We thank Balderramo and Cardenas for their comments on our recently published article examining the association between the Model for End-Stage Liver Disease (MELD) era and the incidence of biliary complications after liver transplantation.1

Although we examined multiple risk factors that can affect biliary complications after liver transplantation, we agree that several operative variables (eg, transfusion requirements) were not completely available in our database and may have affected the biliary complication rate. For sicker patients with higher MELD scores, there is the potential for longer operative times and greater transfusion requirements, but the MELD score at the time of transplantation was not a significant predictor of biliary stricture formation.

As expected, the use of T-tubes was strongly associated with bile leaks but was not associated with the development of biliary anastomotic strictures, so this was not included in the multivariate analysis. A previous bile leak was associated with stricture formation, and this suggested that bile leaks not related to T-tubes were more of a factor in stricture formation.

Unfortunately, we did not have detailed clinical data about the nature of the bile leaks, but we agree that most leaks occur relatively early after transplantation. The mean time to a bile leak (rather than the median) was 102 days with a standard deviation of 44 days; this time approximately corresponded to the typical time of T-tube removal (3 months). A few leaks occurred many months after transplantation and skewed the mean value; only 7.5% of the leaks occurred within the first 2 weeks (there were only 107 leaks in all).

To determine whether bile leaks not related to T-tubes affected the formation of anastomotic strictures, we reanalyzed the data after the removal of bile leaks occurring 60 to 120 days after transplantation (62 leaks in all). We did not have detailed data showing that the leaks were definitely due to T-tube removal, but we considered leaks in this time frame to correspond to the time of T-tube removal. The odds ratio for this group of leaks was 5.03 (P < 0.03), and this suggested that the leaks were associated with the formation of anastomotic strictures.

We echo the sentiment that the continued analysis of biliary complications after liver transplantation is important for minimizing this particular morbidity.


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  • 1
    Sundaram V, Jones DT, Shah NH, de Vera ME, Fontes P, Marsh JW, et al. Posttransplant biliary complications in the pre- and post-Model for End-Stage Liver Disease era. Liver Transpl 2011; 17: 428-435.

Vinay Sundaram , M.D.*, Jawad Ahmad , M.D., F.R.C.P.†, * Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, † Division of Liver Diseases, Mount Sinai Medical Center, New York, NY.