zibiao Zhong, Zhongzhong Liu, Chengbiao Xue, Huaqin Pan, Shaojun Ye. Clinical analysis of long-cycle double plasma molecular adsorption system combined with plasma exchange in bridging therapy for secondary liver transplantation [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 454-456.
[3]	Caihua He, Tianxing Dai, Huanquan Chen, Jianliang Yang, Qiheng Huang, Kai Li, Feng Yuan, Canhua Zhu, Zhitao Chen, Guoying Wang. Early-onset tuberculosis with abdominal wall tuberculosis as the initial manifestation after liver transplantation: a case report [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 457-461.
[4]	Jincai Jiang, Jianhong Hao, Yufu Ye. Advances in liver transplantation for nonresectable colorectal liver metastases [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 470-474.
[5]	Branch of Organ Transplantation of Chinese Medical Association. Chinese expert consensus on prevention and treatment of recurrence and metastasis after liver transplantation for hepatocellular carcinoma (2025 edition) [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 385-397.
[6]	Liver Transplantation Group, Branch of Organ Transplantation of Chinese Medical Association, Branch of Organ Transplant Physicians of Chinese Medical Doctor Association. Chinese clinical practice guideline for prevention and treatment of large-for-size syndrome in liver transplantation (2025 edition) [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(06): 375-384.
[7]	Liver Transplantation Group, Branch of Organ Transplantation of Chinese Medical Association, Branch of Organ Transplant Physicians of Chinese Medical Doctor Association. Chinese guideline for clinical application of basiliximab in liver transplant recipients(2025 edition) [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(05): 285-293.
[8]	Guisheng Ai, Junjie Li, Yan Xie, Jian Yang, Jian He, Lei Zhang, Wentao Jiang. Analysis of risk factors associated with portal vein thrombosis following liver transplantation in adult patients with liver cirrhosis [J]. Chinese Journal of Transplantation(Electronic Edition), 2025, 19(05): 344-350.
[9]	Wei You, Qingqing Li, Hua Jin, Ping Wang, Meiling Zhou, Zun Chen, Yonggang Huang. The influence of mesh repair surgery for diastasis recti abdominis on abdominal core health [J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2026, 20(01): 101-107.
[10]	Hong Wang, Guoqiang Dong, Xingzhou Zhang, Weijun Liu, Nan Zhang. Short-term efficacy comparison between robot-assisted and laparoscopic surgery for complex abdominal wall hernias [J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2026, 20(01): 68-73.
[11]	·Maimaiti Maiwulanjiang, ·Tulading Aliya, ·Tuxun Tuerhongjiang. Immunosuppression strategy for ABO-incompatible liver transplantation [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2026, 15(02): 152-159.
[12]	Xiaozhen Wang, Canhui Chen, Shanhua Tang, Haojia Dai, Yangge Feng, Kai Wang, Qingping Li, Chuanjiang Li. Construction and efficiency comparison of prediction models based on different machine learning technologies for early severe complications after liver transplantation [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2026, 15(02): 197-204.
[13]	Chengli Gao, Kaiming He, Xiao Feng, Kaining Zeng, Hui Tang, Jia Yao, Qing Yang, Huimin Yi, Shuhong Yi, Yang Yang, Binsheng Fu. Safety and efficacy of liver transplantation for children with inherited metabolic liver disease-A single-center analysis of 44 cases [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(06): 844-851.
[14]	Xueli Yan, Deying Kong, Yinghui Hu, Junxi Xiang. Incidence and risk factors of immediate complications after orthotopic liver transplantation [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(06): 894-901.
[15]	Haoran Wang, Xinyuan Liu, Hua Fan. Application of ICG fluorescence imaging in perfusion and functional evaluation of liver graft [J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(06): 912-918.

Please choose a citation manager

Content to export