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Sánchez-Cabús S, Calatayud D, Ferrer J, Molina V, Pavel MC, Sampson J, Saavedra D, Fondevila C, Fuster J, García-Valdecasas JC. Beneficial Effect of a Resorbable Biliary Stent in Living Donor Liver Transplantation. Eur Surg Res 2016; 56:123-31. [PMID: 26840276 DOI: 10.1159/000443271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) entails a significant number of bile duct complications. We aimed to diminish the biliary complication rate with the use of a resorbable biliary stent (RBS) during LDLT. The objective of this study is to describe the surgical techniques and the associated outcomes, especially in terms of safety, of RBS use in LDLT. METHODS From 2011 to 2014, 12 LDLT recipients were enrolled in a clinical trial with the use of a specifically designed RBS. These patients were followed according to the clinical protocol. Specific complications derived from RBS as well as biliary complications were recorded. RESULTS One patient underwent early retransplantation due to a small-for-size syndrome. None of the patients had a complication attributable to the placement, remaining in place, or degradation of the stent. Four of the remaining patients presented with a biliary complication: 1 (9.1%) with a biliary leak alone, 1 (9.1%) with a biliary stenosis alone, and 2 (18.2%) with both. However, none of the leaks could be directly attributed to the RBS. Patient and graft 1-year survival was 100 and 91.7%, respectively. CONCLUSION The use of an RBS in LDLT is not associated with complications, and initial results regarding efficacy and safety are encouraging. The need for a larger and prospective study is warranted.
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Affiliation(s)
- Santiago Sánchez-Cabús
- HPB Surgery and Transplantation Department, Clinic Institute of Digestive and Metabolic Diseases (ICMDiM), Hospital Clx00ED;nic de Barcelona, Barcelona, Spain
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2
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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3
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Sánchez Cabús S, Calatayud D, García-Roca R, Ferrer J, Martí J, Navasa M, Rimola A, Fondevila C, Fuster J, García-Valdecasas JC. [The biliary complications in live donor liver transplant do not affect the long-term results]. Cir Esp 2012; 91:17-24. [PMID: 23044253 DOI: 10.1016/j.ciresp.2012.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 07/12/2012] [Accepted: 07/14/2012] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Living donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. PATIENTS AND METHODS From 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analyzed retrospectively. RESULTS A total of 39 patients (55.7%) had some type of biliary complication. Twenty nine presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs. 29.5% at 5 years, P=.05). With a median follow up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35. CONCLUSIONS LDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications.
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Affiliation(s)
- Santiago Sánchez Cabús
- Unidad de Cirugía Hepatobiliopancreática y Trasplante, Hospital Clínic de Barcelona, Barcelona, España
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4
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Woo SM, Kim HB, Lee KW, Lee WJ, Kim YK, Han SS, Park SJ. New Strategy in Cases of Failed Endoscopic Intervention of Biliary Strictures after Living Donor Liver Transplantation: Percutaneous Transhepatic Biliary Stent Insertion and Subsequent Endoscopic Treatment. KOREAN JOURNAL OF TRANSPLANTATION 2012. [DOI: 10.4285/jkstn.2012.26.3.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sang Myung Woo
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Hyun Beom Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Kwang-Woong Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Jin Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Young-Kyu Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
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5
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Lee YY, Gwak GY, Lee KH, Lee JK, Lee KT, Kwon CHD, Joh JW, Lee SK. Predictors of the feasibility of primary endoscopic management of biliary strictures after adult living donor liver transplantation. Liver Transpl 2011; 17:1467-73. [PMID: 21898773 DOI: 10.1002/lt.22432] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary strictures are a major cause of morbidity and mortality for liver transplant recipients. The endoscopic management of biliary strictures is not well established after living donor liver transplantation (LDLT) in comparison with deceased donor liver transplantation. The aims of this study were to assess the initial success rate of primary endoscopic treatment of biliary strictures after LDLT and to identify predictors of the feasibility of endoscopic management. One hundred thirty-seven adult patients who underwent LDLT and were confirmed to have biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. The biliary strictures were primarily managed endoscopically with internal drainage or nasobiliary catheterization. The initial success rate for the primary endoscopic management of biliary strictures after LDLT was 46.7% (64 of 137 patients), and the feasibility of endoscopic management was associated with the stricture-to-ERCP interval (the interval between the development of the total bilirubin, aspartate aminotransferase, or alanine aminotransferase level to >2 times the upper limit of normal and the performance of ERCP) as well as cholangiographic findings (eg, the stricture morphology and the tip shape of the distal duct). In conclusion, when biliary strictures are noticed after LDLT, prompt endoscopic interventions may improve the initial success rate of primary endoscopic management. In addition, the feasibility of primary endoscopic management can be predicted by the cholangiographic findings, which may help with the choice of the therapeutic modality.
