Intrahepatic Bilioenteric Anastomosis After Biliary Complications of Liver Transplantation: Operative Rescue of Surgical Failures Miguel A ´ ngel Mercado Æ Mario Vilatoba ´ Æ Carlos Chan Æ Ismael Domı ´nguez Æ Rafael Paulino Leal Æ Marco Antonio Olivera Published online: 7 January 2009 Ó Socie ´te ´ Internationale de Chirurgie 2008 Abstract Background Biliary complications after orthotopic liver transplantation (OLT) are multifactorial in origin. In most series, the frequency of such complications ranges from 5– 20%. Most can be treated by endoscopy and/or interventional radiology. For cases in which this option is not successful, surgical approach is indicated. We report the results of reoperation using an intrahepatic bilioenteric anastomosis. Methods The medical charts of patients with biliary complications after OLT during a 10-year period (1997– 2007), who failed to respond to nonsurgical treatment and were surgically treated, were reviewed. Roux-en-Y hepat- ojejunostomy was performed. Segments IV and V were partially removed after cutting the hilar plate, thus obtaining healthy ducts without ischemic or inflammatory reaction and allowing a wide hepatojejunostomy. Results Five cases (8.4%) with biliary complications after duct-to-duct anastomosis not amenable to further endo- scopic management or interventional radiology were identified. Hepaticojejunostomy was achieved in all cases (wide, tension-free, nonischemic, fine hydrolyzable sutures), and segments IV and V were partially removed. No cholangitis, jaundice, and liver function test abnor- malities were present in the postoperative. Mean follow-up was 24 months. Only one patient died of causes not related to bile duct reconstruction during follow-up. Conclusions Intrahepatic hepatojejunostomy with partial resection of segments IV and V offers an excellent thera- peutic alternative for biliary complications that require a surgical approach after OLT. Introduction Bile duct reconstruction in liver transplantation and its complications have been exhaustively studied. Technical considerations have been emphasized and variants of the anastomosis have been developed. Complication rates (fistula, leakage, dehiscence) range from 1 to 15% [1]. Many are managed successfully with endoscopic retro- grade cholangiography dilation and/or stent placement and some require retransplantation [2, 3]. Complications of bile reconstruction have a large spectrum of etiologies. Besides surgical technique, ischemia of the stumps is a frequent cause of leakage and dehiscence [4]. Some surgical teams routinely place a T tube, others place an end prosthesis, and others do not use stents at all. There is insufficient evidence to discourage or support their use [5]. Failure of the anastomosis can result in fistula formation and in a late manner stenosis. These complications are usually treated by endoscopy and/or radiological inter- vention [6, 7]. Surgery is indicated for cases in which failure of these minimally invasive treatments is recog- nized. The surgical approach has a wide spectrum of options, including placing a T tube, conversion to a bilio- enteric anastomosis (more common), or retransplantation. We report our experience with surgical reconstruction of the bile duct using an intrahepatic approach, removing the hilar plate, and the base of segments IV and V to perform hepaticojejunostomy (Roux-en-Y hepatojejunostomy) similar to that performed for iatrogenic injury [8]. M. A ´ . Mercado (&) Á C. Chan Á I. Domı ´nguez Department of Surgery, Instituto Nacional de Ciencias Me ´dicas y Nutricio ´n ‘‘Salvador Zubira ´n’’ (INCMNSZ), Vasco de Quiroga No. 15, Tlalpan 14000, DF, Me ´xico e-mail: mamercado@quetzal.innsz.mx M. Vilatoba ´ Á R. P. Leal Á M. A. Olivera Liver Transplant Unit, Instituto Nacional de Ciencias Me ´dicas y Nutricio ´n ‘‘Salvador Zubira ´n’’, Tlalpan, Me ´xico 123 World J Surg (2009) 33:534–538 DOI 10.1007/s00268-008-9876-2