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Naseer F, Lin CH, Lin TS, Kuo PJ, Chia-Shen Yang J, Chiang YC. Long-term Results in Comparative Analysis of Merits in Using Polypropylene and Polydioxanone for Microsurgical Biliary Reconstruction in Living Donor Liver Transplantation. Transplant Proc 2020; 52:233-238. [DOI: 10.1016/j.transproceed.2019.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/11/2019] [Accepted: 11/02/2019] [Indexed: 01/05/2023]
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Novel Application of Internal-External Drainage Catheter as Biliary Stent for Percutaneous Transhepatic Treatment of Biliary Strictures in Living Donor Liver Transplantation Recipient Patients. Transplant Proc 2019; 51:2469-2472. [PMID: 31405740 DOI: 10.1016/j.transproceed.2019.01.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/21/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Although endoscopic management is considered as the first-line treatment for biliary strictures, it may be challenging in living donor liver transplant recipients due to the complex nature of duct-to-duct reconstruction. In this study we present the use of a pigtail drainage catheter as a biliary stent to treat biliary strictures after a living donor liver transplant. METHODS Twenty-seven patients with biliary strictures were treated with our novel technique. In this technique, a pigtail catheter was trimmed into 3 parts (proximal, middle, and distal portions). A suture string was passed through the distal hole of the middle portion, which was then reversed and used as a stent while the proximal portion was used as a pusher. Following balloon dilation of the stenotic segment, the distal, reversed middle, and proximal portions were loaded over the guidewire. After proper placement of the stent, the retractor suture string, pusher, and guidewire were removed. The stent was removed during the third or fourth month of placement through endoscopic retrograde cholangiopancreatography (ERCP) in all patients. RESULTS No significant complications developed during the procedure or follow-up period. Ten patients required re-stenting by ERCP during the same session. The mean follow-up period was 2 years. Cholestase enzymes and bilirubin levels were within normal limits in all patients during follow-up. CONCLUSION Stents derived from drainage catheter facilitate treatment of biliary strictures in patients not eligible for the retrograde approach. This stent is cheap, easy to implement, can be easily removed by ERCP, and re-stenting can be applicable in retrograde if needed.
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Haberal M, Ayvazoglu Soy EH, Moray G, Caliskan K, Yildirim S, Torgay A. Results of Biliary Reconstruction Using a Polytetrafluoroethylene Graft in Liver Transplant Patients. EXP CLIN TRANSPLANT 2017; 15:71-75. [PMID: 28260438 DOI: 10.6002/ect.mesot2016.o57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Biliary complications after liver transplant are a major concern with their high incidence, the need for repeated and long-term treatment, and their potential effects on graft and patient survival. We report our experience with biliary anastomosis using a spiral polytetrafluoroethylene graft. MATERIALS AND METHODS Between December 8, 1988, and July 2016, we performed 538 liver transplant procedures. We used a spiral polytetrafluoroethylene graft for biliary anastomosis in 10 patients: for biliary stricture reconstruction after liver transplant in 4 patients and during the primary liver transplant in 6 patients. RESULTS Four patients who underwent biliary stricture reconstruction are doing well, with normal liver function. Of the 6 patients who received the graft during primary liver transplant, 2 died from sepsis, although they maintained normal liver function. Of the 4 living patients, 1 had a biliary complication that was reconstructed surgically. The 4 living patients are currently doing well, with normal liver function. CONCLUSIONS Our small series of patients shows that the use of a spiral polytetrafluoroethylene graft is effective at reducing biliary complications in transplant patients.
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Affiliation(s)
- Mehmet Haberal
- Department of Transplant Surgery, Baskent University, Ankara, Turkey
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Abu-Gazala S, Olthoff KM, Goldberg DS, Shaked A, Abt PL. 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. J Gastrointest Surg 2016; 20:765-71. [PMID: 26676929 DOI: 10.1007/s11605-015-3047-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/25/2015] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Samir Abu-Gazala
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA.
