Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft

Continuous versus interrupted suture for end-to-end biliary anastomosis during liver transplantation gives equal results

Biliary complications following orthotopic liver transplantation have been reported in 10% to 30% of patients. Most surgeons perform an end-to-end choledochocholedochostomy with interrupted sutures for biliary reconstruction. The goal of this study was to compare biliary complications between interrupted suture (IS) and continuous suture (CS) techniques during liver transplantation in which an end-to-end choledochocholedochostomy over an internal biliary stent was performed. A retrospective cohort study of 100 consecutive liver transplants occurring between December 2003 and July 2005 was conducted. An end-to-end choledochocholedochostomy over an internal biliary stent was performed during liver transplantation. Data were analyzed using Kaplan-Meier methods, t tests, and chi-square tests of proportions. IS and CS techniques were used in 59 and 41 patients, respectively, for biliary reconstruction during liver transplantation. Mean follow-up time for the CS group was 17 +/- 8 months and 15 +/- 7 months for the IS group (P = .21). The overall biliary complication rate was 15%. There was no difference in the proportion of leaks (CS = 7.3%, IS = 8.5%; P = .83) or strictures (CS = 9.8%, IS = 5.1%; P = .37) between groups. Kaplan-Meier event rates show no difference in leaks (P = .79), strictures (P = .41), graft survival (P = .52), and patient survival (P = .32) by anastomosis type. In conclusion, there was no difference in biliary complications, graft survival, or patient survival between the 2 groups. CS and IS techniques for biliary reconstruction during liver transplantation yield comparable outcomes.

Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases

OBJECTIVE

To determine outcomes for both donors and recipients of adult-to-adult living donor liver transplantation (AALDLT) and independent factors impacting those outcomes.

SUMMARY BACKGROUND DATA

Deceased donors for organ transplantation remain extremely rare, making living donor liver transplantation (LDLT) practically the sole therapeutic modality for patients with end-stage liver disease in Japan.

METHODS

Retrospective analysis of initial LDLT for 335 consecutive adult (>or=18 years) patients performed between November 1994 and December 2003.

RESULTS

: Of the 335 recipients, 275 received right-liver grafts and the remaining 60 recipients received non-right-liver grafts. Three of the 335 liver grafts were domino-splitting livers. Sixty of the 332 donors other than the domino-donors showed major postoperative complications. Multivariate analysis indicated that accumulation of case experience significantly and advantageously affected the surgical outcomes of these living liver donors, and right-liver donation and prolonged donor operation time were shown to be independent risk factors of major complications in the donors. Post-transplant patient and graft survival estimates were 73.1% and 72.5% at 1 year, 67.7% and 66.3% at 4 years, and 64.7% and 61.9% at 7 years, respectively. Obvious pretransplant encephalopathy, a higher (>or=31) modified Model for End-stage Liver Disease score (including points for persistent ascites and low serum sodium) and higher donor age (>or=50 years) were indicated as independent factors predictive of graft failure (graft loss or death) in the multivariate analysis.

CONCLUSIONS

Graft type and degree of experience exerted a significant impact on the surgical outcomes of AALDLT donors but did not significantly affect the survival outcomes of AALDLT recipients. Better pretransplant conditions and younger age (<50 years) among the living donors appeared to be advantageous in terms of gaining better survival outcomes of patients undergoing AALDLT.

Biliary complications in recipients of living-donor liver transplantation

The key points of the management of biliary complications in recipients of living-donor liver transplantation are described. The characteristics of these complications are somewhat different from those in deceased-donor liver transplantation, mainly due to the technical difficulties. Appropriate prevention, diagnosis, and treatment are essential for successful transplants, to avoid the development of secondary biliary cirrhosis when complication occurs.

Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis

BACKGROUND/PURPOSE

The aims of this study were to characterize the features of the biliary complications that occur after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis, and to evaluate the efficacy of treating biliary complications endoscopically.

METHODS

The records of 273 consecutive patients who underwent RL-LDLT with duct-to-duct biliary anastomosis from July 1999 through July 2005 at Kyoto University Hospital were reviewed to determine the overall incidence of postoperative biliary complications and the outcome of endoscopic repair of those complications.

RESULTS

Biliary complications occurred in 93 (34.1%) of the patients. These complications were: 80 biliary strictures (75 anastomotic and 5 nonanastomotic) and 16 biliary leakages (5 patients with biliary leakage also had a biliary stricture); most (72%) of the anastomotic strictures were complex (i.e., fork-shaped or trident-shaped). The strictures and leakages were repaired by the endoscopic placement of multiple inside stents above the sphincter of Oddi, and by nasobiliary drainage, respectively. The procedure was successful in repairing 51 (68.0%) of the anastomotic strictures and 8 (50.0%) of the biliary leakages.

CONCLUSIONS

Endoscopic stenting of the bile ducts is efficacious in treating biliary complications related to RL-LDLT with duct-to-duct biliary anastomosis and the stenting should be attempted before surgical revision of strictures and leakages.