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Affiliation(s)
- Yun Young Lee
- Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
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6
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Kothary N, Patel AA, Shlansky-Goldberg RD. Interventional radiology: management of biliary complications of liver transplantation. Semin Intervent Radiol 2011; 21:297-308. [PMID: 21331141 DOI: 10.1055/s-2004-861564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Major advances in the field of liver transplantation have led to an increase in both graft and patient survival rates. Despite increased graft survival rate, biliary complications lead to significant postoperative morbidity and even mortality. A multidisciplinary approach to these complications is critical. As part of the team approach, less invasive techniques used by the interventional radiologist have an increasing role in the management of complications after liver transplantation. This paper will review the current role of the interventionalist in management of biliary complications.
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Affiliation(s)
- Nishita Kothary
- Division of Vascular and Interventional Radiology, Columbia University Medical Center, New York, New York
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7
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Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2010; 24:379-92. [PMID: 21143651 DOI: 10.1111/j.1432-2277.2010.01202.x] [Citation(s) in RCA: 216] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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8
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Ju M, Choi G, Joo D, Hur K, Choi J, Kim M, Kim S, Kim Y. Use of the Hilar Plate Looping Technique for Bile Duct Dissection in Living Donor Liver Transplantation Significantly Reduces Recipient Biliary Complications. Transplant Proc 2010; 42:4161-3. [DOI: 10.1016/j.transproceed.2010.09.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 09/09/2010] [Indexed: 01/20/2023]
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9
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Ayoub WS, Esquivel CO, Martin P. Biliary complications following liver transplantation. Dig Dis Sci 2010; 55:1540-6. [PMID: 20411422 DOI: 10.1007/s10620-010-1217-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 03/22/2010] [Indexed: 02/08/2023]
Abstract
The aphorism that reconstruction of the biliary anastomosis is the "Achilles heel" of liver transplantation remains valid as biliary complications following liver transplantation remain a major source of morbidity with an incidence of 5-32%. Biliary complications include biliary strictures, biliary leaks, and stones. Biliary strictures can be divided into anastomotic and non-anastomotic. The management of biliary complications previously relied on surgical intervention. However, advances in endoscopic and radiological interventions have resulted in less-invasive options. The management of biliary complications post-liver transplantation requires a multidisciplinary approach and continues to evolve. Biliary complications also reflect the continued expansion of the donor pool with extended, live, and non-heart beating donors.
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Affiliation(s)
- Walid S Ayoub
- Department of Gastroenterology and Hepatology, Stanford University, Suite 210, Palo Alto, CA 94304, USA.
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10
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Abstract
Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.
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García-Valdecasas JC, Fuster J, Fondevila C, Calatayud D. [Adult living-donor liver transplantation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:577-83. [PMID: 19647346 DOI: 10.1016/j.gastrohep.2009.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 02/13/2009] [Indexed: 11/30/2022]
Abstract
Living donor liver transplantation in adults continues to be controversial. Viewed as an alternative to prevent deaths on the waiting list, this type of transplant is the only possibility in Asian countries (Japan, Korea, China, etc) but is not widely applied in the west. This intervention is associated with significant donor morbidity (depending on the scale of the intervention) and mortality which, although sporadic, reduces its acceptance, especially in a context with high cadaveric donation. Outcomes in recipients are similar to those in cadaveric transplant recipients, although the high incidence of biliary complications could compromise long-term results. We describe the experience of Hospital Clínic in a total of 67 transplant recipients. Graft and patient survival at 1 and 5 years was 90.7%, 70.3%, 90.7% and 77.6%, respectively. Although the frequency of biliary complications was high (37.3%), death from sepsis and retransplantation only occurred in two patients.
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Affiliation(s)
- Juan Carlos García-Valdecasas
- Departamento de Cirugía, Universidad de Barcelona, IDIBAPS, CIBEREHD, Unidad de Trasplante Hepático, Hospital Clínic i Provincial de Barcelona, Barcelona, España.
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12
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Haskal ZJ, Brown RS. Role of Biliary Stress Manometry after Biliary Stricture Dilation in Living Donor Liver Transplant Recipients. J Vasc Interv Radiol 2008; 19:216-9. [DOI: 10.1016/j.jvir.2007.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 09/16/2007] [Accepted: 09/17/2007] [Indexed: 11/26/2022] Open
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13
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Venu M, Brown RD, Lepe R, Berkes J, Cotler SJ, Benedetti E, Testa G, Venu RP. Laboratory diagnosis and nonoperative management of biliary complications in living donor liver transplant patients. J Clin Gastroenterol 2007; 41:501-6. [PMID: 17450034 DOI: 10.1097/01.mcg.0000247986.95053.2a] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biliary complications associated with living donor liver transplantation (LDLT) remain a major problem. Information regarding biochemical abnormalities helpful for the diagnosis and the nonoperative management of such complications are limited. METHODS Adult patients who underwent LDLT were retrospectively studied for biliary complications. Clinical findings and laboratory studies, that is, serum bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase were evaluated. Diagnostic percutaneous transhepatic cholangiogram or endoscopic retrograde cholangiogram followed by therapeutic interventions such as endoscopic sphincterotomy, stone extraction, balloon dilation, or stent placement were done as indicated. Follow-up data on clinical and biochemical outcomes were assessed. RESULTS Among the first 29 patients who underwent LDLT, 7 patients (24%) developed biliary complications. Nonoperative treatment was undertaken through endoscopic retrograde cholangiogram in 4 cases, percutaneous transhepatic cholangiogram in 3 cases with a successful clinical outcome in 6 cases (84%). All patients with biliary stricture had a bilirubin level >1.5 mg/dL with 100% sensitivity. CONCLUSIONS A number of patients developed biliary complications after LDLT. Nonoperative treatments were successful in most patients. Elevated serum bilirubin level may be helpful in the diagnosis of biliary stricture complicating LDLT.
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Affiliation(s)
- Mukund Venu
- Digestive Disease and Nutrition, Hepatology, and Transplantation, University of Illinois Medical Center at Chicago, Chicago, IL 60612, USA
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Hampe T, Dogan A, Encke J, Mehrabi A, Schemmer P, Schmidt J, Stiehl A, Sauer P. Biliary complications after liver transplantation. Clin Transplant 2006; 20 Suppl 17:93-6. [PMID: 17100708 DOI: 10.1111/j.1399-0012.2006.00607.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Biliary complications remain a substantial cause of morbidity following liver transplantation. They have been reported to occur in a rate of 10-15% of full-size transplantations and may be higher in living donor, split or reduced size liver transplantations. The most common biliary complications following liver transplantations are leaks and strictures. In both, the incidence varies with respect to type of graft and donor as well as the type of biliary anastomosis. The management of the biliary complications requires a multidisciplinary approach and has changed over the past decade, favoring endoscopic and radiological techniques. Surgical revision including retransplantation is reserved for patients in whom endoscopic and interventional modalities are unsuccessful.
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Affiliation(s)
- T Hampe
- Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany
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15
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Ghobrial RM, Busuttil RW. Challenges of adult living-donor liver transplantation. ACTA ACUST UNITED AC 2006; 13:139-45. [PMID: 16547675 DOI: 10.1007/s00534-005-1020-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Accepted: 05/30/2005] [Indexed: 01/25/2023]
Affiliation(s)
- Rafik Mark Ghobrial
- The Department of Surgery, The Dumont-UCLA Transplant Center, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, California 90095, USA
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16
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Abstract
The increasing awareness of liver diseases and their early detection have led to an increase in the number of transplant waiting list candidates over the past decade. This need has not been matched by the actual number of orthotopic liver transplantations performed. Live donor liver transplantation (LDLT) is an innovative surgical technique intended to expand the available organ donor pool. Although LDLT offers definite advantages to the recipient, it offers none to the donor except for the possibility of psychological well-being. Clinical research studies aimed at the prospective collection of data for donors and recipients need to be conducted.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10039, USA
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Lee KW, Joh JW, Kim SJ, Choi SH, Heo JS, Lee HH, Park JW, Lee SK. High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation. Liver Transpl 2004; 10:1158-62. [PMID: 15350008 DOI: 10.1002/lt.20230] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation.
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Affiliation(s)
- Kwang-Woong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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