| | - Kim M Olthoff
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - David S Goldberg
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Abraham Shaked
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Peter L Abt
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
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Semenkov AV, Filin AV, Kim ÉF, Ushakova IA, Goncharova AV. [The results of biliary reconstructions after liver fragments transplantation]. Khirurgiia (Mosk) 2015:22-28. [PMID: 26356055 DOI: 10.17116/hirurgia2015822-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To analyze the results of repeated reconstructions of choleresis after living related liver fragments transplantation. MATERIAL AND METHODS The study included 268 recipients (145 women and 123 men) aged 5 months - 61 years (mean age 16,11 ± 14,62 years) who underwent liver fragments transplantation in the department of liver transplantation of cad. B.V. Petrovskiy Russian Research Surgery Center from 1997 to 2012. Biliary reconstructions were performed at different terms after transplantation in 37 patients (13.81%). Complications followed repeated reconstructions, the initial conditions for biliary anastomosis formation during transplantation, the results of biliary reconstructions after transplantation were analyzed. RESULTS In most cases despite the prevailing complications there is a combination of various biliary complications requiring biliary reconstruction. It was found that live rfragment used for transplantation, type of primary reconstruction of choler sis, number of bile ducts orifices of graft and biliary anastomoses do not demonstrate statistically significant effect on the incidence of post-transplant biliary reconstructions (p>0.05). Poor prognosis in patients with biliary complications required biliary reconstructionsis determined by the development of graft dysfunction. Early reconstruction before development of liver transplant dysfunction is necessary condition of successful treatment. In the case of graft dysfunction liver retransplantation is unique method of treatment.
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Affiliation(s)
- A V Semenkov
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Filin
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - É F Kim
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - I A Ushakova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Goncharova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
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Zhang S, Zhang M, Xia Q, Zhang JJ. Biliary reconstruction and complications in adult living donor liver transplantation: systematic review and meta-analysis. Transplant Proc 2015; 46:208-15. [PMID: 24507053 DOI: 10.1016/j.transproceed.2013.05.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/28/2013] [Accepted: 05/09/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The purpose of this meta-analysis was to compare outcomes of different techniques used for biliary reconstruction in adult donor liver transplantation. METHODS We searched the literature via Pubmed, Embase, Ovid, the Cochrane Hepato-Biliary Group Controlled Trials Regsistry, the Cochrane Central Registry of Controlled Trials, the Cochrane Library database, and Web of Science. Then with the data extracted from the literature, the effects that biliary reconstruction techniques in living-donor liver transplantation (LDLT) had on the occurrence of biliary complications were compared. With the use of random-effects and fixed-effect models, the results were obtained and expressed as odds ratio. RESULTS We found 16 eligible studies from various medical centers around the world. Duct-to-duct (DD) reconstruction was performed in the majority of patients (922/1,564). Multiple biliary ducts were encountered in 16.7%-60.4%, and ductoplasty was performed in 7.9%-74% of the patients. Both graft and posterior layer of bile duct anastomosis in DD reconstruction were studied, and no statistically differences in incidence of biliary complications were found between the Roux-en-Y hepaticojejunostomy (RYHJ) and DD groups. Nonsurgical management of biliary complications was the first choice of treatment. CONCLUSIONS Our study found that there is no clear evidence in favor of using DD or RYHJ during adult LDLT.
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Affiliation(s)
- S Zhang
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Transplantation Center, Shanghai, China
| | - M Zhang
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Transplantation Center, Shanghai, China
| | - Q Xia
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Transplantation Center, Shanghai, China
| | - J-J Zhang
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Transplantation Center, Shanghai, China.
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Section 9. Technical Details of Microsurgical Biliary Reconstruction in Living Donor Liver Transplantation. Transplantation 2014; 97 Suppl 8:S34-6. [DOI: 10.1097/01.tp.0000446273.13310.77] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Lin TS, Chen CL, Concejero AM, Yap AQ, Lin YH, Liu CY, Chiang YC, Wang CC, Wang SH, Lin CC, Yong CC, Cheng YF. Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation. Liver Transpl 2013. [PMID: 23197399 DOI: 10.1002/lt.23582] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT.
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Affiliation(s)
- Tsan-Shiun Lin
- Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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9
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Is Microsurgical Technique Useful in Biliary Reconstruction of Living Donor Liver Transplantation? Transplant Proc 2012; 44:466-8. [DOI: 10.1016/j.transproceed.2012.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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Abstract
Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.
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Affiliation(s)
- Choong Heon Ryu
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Feng XN, Ding CF, Xing MY, Cai MX, Zheng SS. Technical aspects of biliary reconstruction in adult living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10:136-42. [PMID: 21459719 DOI: 10.1016/s1499-3872(11)60022-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Xiao-Ning Feng
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Kim SH, Lee KW, Kim YK, Cho SY, Han SS, Park SJ. Tailored telescopic reconstruction of the bile duct in living donor liver transplantation. Liver Transpl 2010; 16:1069-74. [PMID: 20818745 DOI: 10.1002/lt.22116] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Duct-to-duct reconstruction (DDR) of the bile duct has recently become the preferred choice in living donor liver transplantation (LDLT), but biliary complications still remain the most common cause of morbidity. We introduce our new technique of tailored telescopic reconstruction (TTR) of the bile duct for reducing bile duct complications in LDLT: the hilar plate covering the right and left hepatic ducts is bisected lengthwise through the right or left hepatic duct opening to make a funnel-shaped top, into which the donor hepatic duct is telescoped to match the recipient bile duct in size, and DDR is performed in the inner tissue of good vascular integrity of the recipient bile duct without redundancy. Forty-five consecutive LDLT procedures from January to August 2008 were analyzed through a comparison of 23 conventional duct-to-duct reconstructions (cDDRs) and 22 TTRs in bile duct anastomoses. At a mean follow-up of 19.5 months, the rates of overall biliary complications, leakage, and strictures were 43.5%, 26.1%, and 34.8%, respectively, for cDDR and 9.1%, 0%, and 9.1%, respectively, for TTR (P < 0.05 for each). In conclusion, TTR of the bile duct results in excellent outcomes with respect to minimization of biliary complications; thus, TTR can be recommended as a preferred method for biliary reconstruction in LDLT.
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Affiliation(s)
- Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-Si, Gyeonggi-Do, Republic of Korea
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14
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Lin TS, Concejero AM, Chen CL, Chiang YC, Wang CC, Wang SH, Liu YW, Yang CH, Yong CC, Jawan B, Cheng YF. Routine microsurgical biliary reconstruction decreases early anastomotic complications in living donor liver transplantation. Liver Transpl 2009; 15:1766-75. [PMID: 19938121 DOI: 10.1002/lt.21947] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Biliary reconstruction using a microsurgical technique in living donor liver transplantation was routinely performed on 88 grafts primarily transplanted into 85 patients. All procedures were performed under a microscope by a single microsurgeon. Except for biliary atresia and Alagille syndrome, duct-to-duct reconstruction was performed. Stents were not used. The outcomes with microsurgical biliary reconstruction (MB) were compared with the outcomes of a cohort of 86 grafts in 85 patients that underwent conventional biliary reconstruction (CB). The identification of complications included only up to 12 months of follow-up for each recipient in both groups. The average graft duct sizes were 2.8 mm for MB and 3.4 mm for CB. Most complications occurred in the first 15 cases with MB, and these cases were considered to constitute the learning curve phase. The MB complication rate was 46.7% in the first 15 cases, 20.0% in the next 15 cases, and 5.4% in the last 55 cases. When the learning curve phase was excluded, the overall complication rate over time with MB (8.9%) was significantly lower than that with CB (21.9%). CB increased the risk of biliary complications by 2.5 times (relative risk: 2.5; attributable risk: 128; odds ratio: 2.9). In conclusion, routine MB is a technical innovation that leads to decreased early anastomotic complications in living donor liver transplantation.
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Affiliation(s)
- Tsan-Shiun Lin
- Liver Transplantation Program, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Reduction of Biliary Complication Rate Using Continuous Suture and No Biliary Drainage for Duct-to-Duct Anastomosis in Whole-Organ Liver Transplantation. Transplant Proc 2009; 41:3126-30. [DOI: 10.1016/j.transproceed.2009.07.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kim BW, Bae BK, Lee JM, Won JH, Park YK, Xu WG, Wang HJ, Kim MW. Duct-to-duct biliary reconstructions and complications in 100 living donor liver transplantations. Transplant Proc 2009; 41:1749-55. [PMID: 19545721 DOI: 10.1016/j.transproceed.2009.02.097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 02/23/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We evaluated the risk factors for biliary complications and surgical procedures for duct-to-duct reconstructions in adult living donor liver transplantation (LDLT). PATIENTS AND METHODS From February 2005 to March 2008, we performed 100 cases of adult LDLT with duct-to-duct biliary reconstruction, using 64 right lobe grafts, 33 left lobe grafts, and 3 right lateral grafts. We employed 4 types of duct-to-duct procedures: all interrupted 6-0 Prolene suture (group 1, n = 9); continuous posterior and interrupted anterior wall 6-0 Prolene suture (group 2, n = 49); all continuous 7-0 Prolene suture (group 3, n = 26); and all continuous 7-0 Prolene suture with external stent (group 4, n = 16). Biliary complications were defined as an anastomosis stricture or a leakage. RESULTS Thirty-four patients experienced biliary complications during the follow-up period (median, 27 months). The incidence of stricture was 27% and that of leakage, 8%. There were no perioperative, intraoperative, or anatomic risk factors for biliary complications, except the type of duct-to-duct procedure. Group 1 and 2 patients showed higher incidences of biliary strictures than groups 3 and 4 (43.1% vs 4.7%; P = .00). Group 3 patients experienced a higher incidence of bile leakage than the other groups (23.1% vs 2.7%; P = .004). CONCLUSIONS The type of biliary reconstruction is a factor affecting biliary complications following duct-to-duct anastomosis in LDLT. Duct-to-duct biliary anastomosis with 7-0 monofilament suture and a small external stent is a feasible procedure in LDLT that significantly reduces the incidence of biliary complications.
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Affiliation(s)
- B W Kim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Prolonged cold ischemic time is a risk factor for biliary strictures in duct-to-duct biliary reconstruction in living donor liver transplantation. Transplantation 2009; 86:1536-42. [PMID: 19077886 DOI: 10.1097/tp.0b013e31818b2316] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Duct-to-duct (DD) anastomosis is an accepted procedure for biliary reconstruction in living donor liver transplantation (LDLT). However, biliary complication rates in LDLT recipients have been reported to be as high as 20% to 30% or more. In this study, we examined various potential risk factors for biliary stricture (BS) that occurs in the context of DD reconstruction in a single-active transplant center. METHODS Enrolled in this study were adults who underwent their first LDLT with DD reconstruction between August 2002 and May 2007 (n=283). BSs were defined as anastomotic strictures that required interventions or operative procedures to be corrected. We reviewed retrospectively the medical records of recipients, including medical history, surgical procedures, and progress, and analyzed risk factors of BS with the Kaplan-Meier method. RESULTS BS occurred in 58 of the 283 recipients (20.5%). The mean follow-up period was 24.4 months posttransplant (SD=16.5). The univariate analysis revealed that recipient age (P=0.032), bile duct size (P=0.003), biliary reconstruction surgeon (P=0.023), perfusion solution (P=0.001), cold ischemic time (CIT) (P<0.001), and biliary leakage history (P<0.001) were significant risk factors. In the multivariable analysis, CIT (P=0.001), biliary leakage history (P=0.002), bile duct size (P=0.021), and recipient age (P=0.036) were significant risk factors for BS. And, a CIT cutoff value of 71 min was calculated using the minimum P value approach with correction by the Miller and Siegmund method (P=0.0186). CONCLUSIONS In this study, prolonged CIT is identified as a risk factor for BS in DD biliary reconstruction in LDLT.
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Yamamoto S, Sato Y, Oya H, Nakatsuka H, Kobayashi T, Hara Y, Watanabe T, Kurosaki I, Hatakeyama K. Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation. World J Gastroenterol 2007; 13:4236-41. [PMID: 17696254 PMCID: PMC4250624 DOI: 10.3748/wjg.v13.i31.4236] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate risk factors of biliary anastomotic complications (BACs) and outcomes according to type of biliary reconstruction.
METHODS: A total of 33 consecutive adult living donor liver transplantation (LDLT) were reviewed, 17 of which had undergone Duct-to-Duct anastomosis (D-D). The remaining 16 patients received Roux-en-Y anastomosis (R-Y). The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively.
RESULTS: The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy (71.4% vs 10%, P = 0.050). There was no significant difference in the incidence of biliary leakage in patients with D-D vs those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D (60%) than in R-Y (0%) (P = 0.026). However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D (71.4% vs 0%, P = 0.008). In D-D, use of T-tube stent remarkably reduced the incidence of BACs, compared with straight tube stent (0% vs 50%, P = 0.049).
CONCLUSION: Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.
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Affiliation(s)
- Satoshi Yamamoto
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori 1-757, Niigata 951-8510, Japan.
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Kobayashi T, Sato Y, Yamamoto S, Takeishi T, Oya H, Hirano KI, Nakatsuka H, Watanabe T, Hatakeyama K. Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation. ACTA ACUST UNITED AC 2007; 14:177-82. [PMID: 17384910 DOI: 10.1007/s00534-006-1120-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 03/20/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. METHODS We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. RESULTS Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). CONCLUSIONS Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.
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Affiliation(s)
- Takashi Kobayashi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata 951-8510, Japan
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20
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Takatsuki M, Eguchi S, Kawashita Y, Kanematsu T. Biliary complications in recipients of living-donor liver transplantation. ACTA ACUST UNITED AC 2006; 13:497-501. [PMID: 17139422 DOI: 10.1007/s00534-005-1082-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 11/25/2005] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Mitsuhisa Takatsuki
- Department of Transplantation and Digestive Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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21
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Abstract
Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.
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Affiliation(s)
- Sheung Tat Fan
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China.
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22
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Liu CL, Fan ST. Adult-to-adult live-donor liver transplantation: the current status. ACTA ACUST UNITED AC 2006; 13:110-6. [PMID: 16547671 DOI: 10.1007/s00534-005-1016-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Accepted: 05/30/2005] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Chi Leung Liu
- Centre for the Study of Liver Disease, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China
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23
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Giacomoni A, Lauterio A, Slim AO, Vanzulli A, Calcagno A, Mangoni I, Belli LS, De Gasperi A, De Carlis L. Biliary complications after living donor adult liver transplantation. Transpl Int 2006; 19:466-73. [PMID: 16771867 DOI: 10.1111/j.1432-2277.2006.00274.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Alessandro Giacomoni
- Department of Hepatobiliary Surgery and Transplantation, Niguarda Hospital, Milan, Italy.
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24
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Ramacciato G, Varotti G, Quintini C, Masetti M, Di Benedetto F, Grazi GL, Ercolani G, Cescon M, Ravaioli M, Lauro A, Pinna A. Impact of biliary complications in right lobe living donor liver transplantation. Transpl Int 2006; 19:122-7. [PMID: 16441361 DOI: 10.1111/j.1432-2277.2005.00248.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Ramacciato
- Department of Surgery and Transplantations, Liver and Multiorgan Transplantation Unit, S.Orsola Hospital, University of Bologna, Italy
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25
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Hashimoto M, Sugawara Y, Tamura S, Kishi Y, Matsui Y, Kaneko J, Makuuchi M. T-tube drainage for biliary stenosis after living donor liver transplantation. Transplantation 2006; 81:293-5. [PMID: 16436976 DOI: 10.1097/01.tp.0000194865.51104.1b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Masao Hashimoto
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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26
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Yi NJ, Suh KS, Cho JY, Kwon CH, Lee KU. In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis. Transpl Int 2005; 18:1240-7. [PMID: 16221154 DOI: 10.1111/j.1432-2277.2005.00209.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Chongno-Gu, Seoul, Korea
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27
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Xu SR, Wang XH, Li XC, Zhang F, Cheng F, Li GQ, Wang K. Application of duct-to-duct biliary reconstruction in living donor liver transplantation. Shijie Huaren Xiaohua Zazhi 2005; 13:2630-2633. [DOI: 10.11569/wcjd.v13.i21.2630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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28
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Liu CL, Lo CM, Fan ST. What is the best technique for right hemiliver living donor liver transplantation? With or without the middle hepatic vein? Duct-to-duct biliary anastomosis or Roux-en-Y hepaticojejunostomy? J Hepatol 2005; 43:17-22. [PMID: 15921816 DOI: 10.1016/j.jhep.2005.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Chi Leung Liu
- Department of Surgery, Centre for the Study of Liver Disease, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong, China
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29
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Todo S, Furukawa H, Kamiyama T. How to prevent and manage biliary complications in living donor liver transplantation? J Hepatol 2005; 43:22-7. [PMID: 15921817 DOI: 10.1016/j.jhep.2005.05.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Satoru Todo
- The First Department of Surgery, Hokkaido University School of Medicine, N-15, W-7, Kita-ku, Sapporo 060-8638, Japan.
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30
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Kobayashi T, Sato Y, Yamamoto S, Takeishi T, Oya H, Nakatsuka H, Watanabe T, Hatakeyama K. Biliary reconstruction and complications of left lobe living donor liver transplantation. Transplant Proc 2005; 37:1122-3. [PMID: 15848642 DOI: 10.1016/j.transproceed.2004.12.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living donor liver transplantation. The aim of this study was to analyze the clinical implications of three methods of biliary reconstruction in left lobe adult living donor liver transplantation. We retrospectively compared three groups of patients who underwent various biliary reconstructions: those who had Roux-en-Y hepaticojejunostomy (HJ) (n = 11); duct to duct hepaticohepaticostomy (HH) with an external stent (n = 11); or HH with T-tube (n = 6). The median follow-up for each group was 29, 28, and 8 months, respectively. Bile leaks were observed in 45.5% of both the HJ and the HH with external stent groups. Biliary anastomotic strictures occurred in 9.1% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with an external stent. No biliary complications were observed in the HH over a T-tube group (P = .049). Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up, these encouraging preliminary results warrant further studies of this biliary reconstruction technique for left lobe adult living donor liver transplantations.
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Affiliation(s)
- T Kobayashi
- Graduate School of Medical and Dental Sciences, Division of Digestive and General Surgery, Nigata University, 1757-Asahimachi-dori, 951-8510, Nagata, Japan
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31
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Suh KS, Choi SH, Yi NJ, Kwon CH, Lee KU. Biliary reconstruction using the cystic duct in right lobe living donor liver transplantation. J Am Coll Surg 2004; 199:661-4. [PMID: 15454156 DOI: 10.1016/j.jamcollsurg.2004.05.278] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2003] [Revised: 03/05/2004] [Accepted: 05/25/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Chongno-gu, Seoul, Korea.
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32
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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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33
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Sugawara Y, Sano K, Kaneko J, Akamatsu N, Kishi Y, Kokudo N, Makuuchi M. Duct-to-duct biliary reconstruction for living donor liver transplantation: experience of 92 cases. Transplant Proc 2004; 35:2981-2. [PMID: 14697955 DOI: 10.1016/j.transproceed.2003.10.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Bile duct-to duct reconstruction is now performed in living donor liver transplantation (LDLT) for adult patients. To confirm the feasibility, the results after the reconstruction were retrospectively analyzed. The subjects were 92 adult patients who underwent LDLT at the University of Tokyo Hospital. During the observation period (median 546 days), biliary complications were observed in 28 cases (30%). The complications included bile juice leakage in 11, stenosis at the anastomotic site in 9, and tube trouble in 8. Of these, 20 patients required surgical revision. The results suggest that duct-to-duct reconstruction provides satisfactory results, although long-term observation will be necessary.
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Affiliation(s)
- Y Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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34
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Liu CL, Lo CM, Chan SC, Fan ST. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage. Transplantation 2004; 77:726-32. [PMID: 15021836 DOI: 10.1097/01.tp.0000116604.89083.2f] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease and Department of Surgery, University of Hong Kong, Pokfulam, Hong Kong, China.
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35
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Liu CL, Lo CM, Chan SC, Fan ST, Wong J. Internal hernia of the small bowel after right-lobe live donor liver transplantation. Clin Transplant 2004; 18:211-3. [PMID: 15016138 DOI: 10.1046/j.1399-0012.2003.00125.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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36
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Liu CL, Chan SC, Lo CM, Tso WK, Fan ST. Pseudo pseudocyst after right lobe live donor liver transplantation. Liver Transpl 2004; 10:571-2. [PMID: 15048804 DOI: 10.1002/lt.20057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease, The University of Hong Kong, Pokfulam, Hong Kong, China.
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37
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Icoz G, Kilic M, Zeytunlu M, Celebi A, Ersoz G, Killi R, Memis A, Karasu Z, Yuzer Y, Tokat Y. Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations. Liver Transpl 2003; 9:575-80. [PMID: 12783398 DOI: 10.1053/jlts.2003.50129] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Gokhan Icoz
- Department of Surgery, Ege University Medical School, Izmir, Turkey
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Soejima Y, Shimada M, Suehiro T, Kishikawa K, Minagawa R, Hiroshige S, Ninomiya M, Shiotani S, Harada N, Sugimachi K. Feasibility of duct-to-duct biliary reconstruction in left-lobe adult-living-donor liver transplantation. Transplantation 2003; 75:557-9. [PMID: 12605127 DOI: 10.1097/01.tp.0000048220.90971.5a] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A Roux-en-Y choledochojejunostomy (CDJ) has been the sole method of choice for the reconstruction of the bile duct in living-donor liver transplantation (LDLT) using left-lobe grafts. In this study, we evaluated the feasibility of duct-to-duct (DD) biliary reconstruction in adult-to-adult LDLT using left-lobe grafts. Between October 1996 and October 2001, 46 adult-to-adult LDLTs using the left lobe were performed at our institution. The DD biliary reconstruction (hepaticocholedochostomy) over a T-tube was performed for seven of the last nine recipients (DD group, n=7), whereas the conventional Roux-en-Y CDJ was used for the remaining cases (CDJ group, n=39). The technical problems and the incidence of biliary complications were compared between the groups. Bile leakage developed in only 1 of 7 (14%) in the DD group (leakage from a T-tube exit site), whereas it occurred in 8 of 39 (20%) in the CDJ group. Up to now, no patients from the DD group developed anastomotic stricture, whereas twelve (30.7%) patients from the CDJ group did. Other complications included bleeding from the Roux-en-Y jejunojejunostomy (n=1) and anastomotic occlusion caused by an internal stent (n=1), and both complications were associated with CDJ. In conclusion, DD anastomosis is a simple and viable option for biliary reconstruction in left-lobe LDLTs. A long-term follow-up, especially regarding the incidence of biliary stricture, is thus warranted in such patients.
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Affiliation(s)
- Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Abstract
OBJECTIVE To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications. SUMMARY BACKGROUND DATA Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined. METHODS From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors. RESULTS The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered. CONCLUSIONS With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.
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Fan ST, Lo CM, Liu CL, Tso WK, Wong J. Biliary reconstruction and complications of right lobe live donor liver transplantation. Ann Surg 2002; 236:676-83. [PMID: 12409675 PMCID: PMC1422628 DOI: 10.1097/00000658-200211000-00019] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications. SUMMARY BACKGROUND DATA Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined. METHODS From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors. RESULTS The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered. CONCLUSIONS With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.
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Affiliation(s)
- Sheung-Tat Fan
- Centre for the Study of Liver Disease, Department of Surgery and Diagnostic Radiology, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Kawachi S, Shimazu M, Wakabayashi G, Hoshino K, Tanabe M, Yoshida M, Morikawa Y, Kitajima M. Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction. Surgery 2002; 132:48-56. [PMID: 12110795 DOI: 10.1067/msy.2002.125314] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to compare the incidence of biliary complications after adult living donor liver transplantation (ALDLT) with Roux-en-Y hepaticojejunostomy (R-Y HJ) or duct-to-duct hepaticocholedochostomy (D-D HC). METHODS Biliary complications were reviewed in 20 consecutive ALDLT recipients surviving more than 1 month, including 10 patients who underwent R-Y HJ and 10 patients who underwent D-D HC reconstructions. RESULTS Ten biliary complications were seen in 8 patients (40%) from the study group. Specifically, 1 case of biliary leakage and 1 case of biliary hemorrhage were observed in the R-Y HJ group (20%), and 2 biliary leakages, 4 biliary strictures, and 2 C-tube related biliary leakages were seen in 6 patients from the D-D HC group (60%). Three of the 5 patients (60%) who underwent right lobe graft ALDLTs experienced biliary stricture. All cases of biliary leakage and biliary hemorrhage were stopped spontaneously by continuous drainage. Three patients in the D-D HC group with anastomotic strictures were successfully treated with percutaneous interventions. Only 1 patient with anastomotic stricture in the D-D HC group with left lobe graft required intrahepatic R-Y HJ reanastomosis. Two cases of C-tube related biliary leakages were treated with endoscopic management. CONCLUSIONS Biliary complications such as anastomotic strictures were common in the D-D HC group rather than in the R-Y HJ group. D-D HC reconstruction should be applied cautiously, especially in the right lobe graft ALDLT cases.
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Affiliation(s)
- Shigeyuki Kawachi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Sugawara Y, Makuuchi M, