Meta-Analysis
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2021; 27(14): 1507-1523
Published online Apr 14, 2021. doi: 10.3748/wjg.v27.i14.1507
T-tube vs no T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis
Jun-Zhou Zhao, Lin-Lan Qiao, Zhao-Qing Du, Jia Zhang, Meng-Zhou Wang, Tao Wang, Wu-Ming Liu, Lin Zhang, Jian Dong, Zheng Wu, Rong-Qian Wu
Jun-Zhou Zhao, Lin-Lan Qiao, Zhao-Qing Du, Jia Zhang, Meng-Zhou Wang, Tao Wang, Wu-Ming Liu, Lin Zhang, Jian Dong, Zheng Wu, Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
Jun-Zhou Zhao, Lin-Lan Qiao, Zhao-Qing Du, Jia Zhang, Rong-Qian Wu, National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
Author contributions: All authors contributed to the study; Zhao JZ participated in the search strategy design and performed most statistical analyses and paper writing; Qiao LL, Du ZQ, and Zhang J did a literature search of the databases in parallel, built up selection criteria, and selected the potential studies; Wang MZ and Wang T defined the interventions and outcomes; Liu WM, Zhang L, and Dong J assessed the studies’ quality and figured out the characteristics of the selected studies; Wu Z assisted with the design of the study; Wu RQ designed and supervised the study and revised the manuscript.
Supported by National Natural Science Foundation of China, No. 81770491; and The Innovation Capacity Support Plan of Shaanxi Province, No. 2020TD-040.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist and finished the manuscripts according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Rong-Qian Wu, MD, PhD, Professor, National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, No. 76 West Yanta Road, Xi’an 710061, Shaanxi Province, China. rwu001@mail.xjtu.edu.cn
Received: December 3, 2020
Peer-review started: December 3, 2020
First decision: December 21, 2020
Revised: December 29, 2020
Accepted: March 18, 2021
Article in press: March 18, 2021
Published online: April 14, 2021
Abstract
BACKGROUND

Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation (OLT) remains a debatable question. Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures. Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications. Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated.

AIM

To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT.

METHODS

In the electronic databases MEDLINE, PubMed, Scopus, ClinicalTrials.gov, the Cochrane Library, the Cochrane Hepato-Biliary Group Controlled Trails Register, and the Cochrane Central Register of Controlled Trials, we identified 17 studies (eight randomized controlled trials and nine comparative studies) from January 1995 to October 2020. The data of the studies before and after 2010 were separately extracted. We chose the overall biliary complications, bile leaks or fistulas, biliary strictures (anastomotic or non-anastomotic), and cholangitis as outcomes. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to describe the results of the outcomes. Furthermore, the test for overall effect (Z) was used to test the difference between OR and 1, where P ≤ 0.05 indicated a significant difference between OR value and 1.

RESULTS

A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis. The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010 (P = 0.012, OR = 0.62, 95%CI: 0.42-0.90), while the same benefit was not seen in studies after 2010 (P = 0.60, OR = 0.76, 95%CI: 0.27-2.12). No significant difference in the incidence of overall biliary complications (P = 0.37, OR = 1.41, 95%CI: 0.66-2.98), bile leaks (P = 0.89, OR = 1.04, 95%CI: 0.63-1.70), and cholangitis (P = 0.27, OR = 2.00, 95%CI: 0.59-6.84) was observed between using and not using a T-tube before 2010. However, using a T-tube appeared to increase the incidence of overall biliary complications (P = 0.049, OR = 1.49, 95%CI: 1.00-2.22), bile leaks (P = 0.048, OR = 1.91, 95%CI: 1.01-3.64), and cholangitis (P = 0.02, OR = 7.21, 95%CI: 1.37-38.00) after 2010. A random-effects model was used in biliary strictures (after 2010), overall biliary complications (before 2010), and cholangitis (before 2010) due to their heterogeneity (I2 = 62.3%, 85.4%, and 53.6%, respectively). In the sensitivity analysis (only RCTs included), bile leak (P = 0.66) lost the significance after 2010 and a random-effects model was used in overall biliary complications (before 2010), cholangitis (before 2010), bile leaks (after 2010), and biliary strictures (after 2010) because of their heterogeneity (I2 = 92.2%, 65.6%, 50.9%, and 80.3%, respectively).

CONCLUSION

In conclusion, the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.

Keywords: Orthotopic liver transplantation, T-tube, Biliary tract reconstruction, Biliary complications, Biliary strictures, Meta-analysis

Core Tip: This is the first meta-analysis that compared the postoperative outcomes with or without a T-tube in biliary reconstruction during orthotopic liver transplantation (OLT) before and after 2010. Before 2010, T-tube was favorable for biliary stricture and had no influence on overall biliary complications, bile leaks, and cholangitis. After 2010, not using a T-tube was good for overall biliary complications and cholangitis; however, using a T-tube was not associated with biliary strictures and showed an unbeneficial trend for bile leaks. Therefore, the studies published in the last decade did not provide enough evidence to support the use of T-tube during adult OLT.