Results of Biliary Reconstructions in Liver Transplantation at Our Center

Biliary complications are some of the most critical problems in liver transplantation. Despite various refinements in surgical technique, different types of liver transplantations are associated with significant numbers of biliary problems. In this study, we analyzed the results of biliary reconstructions in 127 liver transplant recipients at our center from April 2001 to May 2006. Through November 2004, we used different techniques for biliary reconstruction in 66 of these patients, including duct-to-duct (DD) anastomoses, Roux-en-Y hepaticojejunostomy (RYHJ), anastomoses over T tubes or stents, and anastomoses without stenting. During the first period, we used a DD anastomosis in 15 cadaveric whole liver grafts and in 25 right lobe and 12 left lobe or left lateral segment grafts from living-related donors. RYHJ was preferred in 2 cadaveric and 12 left lateral segment grafts. Beginning in November 2004, we employed intraoperative transhepatic biliary catheter insertion in 61 patients (29 children, 32 adults). In the most recent 61 cases of 13 liver grafts from cadavers and 48 from living-related donors, 14 patients (2 children and 12 adults) received whole-liver grafts, 22 (all adults) a right lobe, and 26 (all children) a left lateral or left lobe. Intraoperative transhepatic biliary catheter insertion was performed with DD anastomosis in 55 cases and with RYHJ in 6 cases. The mean complication rate decreased from 24% to 8.1% during the period using a new biliary reconstruction technique. Five biliary complications occurred in four patients. The new technique of biliary reconstruction using intraoperative biliary catheter insertion has significantly reduced the biliary complication rate. Transhepatic biliary stenting prevents biliary complications and maintains percutaneous access when problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe way to provide good biliary drainage after liver transplantation.

Endoscopic management of biliary complications after adult living donor liver transplantation

OBJECTIVES

Biliary complications are one of the important issues to be addressed after liver transplantation. Endoscopic management of biliary complications after deceased donor liver transplantation (DDLT) is widely accepted, but it remains to be established in patients after living donor liver transplantation (LDLT). Endoscopic management in LDLT patients is difficult mainly because of the complexity of duct-to-duct reconstruction.

METHODS

A total of 174 adult LDLTs with duct-to-duct reconstruction were performed in our institution. Biliary complications developed in 53 patients (30%). Among these, 18 patients were referred for endoscopic management and were the subjects of the present study. Success rate, early morbidity, and outcome were evaluated in these 18 patients.

RESULTS

The type of graft was the right liver in six, left liver in eight, and right lateral sector in four patients. Ten out of 18 patients had one biliary anastomosis and the remaining eight had multiple anastomoses. Six patients had a previous history of surgical or percutaneous intervention for biliary complications after LDLT. Seventeen patients had one or more biliary strictures. Biliary casts were found in nine patients, three of whom had concomitant bile leaks. Strictures were successfully treated with endoscopic balloon dilation in 12 (71%) of the 17 patients (nasobiliary catheter placement in eight and stent placement in four patients). Bile leak was successfully managed in two of three patients. Biliary casts were removed by endoscopic papillary balloon dilation in eight of nine patients. Five patients with failed endoscopic therapy were converted to percutaneous or surgical intervention. Endoscopic-procedure-related cholangitis developed in one patient. During follow-up with median periods of 10 months (range 2-20 months), four of nine patients without stent placement developed biliary strictures, and these were relieved by additional endoscopic management.

CONCLUSIONS

Endoscopic approach has the potential to be a first-line therapy for the management of biliary complications after LDLT.

Adult-to-adult live-donor liver transplantation: the current status

Adult-to-adult live-donor liver transplantation (ALDLT) has emerged successfully to partially relieve the refractory shortage of deceased donor grafts caused by the increasing demands of patients with endstage liver diseases. Following the first successful live-donor liver transplantation (LDLT) for a child with biliary atresia in 1989, further extension of the technique, using left-lobe liver grafts for LDLT for large adolescents and adults, has resulted in satisfactory graft and patient survival outcomes. However, small-for-size syndrome may occur in some patients with large body size, and in those with acute-on-chronic liver failure or severe portal hypertension. To overcome the problem of graft-to-body-size mismatch, ALDLT, using a right-lobe liver graft was developed. Although routine inclusion of the middle hepatic vein (MHV) in the right-lobe liver graft is still controversial, the importance of providing good venous drainage for the right anterior sector to ensure better early graft function has gained wide recognition. Preservation of the MHV in the donor is intuitively considered important in reducing the donor risk. However, there are scarce data supporting the contention that postoperative complication is related to the absence of the MHV in the left-liver remnant. Duct-to-duct biliary reconstruction has potential advantages over hepaticojejunostomy, and has become the preferred technique in ALDLT. However, biliary complications, especially biliary strictures on long-term follow-up, occur in about 30% of the recipients. The potential beneficial effect of internal or external biliary drainage in reducing the biliary complication rate after duct-to-duct biliary reconstruction in ALDLT also remains controversial. Dual-liver grafts and right-posterior sector grafts have been used in ALDLT, and are reported to result in satisfactory survival outcomes at selected transplant centers. There is no strong evidence supporting the postulate that patients with hepatitis C infection have an inferior survival outcome after ALDLT when compared with recipients of a deceased-donor liver transplant. ALDLT has contributed to satisfactory survival outcomes in patients with hepatocellular carcinoma (HCC). It allows early surgery for the patients and eliminates the uncertainty of prolonged waiting for a deceased-donor liver graft, and the risks of dropout related to disease progression. The exact selection criteria of patients with HCC for ALDLT have yet to be defined.

