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    Anastomose biliar com ou sem tubo em t durante transplante hepático em adultos: revisão sistemática e metanálise
    (Universidade Federal de São Paulo (UNIFESP), 2021) Oliveira Filho, Jose Jeova de [UNIFESP]; Linhares, Marcelo Moura [UNIFESP]; Universidade Federal de São Paulo
    Introduction: In liver transplantation, biliary complications, especially leaks/fistulas and stenosis, remain the main causes of surgical morbidity (5% to 35%) and mortality (10% to 60%). The end-to-end choledochocholedocostomy is the most commonly adopted biliary anastomosis technique, be it associated or not with the use of a T-tube. There is no consensus regarding the use of the T-tube as a drainage technique during biliary reconstruction. Objectives: Analyzing the results of biliary anastomosis, with or without the use of a T-tube in adults undergone liver transplantation. Methods: Systematic review of randomized clinical trials. The research was conducted on the Cochrane Hepato-Biliary Group Controlled Trials Register (Cochrane Hepato-Biliary Group Module) databases, Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE Ovid, Embase Ovid, Latin American and Caribbean Health Sciences Database (LILACS; Virtual Health Library - BVS), Science Citation Index Expanded (Web of Science), Conference Proceedings Citation Index - Science (Web of Science) (Royle 2003), Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO), ClinicalTrial.gov (clinicaltrials.gov/), and WHO International Clinical Trial Registry Platform (www.who.int/ictrp). There were no restrictions on language and publication date. Randomized clinical trials comparing choledochocholedocostomy with or without the use of a T-tube were included. The primary outcomes studied were mortality, serious adverse events (anastomotic and non-anastomotic stenosis, anastomotic and non-anastomotic biliary leakage, complications related to the T-tube, retransplantation and non- biliary complications) and quality of life. Secondary outcomes were non-serious adverse events (systemic and other biliary complications) and pain. We used the standard methodological procedures expected by Cochrane and Cochrane Hepato-Biliary Group Module and performed the analyzes using Review Manager 5.4. We used a random-effects model meta-analysis and presented the results of the review incorporating the methodological quality of the studies using GRADE. In our review, we used dichotomous results and expressed the results as hazard ratio (HR) with a 95% confidence interval (CI). Results: The review included seven randomized controlled trials, with a total of 881 adult participants, averaged 50.4 years old and with an average follow-up period from 8 to 35 months. Has been demonstrated the occurrence of a greater number of anastomotic stenosis in the control group (without T-tube) just as it was observed greater number of complications related to the T-tube and greater overall risk of serious adverse events in this same group, being these differences were statistically significant. There was no evidence of an overall significant difference between T-tube and non-T-tube groups, regarding the other outcomes. Heterogeneity between studies was variable. All studies presented a high risk of biases and we classified the evidence from low-quality to very low-quality. Conclusions: There was low-quality to very low-quality evidence showing that biliary anastomosis without a T-tube may be associated with an increased risk of anastomotic stenosis and that biliary anastomosis with a T-tube may be associated with an increased risk of complications related to its use, such as leakage and cholangitis and the increased overall risk of serious adverse events. We suggest more randomized controlled trials, especially with a longer observation period and better evidence quality.