Biliary reconstruction using the cystic duct in right lobe living donor liver transplantation

Long-Term Feasibility of Rescue Reconstruction for Isolated Bile Ducts With Using Cystic Duct in Living Donor Liver Transplantation

BACKGROUND

The isolated bile duct is sometimes observed in the right liver graft of living donor liver transplantation (LDLT). Even though, as a rescue option, it is known to use the recipient's cystic duct (CyD) for duct-to-duct anastomosis, the long-term feasibility of rescue duct-to-CyD (D-CyD) anastomosis remains unclear.

METHODS

We prospectively collected data in the right liver-LDLT cohort and compared rescue D-CyD anastomosis (n = 4) with standard duct-to-hepatic duct (D-HD, n = 45) anastomosis (D-CyD group, n = 4).

RESULTS

The observation period was over 5 years (range, 68-171 mo) after LDLT. The D-CyD group included the following anastomosis procedures: anastomosis between the intrahepatic bile duct of the graft and the CyD of the recipient and anastomosis between the posterior HD and the CyD. Surgical outcomes between the 2 groups are similar, excluding the time for the biliary reconstruction (D-CyD, 116 ± 13 min vs D-HD, 57 ± 3 min). During the period, one recipient in the D-CyD group exhibited postoperative biliary stricture and biliary stone, and 6 recipients underwent those complications in the D-HD group (D-CyD, 25.0% vs D-HD, 13.3%) All recipients in the D-CyD group are presently alive and have not experienced liver dysfunction.

CONCLUSIONS

Our findings suggest that rescue D-CyD anastomosis for an isolated bile duct in a right liver LDLT is acceptable as a life-saving option in terms of long-term feasibility.

Using the Cystic Duct for Biliary Reconstruction in Dual-Graft Living Donor Liver Transplantation: A Case Report

In Taiwan, living donor liver transplant (LDLT) has accounted for the majority of liver transplantation due to organ shortage. Dual-graft LDLT is a feasible way to resolve the insufficient graft size and remnant liver in donors. We presented a heavy-weight patient underwent dual-graft LDLT, and cystic duct was used to resolve the inadequate bile duct length and limited appropriate position in dual-graft LDLT. We harvested a right lobe graft (segment 5, 6, 7, and 8 without middle hepatic vein) and a left lobe graft (segment 1, 2, 3, and 4 without middle hepatic vein) stepwise, and placed the grafts orthotopically. For proper tension and length of biliary reconstruction, we anastomosed the right intrahepatic duct of the right lobe graft to cystic duct of the recipient. Before the biliary reconstruction, the metal probe was inserted in the lumen of cystic duct in recipient to ensure the patency and destroy the Heister valve of cystic duct, then the internal biliary stent (5 Fr pediatric feeding tube) was placed in the donor's right intrahepatic duct to recipient's cystic duct and common bile duct, which allows the endoscopic removal of the internal stent. The patient has survived more than 16 months with normal liver function.

Cystic duct anastomosis can be a viable option for biliary reconstruction in case of multiple ducts in right lobe living-donor liver transplantation

Backgrounds/Aims

Multiple ducts in right lobe living-donor liver transplant (LDLT) pose a technical challenge in biliary reconstruction. In the absence of separate recipient hepatic ducts for duct-to-duct anastomoses and certain demerits of hepaticojejunostomy, duct to duct anastomoses with the recipient cystic duct might be a possible solution.

Methods

A total of 329 recipients of LDLT who underwent two or more separate biliary anastomoses at our centre between January 2014 and November 2019 were studied retrospectively. Records of demographic data, donor and graft characteristics, operative details, postoperative biochemical parameters, and biliary complications were analysed.

Results

Of 329 recipients, 236 patients (71.7%) underwent purely duct-to-duct (DD group) anastomoses, 38 patients (11.5%) underwent at least one anastomosis with the cystic duct (CD group), and 55 patients (16.7%) underwent at least one hepaticojejunostomy (HJ group). At one year, biliary complication rates of these three groups were 20.3%, 26.3%, and 20.0%, respectively (p = 0.68). Postoperative intensive care unit and overall hospital stay were similar among the three groups. Grades IIIa, IIIb, IV, and V Clavien-Dindo complications were identical. One-year patient survival and graft survival were also similar among the three groups.

Conclusions

Biliary outcomes using the cystic duct may have acceptable outcomes. Similar postoperative results as other means of biliary reconstruction could be anticipated with the cystic duct anastomoses in case of multiple ducts in the graft.

Results of Using the Cystic Duct for Reconstruction of One of the Multiple Bile Ducts in Right Lobe Living Donor Liver Transplantation

BACKGROUND

In right-lobe liver grafts, variations in the biliary tree anatomy can result in multiple bile duct orifices. We present our experience of 10 patients in which biliary reconstruction was performed with the cystic duct for 1 of the anastomoses with 2 separated ducts. Also, we investigated whether the bile duct anastomosis technique, number of bile duct anastomoses, and use of biliary stents affect the rate of biliary complications.

METHODS

We evaluated patients who underwent right-lobe living donor liver transplantation (LDLT) at İstinye University Hospital and İstanbul Aydın University Hospital between December 2017 and June 2020. The patients were divided into 4 groups: duct-to-duct (D-D), duct-to-sheath, double duct-to-duct, and duct-to-duct plus cystic duct-to-duct. Biliary complication rates were compared among these 4 groups, between single- and double-duct groups, and between stent (+) and stent (-) groups.

RESULTS

Ninety-three patients who underwent right-lobe LDLT (60 men, 33 women) with a mean age of 51 ± 13 years were included. Mean follow-up time was 18.5 ± 8.3 months. The overall biliary complication rate was 17.2% for all patients, 12.1% for the D-D (single-duct) group (33 patients), 16.1% for the duct-to-sheath group (31 patients), 26.3% for the double duct-to-duct group (19 patients), 20% for the duct-to-duct plus cystic duct-to-duct group (10 patients), 20% for the double-duct group (60 patients), 14.5% for the stent (+) group (69 patients), and 25% for the stent (-) group (24 patients). There were no significant differences among these groups in terms of biliary complication rates. Bile stricture occurred in only 1 cystic duct anastomosis (10%), and no bile leakage was observed.

CONCLUSIONS

Multiple D-D biliary reconstruction using the cystic duct with external drainage tubes is feasible and safe for LDLT.

Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation

Background

One of the major issues related to the living donor liver transplantation recipient outcome is still the high rate of biliary complication, especially when multiple biliary ducts are present and multiple anastomoses have to be performed.

Case presentation and conclusion

We report a case of adult-to-adult right lobe living donor liver transplantation performed for a recipient affected by alcohol-related cirrhosis with MELD score of 17. End-stage liver disease was complicated by refractory ascites, portal hypertension, small esophageal varices and portal gastropathy, hypersplenism, and abundant right pleural effusion. Here in the attached video we described the adult-to-adult LDLT procedures, where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. LDLT required a biliary reconstruction using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic catheter. None major complications were detected during post-operative clinical courses. Actually, the donor and the recipient are alive and well. The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure. No living donor right lobe transplantation should be refused because of the presence of multiple biliary ducts.

The Preliminary Study on Procurement Biliary Convergence from Donors with Complicated Bile Duct Variant in Emergency Right Lobe Living Donor Liver Transplantation

BACKGROUND

The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the bile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high model for end-stage liver disease score patients.

METHODS

The common hepatic duct (CHD) and the left hepatic duct (LHD) of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed.

RESULTS

Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up; significant differences (P < 0.05) were found when two stages were compared.

CONCLUSION

Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant right hepatic ducts in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.

En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation

OBJECTIVE

Techniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants.

METHODS

This was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection.

RESULTS

A total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3%, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs. 23.5%., respectively, p = 0.049).

CONCLUSION

En bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.

A complete treatment of adult living donor liver transplantation: a review of surgical technique and current challenges to expand indication of patients

The growing disparity between the number of liver transplant candidates and the supply of deceased donor organs has motivated the development of living donor liver transplantation (LDLT). Over the last two decades, the operation has been markedly improved by innovations rendering modern results comparable with those of deceased donor liver transplantation (DDLT). However, there remains room for further innovation, particularly in adult living donor liver transplantation (ALDLT). Unlike whole-size DDLT and pediatric LDLT, size-mismatching between ALDLT graft and recipient body weight and changing dynamics of posttransplant allograft regeneration have remained major challenges. A better understanding of the complex surgical anatomy and physiologic differences of ALDLT helps avoid small-for-size graft syndrome, graft congestion from outflow obstruction and graft hypoperfusion from portal flow steal. ALDLT for high-urgency patients (Model for End-Stage Liver Disease score >30) can achieve results comparable to DDLT in high volume centers. Size limitations of partial grafts and donor safety issues can be overcome with dual grafts and modified right-lobe grafts that preserve the donor's middle hepatic vein trunk. Extended application of LDLT for unresectable hepatocellular carcinoma above Milan criteria is an optional strategy at the cost of slightly compromised survival. ABO-blood group incompatibility obstacles have been broken down by introducing a paired donor exchange program and refined peri-operative management of ABO-incompatible ALDLT. This review focuses on recent innovations of surgical techniques, safe donor selection, current strategies to expand ALDLT with broadened patient selection criteria and important aspects of teamwork required for success.

Technical aspects of biliary reconstruction in adult living donor liver transplantation

BACKGROUND

The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction.

DATA SOURCES

MEDLINE and PubMed were searched for articles on "living donor liver transplantation", "biliary complication", "anatomical variation", "biliary reconstruction", "stenting" and related topics.

RESULT

In this review, biliary complications were analyzed with respect to anatomical variation, surgical techniques in biliary reconstruction, and protection of the arterial plexus of the hilar bile duct.

CONCLUSION

Transecting the donor bile duct at the right place to secure a larger bile duct stump, anastomosing techniques, and stenting methods as well as preserving the blood supply to the bile duct are all important in reducing biliary complications.

Salvage cystic duct anastomosis using a magnetic compression technique for incomplete bile duct reconstruction in living donor liver transplantation

In living donor liver transplantation (LDLT), bile duct reconstruction is often technically demanding due to the frequently anomalous anatomy of the bile duct, as well as the high incidence of biliary complications. A bile duct branch may also be accidentally left without anastomosis at the time of LDLT and found to be obstructed after surgery. Surgical revision for such cases is sometimes not feasible because of the invasiveness of the procedure. We report a case in which a bile duct branch was intentionally left without anastomosis and was later successfully anastomosed to the cystic duct stump using a magnetic compression anastomosis (MCA) technique. A combination of the MCA technique and cystic duct anastomosis is life-saving in certain situations and should be considered as the treatment of choice.

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.

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.