Hilar early division of the hepatic duct in living donor right hepatectomy: the probe-and-clamp technique

The division of the hepatic duct is one of the most challenging passages of the donor hepatectomy. We report our experience with the early division, prior to the liver parenchyma resection, of the hepatic duct and the definition of the biliary anatomy with a probe inserted in the proper hepatic duct. From February 2002 to December 2004, 40 donors (25 male, 15 female; mean age 34, range 20-57) underwent right hepatectomy. The yield was a single duct in 24 donors (60%), two ducts in 12 donors (30%), and three ducts in one donor (2.5%), and three donors had aberrant anatomy yielding two ducts (7.5%). By means of a ductoplasty, a single orifice for the recipient biliary anastomosis was obtained in 77.5% of the cases. Three donors (7.5%) suffered a resection surface bile leak. The technique of hepatic duct probing and early division provides a precise definition of the biliary anatomy and facilitates one of the most challenging passages of the donor hepatectomy. This technique should also contribute to maximizing the preservation of the vascular supply of the hepatic duct and the yield of a single orifice for the recipient anastomosis. At a median follow-up of 21 months (range 10-44), neither short- nor long-term complications had been caused by the small donor choledochotomy.

Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution

Biliary complications, biliary strictures (BS) in particular, continue to be a significant cause of morbidity after LDLT despite technical refinement. In this study, we assessed the incidence of BS and their management in living donor liver transplantation (LDLT) with special reference to the type of biliary reconstruction. A total of 182 LDLTs performed at our institution for either adult (n = 157) or pediatric (n = 25) patients were included in the study. The duct-to-duct (DD) biliary reconstruction was performed for 106 cases, while the conventional Roux-en-Y hepaticojejunostomy (HJ) was utilized for the remaining 76 cases. Overall, BS developed in 46/182 (25.3%) of the cases (DD, 26.4%; HJ, 25.0%). The 1- and 3-year cumulative incidences of BS were 22.9% and 31.9%, respectively, in the DD group, and 15.2% and 29.1%, respectively, in the HJ group (P= not significant). The left-lobe LDLT was more prone to develop BS. Continuous anastomosis tended to be associated with the high incidence of BS in the DD group. The incidence of anastomotic leak was significantly lower in the DD group. Intervention via either pre-cutaneous or endoscopic approach was successful in the majority of cases, although recurrence could occur in some patients. In conclusion, BS was not associated with the type of reconstruction in LDLT. The primary radiological or endoscopic interventions were satisfactory treatments of choice. Technical refinement is an important factor to reduce the incidence of BS.

Biliary complications after living donor adult liver transplantation

The highest rate of complications characterizing the adult living donor liver transplantation (ALDLT) are due to biliary problems with a reported negative incidence of 22-64%. We performed 23 ALDLT grafting segments V-VIII without the middle hepatic vein from March 2001 to September 2005. Biliary anatomy was investigated using intraoperative cholangiography alone in the first five cases and magnetic resonance cholangiography in the remaining 18 cases. In 13 cases we found a single right biliary duct (56.5%) and in 10 we found multiple biliary ducts (43.7%). We performed single biliary anastomosis in 17 cases (73.91%) and double anastomosis in the remaining six (26%) cases. With a mean follow up of 644 days (8-1598 days), patient and graft survivals are 86.95% and 78.26%, respectively. The following biliary complications were observed: biliary leak from the cutting surface: three, anastomotic leak: two, late anastomotic strictures: five, early kinking of the choledochus: one. These 11 biliary complications (47.82%) occurred in eight patients (34.78%). Three of these patients developed two consecutive and different biliary complications. Biliary complications affected our series of ALDLT with a high percentage, but none of the grafts transplanted was lost because of biliary problems. Multiple biliary reconstructions are strongly related with a high risk of complication.

Biliary reconstruction in right lobe living-donor liver transplantation: Comparison of different techniques in 321 recipients

OBJECTIVE

To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction.

SUMMARY BACKGROUND DATA

Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported.

METHODS

Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed.

RESULTS

The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment.

CONCLUSIONS

The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.

Biliary reconstruction in right lobe living-donor liver transplantation: Comparison of different techniques in 321 recipients

OBJECTIVE

To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction.

SUMMARY BACKGROUND DATA

Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported.

METHODS

Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed.

RESULTS

The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment.

CONCLUSIONS

The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.

Long-term incidence, risk factors, and management of biliary complications after adult living donor liver transplantation

A considerable proportion of adult living donor liver transplantation (LDLT) recipients experience biliary complication (BC), but there are few reports regarding BC based on long-term studies of a large LDLT population. The present study examined BC incidence, risk factors and management using single-center data from 259 adult patients (225 right liver and 34 left liver grafts) between 2000 and 2002. The mean follow-up period was 46 +/- 14 months. Biliary reconstruction included single duct-to-duct anastomosis (DD, n = 141), double DD (n = 19), single hepaticojejunostomy (HJ, n = 67), double HJ (n = 28), and combined DD and HJ (n = 4). There were 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. Most leaks occurred within the first month, whereas stenosis occurred over 3 yr. Most stenoses were successfully treated using radiological intervention. Cumulative 1-, 3-, and 5-yr BC rates were 12.9%, 18.2%, and 20.2%, respectively. BC occurred much more frequently in right liver grafts compared to left liver grafts (P = 0.024). Stenosis-free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small-sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P = 0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P = 0.471). In conclusion, close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter.

Impact of biliary complications in right lobe living donor liver transplantation

Biliary reconstruction is one of the most challenging parts of right lobe living donor liver transplantation (RL LDLT), and biliary complications have been reported as the first source of surgical complications of this procedure. We reviewed biliary reconstruction and complications in 27 consecutive RL LDLTs. We compared the first 14 procedures (group 1) to the last 13 (group 2). Seven patients (25.9%) experienced a biliary complication (five leaks and two strictures). The incidence of biliary complications was 11.1% in RL grafts with a single duct and 55.5% in graft presenting multiple bile ducts (P = 0.03). Four of the 18 patients with a duct-to-duct reconstruction (22.2%) and three of the 11 patients with a Roux-en-Y reconstruction (27.3%) developed a biliary complication (P = ns). The incidence of biliary complications significantly decreased from 42.9% (n = 6) in the first group to 7.6% (n = 1) in the second group (P = 0.05). The overall 1-year graft and patient survival were 57.1% and 64.3% in group 1 versus 100.0% and 100% in group 2 (P = 0.01; P = 0.006). Biliary complications remain one of the most important technical complications affecting RL LDLT. Nevertheless, attention and surgical refinement can lead to a significant reduction of the biliary complication rate, improving graft and patient survival.

Operative outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative study with cadaveric whole-graft liver transplantation in a single center

OBJECTIVE

To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution.

SUMMARY BACKGROUND DATA

Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT.

PATIENTS AND METHODS

A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56).

RESULTS

Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group.

CONCLUSION

RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.

Feasibility of duct-to-duct biliary reconstruction in pediatric living related liver transplantation: report of three cases

Feasibility of duct-to-duct biliary reconstruction in adult living related liver transplantation (LRLTx) has been recently reported; however, little has been known of its surgical outcome in children. To assess the feasibility and safety of duct-to-duct biliary reconstruction in children, the surgical outcomes of duct-to-duct biliary reconstruction were retrospectively analyzed. The subjects were three children who underwent LRLTx in our hospital each utilizing allografts with a right lobe, a left robe and a lateral segment, respectively. The cause of end-stage liver disease in each of them was fulminant Wilson's disease, fulminant hepatic failure and unresectable hepatoblastoma. Duct-to-duct anastomosis was performed in younger patients and adolescents with interrupted and continuous sutures, respectively. The diameter of bile duct in allografts was from 4 to 6 mm and 12 or 13 stitches were required for anastomosis. Post-operative choledochography from the external tube showed neither stenosis nor leakage and the tube was evacuated within 3 months after LRLTx. No biliary complications were observed with the median follow-up of 28 months. In conclusion, our results show that duct-to-duct biliary reconstructions in pediatric LRLTx seemed to be feasible and safe. Further studies are required to elucidate its real impact on pediatric LRLTx.

T-tube drainage for biliary stenosis after living donor liver transplantation

The optimal strategies for bile duct stenosis after living donor liver transplantation with duct-to-duct biliary reconstruction remain unclear. Patients who underwent liver transplantation with duct-to-duct bile duct reconstruction (n=182) and were complicated with biliary stenosis (n=34) were analyzed. Treatment of biliary stenosis was attempted using an endoscopic approach or transhepatic biliary drainage. When this failed, the T-tube drainage technique was indicated. T-tube placement was performed in 14 patients. Intraoperative ultrasonography was performed to identify the bile duct. The common bile duct was cut open, a Kelly clamp was inserted and the stenotic portion was dilated, and a T-tube was inserted. The patients were scheduled to have the tube removed 1 year after insertion. Complications following T-tube placement or T-tube removal were negligible. The present technique can be an effective therapeutic option when endoscopic treatment is unsuccessful.

In situ dye injection bile leakage test of the graft in living donor liver transplantation

BACKGROUND

Bile leakage after living donor liver transplantation (LDLT) remains a serious problem, resulting in lower survival rates. The aim of this study is to clarify the benefits of in situ leakage testing of the cut surface of grafts in LDLT.

METHODS

A total of 135 LDLTs were analyzed. The patients were divided into the following two groups according to the in situ dye injection leakage test of the cut surface: test group (n=40) and control group (n=40). The incidence of bile leakage and the risk factors were identified by analyzing the recipients, donors, and transplantation variables.

RESULTS

Bile leakage occurred in 12.5% (10/80) of LDLTs. In the control group, there were nine cases of bile leakage (22.5%). On the other hand, there was only one case (2.5%) of bile leakage in the test group (P<0.05). The bile leakage case in the test group was resolved preservationally. However, 2 of the 9 (22.2%) bile leakage cases in the control group required surgery.

CONCLUSION

Although there is biliary complication, especially bile leakage from the cut surface, as an inevitable consequence of LDLT, this study suggests that there is advantage in conducting bile leakage testing to minimize the incidence of bile leakage from the cut surface, which is associated with a high risk of graft failure.

In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis

Roux-en-Y hepaticojejunostomy (RYHJ) has been the standard biliary reconstruction in adult-to-adult living donor liver transplantation (ALDLT). Recently, duct-to-duct anastomosis (DD) has been introduced. This study compared the outcomes of RYHJ and DD. For 4 years, 74 recipients underwent ALDLT and were followed up for at least 2 years. The patients were divided into three groups, RYHJ group (n = 18), DD with a stent (DD + S) group (n = 35), and DD without a stent (DD - S) group (n = 21). Overall, biliary complications were developed in 32.4% patients. The biliary complication rate was 11.1%, 48.5% and 33.3% in RYHJ, DD + S and DD - S groups, respectively (P = 0.047). Bile leaks occurred in 28.5% of DD + S group. The incidence of biliary stricture was 5.3%, 20.2% and 28.6% in RYHJ, DD + S and DD - S group, respectively. Most complications (83.3%) were resolved nonsurgically. RYHJ has a better long-term outcome than DD in ALDLT. Subgroup analysis of DD group showed that DD - S group had no bile leaks, but still had a higher incidence of bile duct strictures. However, because this study was a retrospective review there are limitations in analyzing the data and confirming the conclusion. A randomized-prospective study will be needed to confirm these findings.

