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Table 9.19. Manifestations of hepatic artery thrombosis

1. Elevation of the transaminases and bilirubin

2. Fulminant hepatic failure

3. Sepsis with hepatic abscesses or gangrene of the liver

4. Biliary anastomotic disruption

5. Biliary tract strictures with ischemic compromise of the bile duct. These early leaks are best treated by reoperation and revision to a Roux-en-Y choledochojejunostomy. Localized leaks may be treated with endoscopic retrograde cholangiography (ERCP) and sphincterotomy with stenting of the bile duct leak.

Biliary leaks from the raw surface of split livers can be treated conservatively, especially if the leak is contained and adequately drained. If the leak continues, ERCP with sphincterotomy may be necessary. Delayed complications include stenoses of the bile duct anastomosis and intrahepatic biliary strictures which may or may not be related to hepatic artery thrombosis. These are typically managed by skilled ERCP intervention with dilatation and stenting. Where these fail, biliary reconstruction with a Roux-en-Y choledochojejunostomy may be necessary. Finally, dysfunctional motility of the bile duct and of the Sphincter of Oddi may result in functional obstruction in the absence of mechanical obstruction.25 These types of problems manifest later on in the postoperative period. Also, biliary casts and stones can form, especially in the presence of longstanding T-tubes and may result in biliary obstruction requiring ERCP intervention.

The use of either endoscopic or percutaneous (transhepatic) techniques in the management of biliary complications is dictated by the availability of skilled interventional endoscopists and radiologists at the particular institution. In our opinion, endoscopic (ERCP) intervention is preferred and percutaneous transhepatic procedures are used, when for technical reasons, endoscopic access to the involved biliary tract is not possible.

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