Application of duct-to-duct biliary reconstruction in living donor liver transplantation

AIM: To evaluate the operative outcome, complication, and managing principles of the duct-to-duct biliary reconstruction in living donor liver transplantation (LDLT).

METHODS: The clinical data of 24 patients who underwent LDLT (6 for right lobe, 16 for left lobe, and 2 for left lateral lobe) were analyzed retrospectively. The duct-to-duct biliary anastomosis with T tube drainage was used in the biliary reconstruction.

RESULTS: Of the 24 patients underwent duct-to-duct biliary reconstruction, 18 were treated by connecting the donors' right hepatic duct with the recipients' common bile duct, and 5 by connecting the donors' left hepatic duct with the recipients' common hepatic duct. For the other patient, the two opens of hepatic duct were respectively connected to the recipient's common hepatic and bile duct. Biliary leakage appeared in 2 patients, and stenosis of biliary tract happened in 1 patient. Two patients had cholangitis after the operation. One case developed biliary peritonitis after the T tube was taken out, but recovered after treatment with biliary duct drainage. The overall rate of biliary tract complication was 25%, and the complication appeared at 2 d-9 mo after the operation.

CONCLUSION: The duct-to-duct biliary reconstruction is feasible and effective in LDLT.

Feasibility of using the cystic duct for biliary reconstruction in right-lobe living donor liver transplantation

Duct-to-duct biliary reconstruction has been introduced in adult living donor liver transplantation (LDLT). In right-lobe grafts, however, the presence of two or three separated bile duct orifices is not rare and makes an alternative approach for reconstruction necessary. We used the cystic duct for one of the anastomoses in biliary reconstruction for 5 right-lobe living donor liver transplants with two separated ducts. Before the anastomosis, the inside lumen of the cystic duct was straightened with a metal probe. Two external drainage tubes were placed in all recipients, and posttransplant cholangiography through the tubes approximately one month after transplantation showed no leakage or stricture at any of the anastomotic sites. The drainage tubes were removed between 17 and 37 weeks after transplantation. All of the patients except one who died of chronic rejection have been doing well without any late biliary complications during follow-up periods ranging from 10 to 28 months after transplantation. In conclusion, our results indicate that biliary reconstruction using the cystic duct is feasible and safe for living donor liver transplantation and that external drainage tubes may be effective for prevention of complications.

Biliary complications after a right-lobe living donor liver transplantation

Right-lobe living donor liver transplantation (RL-LDLT) has become an acceptable procedure for adult patients with end-stage liver disease in this decade. However, biliary complications in RL-LDLT remain a serious problem: the incidence of anastomotic biliary leakage and stricture after RL-LDLT is reported to be 4.7%-18.2% and 8.3%-31.7%, respectively. The incidence varies according to the type of biliary reconstructions between Roux-en-Y hepaticojejunostomy and duct-to-duct biliary reconstruction. The anatomical biliary diversity of a right-lobe graft makes it difficult to reconstruct the biliary system. Indeed, most biliary strictures in patients with duct-to-duct reconstruction develop in multibranched fashion. In this regard, endoscopic biliary stenting appears to be efficacious for treating multibranched biliary strictures because multiple stenting permits the drainage of each segmental branch of the stricture. In this review, we describe various aspects of biliary complications occurring in RL-LDLT and their treatment.

Complicações biliares pós-transplante hepático intervivos

OBJETIVO: A reconstituição biliar no transplante hepático intervivos é associada à elevada taxa de complicações. O objetivo do presente estudo é apresentar a nossa experiência com as complicações biliares pós-transplante hepático intervivos e o seu tratamento. MÉTODO: De um total de 300 transplantes hepáticos, 51 (17%) foram com doadores vivos. Todos receptores tinham o grupo sangüíneo ABO idêntico aos dos doadores. Os prontuários eletrônicos dos receptores foram avaliados para determinar a presença e o tipo de anomalia da via biliar, o tipo de reconstituição da via biliar, presença de complicações vasculares e biliares e o método e o resultado do tratamento das complicações. RESULTADOS: A via biliar era dupla em sete enxertos (16,7%) e tripla em dois (4,8%) enxertos do lobo hepático direito. Nos demais, ela era única. O tipo de reconstituição mais comum foi a hepaticohepaticostomia única ou dupla (38 transplantes; 75%). Complicações biliares ocorreram em 21 pacientes (41,2%) e incluíram fístula biliar em 11 (21,6%), estenose biliar em seis (11,8%) e fístula com estenose em quatro (7,8%). O local da fístula foi na anastomose biliar em 11 pacientes (21,6%) e na superfície cruenta do fígado em quatro (7,8%). O tratamento consistiu de inserção de prótese biliar em oito, papilotomia em um, retransplante em dois que tinham trombose da artéria hepática e sutura do ducto em um. A fístula fechou com o tratamento conservador em três pacientes. A maioria dos pacientes com estenose biliar foi tratada com dilatação seguida da colocação de prótese biliar. CONCLUSÕES: As complicações biliares são freqüentes após o transplante hepático intervivos e são associadas à elevada taxa de morbidade e mortalidade.

Update on biliary endoscopy

PURPOSE OF REVIEW

Since the introduction of endoscopic retrograde cholangiopancreatography, there have been great improvements in the technique, equipment, and clinical utility of biliary endoscopy. In many cases, therapeutic endoscopic retrograde cholangiopancreatography can take the place of invasive surgery, including common bile duct exploration, thereby decreasing the patient's morbidity and recuperation time. Even with advances, such as stent placement for biliary strictures in a patient after liver transplantation, there is still room for improvement.

RECENT FINDINGS

Research over the past year has been focused on areas including improved imaging and tissue sampling of the biliary tree through endoscopic ultrasound techniques, better identification of patients at risk for pancreatitis after endoscopic retrograde cholangiopancreatography, and refinements in photodynamic therapy for the treatment of cholangiocarcinoma. International research has continued to emphasize biliary sphincterotomy compared with balloon dilation for the management of choledocholithiasis. Further developments in other fields, such as living related liver transplantation, provide challenges for the biliary endoscopist.

SUMMARY

This review focuses on some of the work being performed in the field of biliary endoscopy. The key studies were chosen to highlight some of the areas currently being investigated as well as to indicate certain fields that need further development.

Duct-to-duct biliary reconstruction in adult living-donor liver transplantation

BACKGROUND

Bile duct-to-duct reconstruction is now used in living-donor liver transplantation (LDLT) for adult patients.

METHODS

The results of duct-to-duct reconstruction were retrospectively analyzed. The subjects were 81 adult patients who underwent LDLT at the University of Tokyo Hospital with a follow-up period of at least 1 year. The hilar plate of the recipient was dissected to at least the second-order branch of the bile ducts. Duct-to-duct anastomosis was performed with interrupted sutures, and an external stent tube was inserted from the orifice opposite the hilar plate.

RESULTS

During the observation period (median, 664 days), biliary complications were observed in 26 cases (32%). The complications included bile juice leakage at the anastomosis or dissection plane of the graft in 12 patients, anastomotic stenosis in 10 patients, and tube trouble in 6 patients. Two patients had bile juice leakage followed by stenosis. Of the 26 patients, 21 required surgical revision.

CONCLUSIONS

The current technique did not reduce morbidity as expected. Further technical advancement and refinement are needed for better results.

Biliary complications in 96 consecutive right lobe living donor transplant recipients

BACKGROUND

Biliary reconstruction represents one of the most challenging parts of right lobe (RL) living donor liver transplantations (LDLTs). Different causes, surgical techniques, and treatments have been suggested but are incompletely defined.

METHODS

Between June 1999 and January 2002, 96 RL LDLTs were performed in our center. We reviewed the incidence of biliary complications in all the recipients.

RESULTS

Roux-en-Y reconstruction was performed in 53 cases (55.2%) and duct-to-duct was performed in 39 cases (40.6%). Both procedures were performed in 4 cases (4.2%). Multiple ducts (> or =2) were found in 58 grafts (60.4%). Thirty-nine recipients (40.6%) had 43 biliary complications: 21 had bile leaks, 22 had biliary strictures, and 4 had both complications. Patients with multiple ducts had a higher incidence of bile leaks than those patients with a single duct (P=0.049). No significant differences in complications were found between Roux-en-Y or duct-to-duct reconstructions. Freedom from biliary complications was 59% at 1 year and 55% at 2 years. The overall 1-year and 2-year survival rates for patients were 86% and 81%, respectively. The overall 1-year and 2-year survival rates for grafts were 80% and 77%, respectively. Occurrence of bile leaks affected patient and graft survival (76% and 65% 2-year patient and graft survival, respectively, vs. 89% and 85% for those without biliary leaks, P=0.07).

CONCLUSIONS

Despite technical modifications and application of various surgical techniques, biliary complications remain frequent after RL LDLT. Patients with multiple biliary reconstructions had a higher incidence of bile leaks. Patients who developed leaks had lower patient and graft survival rates.

Lessons learned from one hundred right lobe living donor liver transplants

OBJECTIVE

To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience.

SUMMARY BACKGROUND DATA

Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity.

METHODS

One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2.

RESULTS

The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014).

CONCLUSIONS

There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.

Lessons learned from one hundred right lobe living donor liver transplants

OBJECTIVE

To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience.

SUMMARY BACKGROUND DATA

Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity.

METHODS

One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2.

RESULTS

The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014).

CONCLUSIONS

There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.

Remaining caudate lobe in the right lobe graft in living donor liver transplantation: a blind spot?

The right margin of the caudate lobe is obscure. Therefore, a part of the caudate lobe (a part of the right side of the paracaval portion) seems almost always to remain with the right lobe graft during the standard harvesting procedure. We reviewed the intraoperative findings and the postoperative courses of donors and recipients of 11 consecutive living donor liver transplantations using right lobe grafts. Further, we used computed tomography during the postoperative course to investigate whether the remaining caudate lobe was present in the right lobe graft and whether it produced serious complications. Four recipients displayed an intraoperative bile leak from a remaining part of the caudate lobe after the completion of biliary reconstruction. With the exception of one case who developed repeated bile leakage from the same origin which eventually healed during a long-term postoperative course, Most recipients showed no postoperative biliary complications. Although a remaining caudate lobe was detected on postoperative computed tomography in all recipients, it produced no serious complications. In conclusion, a part of the right side of the paracaval portion of the caudate lobe almost always remains with a right lobe graft during the standard harvesting procedure. However, the implications of this phenomenon seem to be benign.

Endoscopic management of biliary complications after adult living donor liver transplantation

OBJECTIVES

Biliary complications and their treatment in adult cadaveric liver transplantation (CLT) are well described. However, biliary complications and their management in living donor liver transplantation (LDLT) are not well characterized. We assessed the role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of biliary complications following LDLT.

METHODS

We performed a retrospective cohort analysis of all LDLT recipients with duct-to-duct anastomoses (n = 15). Specific data included referral for ERCP, diagnosis, and therapy. Comparisons were made to a 260 CLT recipient cohort.

RESULTS

Greater percentage of LDLT recipients underwent ERCP (73%) compared to CLT recipients (25%; p= 0.001). Biliary complications diagnosed by ERCP in LDLT recipients consisted of bile leaks and strictures, and were more frequent than in CLT recipients (leaks: 53%vs 12%; p= 0.001; strictures: 27%vs 5%; p= 0.01). Most leaks occurred at T-tube sites (LDLT: 87%; CLT: 65%). Diagnosis and therapy of leaks required a median of 2 ERCP procedures in both groups. Bile leaks were successfully treated endoscopically in 100% and 84% of LDLT and CLT recipients, respectively (p= 0.56). Most biliary strictures were anastomotic (LDLT: 100%; CLT: 64%). Strictures were diagnosed and treated with a median of 1.5 and 2 ERCP procedures in the LDLT and CLT groups, respectively. The duration of endoscopic therapy was a median of 10 and 14 wk, and success rates were 75% and 62% (p= 1.0) in LDLT and CLT groups, respectively.

CONCLUSIONS

LDLT is associated with increased biliary complications as compared to CLT. ERCP is useful for diagnosis, can successfully treat most LDLT-related biliary complications, and should be attempted prior to more invasive interventions.

Advances in adult living donor liver transplantation: a review based on reports from the 10th anniversary of the adult-to-adult living donor liver transplantation meeting in Tokyo

In 1993, the Shinshu Group performed the first successful adult-to-adult living donor liver transplantation (LDLT). During the first 10 years of LDLT, many technical innovations have been reported. The major limitation of LDLT for adult recipients is the size of the graft. To overcome the problem, several graft types were designed, including left liver graft with caudate lobe, right liver, modified right liver, and right lateral sector and dual grafts. The necessity and criteria of reconstruction of middle hepatic vein is still on debate in right liver graft without trunk of middle hepatic vein. Biliary reconstruction remains a significant source of morbidity in LDLT. Donor safety must always be the primary consideration in LDLT and the selection criteria and management of the living donor must continue to be refined. On February 21, 2004, the 10(th) anniversary of the adult-to-adult LDLT meeting was held in Tokyo to review the accumulated experience and the presented information is summarized.

Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage

BACKGROUND

Duct-to-duct biliary reconstruction is frequently used in right-lobe live-donor liver transplantation (RLDLT), and routine biliary drainage has been recommended. The aim of the present study was to evaluate the safety and operative outcomes of duct-to-duct biliary reconstruction after RLDLT without biliary drainage.

METHODS

The study comprised 41 RLDLT recipients who had duct-to-duct biliary reconstruction. During donor and recipient operations, precautions were taken to preserve blood supply to the bile duct. Biliary anastomosis was performed with fine Prolene sutures without stents or drainage tubes. The operative outcomes were prospectively evaluated.

RESULTS

The median postoperative intensive care unit and hospital stay were 3 days (range, 1-47 days) and 19 days (range, 8-114 days), respectively. There was no hospital mortality. At a median follow-up of 13.3 months (range, 4.0-26.8 months), the graft and patient survival rates were 95% and 98%, respectively. Three (7%) patients had biliary leakage. These three patients and the other seven patients developed late biliary stricture. The overall biliary complication rate was 24%. On multivariate analysis, preoperative Model for End-Stage Liver Disease (MELD) score of greater than or equal to 35 was the risk factor associated with biliary complication (P =0.032; risk ratio, 4.58).

CONCLUSIONS

Duct-to-duct anastomosis without biliary drainage is safe in RLDLT. Patients with a high preoperative MELD score were associated with an increased incidence of biliary complications. Further studies are required to investigate the hemodynamic changes and modulation of blood flow of liver grafts in patients with chronic liver disease, which may significantly affect the incidence of biliary complications.

Living related liver donor transplantation: techniques and caution

LDLT is often performed under less than ideal circumstances, such as limited graft mass, aberrant vascular and biliary anatomy, limited sources of venous grafts, and a recipient in a state of deterioration. The margin for error is small in both recipients and donors. Every step of the surgery needs to be planned and performed in a meticulous and synchronized manner. Small errors or absences of coordination can lead to unexpected complications. In addition, use of a segmental graft requires the knowledge of the safety margin of hepatic adaptation to nonphysiologic situations for the safety of both recipient and donor. Scientific and clinical evidences for precise individualization of the tactics are still not sufficient. Further accumulation of knowledge and experience is awaited for the safest performance of this evolving surgery.

Internal hernia of the small bowel after right-lobe live donor liver transplantation

Internal hernia of small bowel is an uncommon but potentially fatal complication of liver transplantation. We report on four patients in whom internal hernia of small bowel occurred after right-lobe live donor liver transplantation (LDLT). Three patients had small bowel herniation with volvulus around the Roux-en-Y loop whereas the other patient had herniation through the mesenteric window of transverse mesocolon after hepaticojejunostomy for biliary reconstruction. Based on clinical and radiologic findings, early diagnosis was made in all cases. All patients survived following surgical reduction of the hernia and closure of the mesenteric defect without bowel resection. Transplant surgeons should be aware of this serious complication so that early diagnosis and appropriate operative intervention can be made. The complication can be avoided with duct-to-duct biliary reconstruction or meticulous closure of all mesenteric defects with non-absorbable suture materials after hepaticojejunostomy in patients undergoing right-lobe LDLT.

Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation

BACKGROUND

The aims of this study were to characterize the features of the biliary strictures that occur after duct-to-duct biliary reconstruction during right-lobe living-donor liver transplantation (LDLT) and to evaluate the feasibility of correcting such stricture endoscopically by inserting an "inside stent," that is, a short internal stent, above the sphincter of Oddi.

METHODS

Biliary stricture occurred in 26 (35.6%) of 73 consecutive patients who underwent right-lobe LDLT with duct-to-duct biliary reconstruction from July 1999 through October 2001 and survived for more than 3 months. Of the 26 patients who had biliary stricture, 22 were referred for endoscopic retrograde cholangiography (ERC) and 4 for percutaneous cholangiography.

RESULTS

ERC disclosed biliary stricture in 19 (86.4%) of the 22 patients who underwent the procedure. One patient had an unbranched stricture, 16 had a fork-shaped stricture, 1 had a trident-shaped stricture, and 1 had a stricture with more than three branches. Fourteen (73.7%) of the patients with strictures were treated endoscopically by inserting inside stents ranging from 7 F to 12 F in size, three underwent a Roux-en-Y hepaticojejunostomy to repair their stricture, and two were closely observed as outpatients. Of the 14 patients who were treated with the inside-stent, only 1 had acute cholangitis immediately after the procedure and underwent a Roux-en-Y hepaticojejunostomy. The other 13 patients who were treated with the inside stent have not required surgical repair for as long as an average of 586 days.

CONCLUSION

Endoscopic placement of an inside stent is useful for treating biliary strictures in patients who have undergone right-lobe LDLT with duct-to-duct reconstruction.

Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations

Biliary complications appear to be the leading cause of postoperative complications after living donor liver transplantation (LDLT). The aim of this study is to analyze the complications, treatment modalities, and outcomes of biliary anastomoses in a series of 50 consecutive right-lobe LDLTs. Median patient age was 45 years, and median right-lobe graft volume was 740 g. Graft-recipient weight ratio was 0.69 to 1.80. Median follow-up time was 15 months (range, 2 to 38 months). Eleven of 50 patients died, resulting in an overall allograft and patient survival rate of 78%. In biliary reconstruction, a duct-to-duct (D-D) anastomosis or a standard Roux-en-Y (R-Y) anastomosis was performed. Twenty-nine grafts (58%) had a single duct for anastomosis. Seventeen grafts (34%) had two bile duct orifices, and four grafts (8%) had three bile duct orifices. A D-D anastomosis was performed in 36 cases (72%), whereas R-Y reconstruction was preferred in 14 cases (28%). The overall incidence of biliary anastomotic complications was 30% in this series. Five patients developed biliary leaks, presumably from the cut surface, and all of them healed spontaneously. Two bilomas were drained percutaneously. Anastomotic strictures occurred in 8 patients (16%) and were significantly greater than in the R-Y group (P =.03). Although strictures seemed to develop more frequently in allografts with multiple bile ducts, this did not reach statistical significance (P =.05). All strictures were managed by nonsurgical measures initially. Restenosis occurred in 2 patients, both of whom had an R-Y anastomotic stricture. These anastomoses were revised surgically, giving a reoperation rate of 4% for biliary problems. No graft or patient was lost because of biliary problems. Our data suggest that D-D anastomosis is a safe and feasible method of biliary reconstruction in LDLT by preserving physiological bilioenteric continuity and allowing easy access through endoscopic techniques.

An endoscopic approach to biliary complications following orthotopic liver transplantation

Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12-year period.

METHODS

OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications.

RESULTS

Seventy-nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty-four (15.1%) patients had at least one or more biliary complications. The mean follow-up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T-tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty-five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re-transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage.

CONCLUSIONS

ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.

Long-term results of percutaneous management for anastomotic biliary stricture after orthotopic liver transplantation

The purpose of this study was to evaluate the results of percutaneous transhepatic management (PTM) of anastomotic biliary strictures (BS). Among 168 liver transplant adult recipients, BS was identified in 30 patients. In 6 patients, narrowing of the anastomosis was found early, and in all cases disappeared spontaneously with prolonged draining of the bile tube. Within a mean time of 14 months after transplantation, 24 patients had symptomatic BSs, revealed by cholestasis (n = 17) or cholangitis (n = 7). Twenty-two patients underwent PTM as first treatment of BS (balloon dilatation or stent placement). We evaluated the primary and secondary patency rate of PTM. In 1 patient, PTM failed because the stricture could not be passed with the guide wire, necessitating conversion to a Roux-en-Y choledochojejunostomy (CDJ). Fourteen patients were treated by percutaneous balloon dilatation from which 8 patients (57.2%) were recurrence-free with a mean follow-up of 61 months. One patient with a patent biliary anastomosis underwent retransplantation for acute rejection. Twelve patients received metallic expandable stent placement as their primary treatment (n = 7) or after failure of balloon dilatation (n = 5). Recurrent stricture was found in 7 cases (58%) and was treated by PTM (n = 6) or surgery (n = 1). The primary patency rate for PTM was 58.8% at 12 months and the secondary patency rate 88.4%, with a mean follow-up of 47 months (median: 44 months). The mortality rate was 3.5% (one death). PTM with balloon dilatation, stent placement, or both, represent a safe method to treat anastomotic BSs after orthotopic liver transplantation (OLT) resulting in a secondary patency rate of 88% at 5 years.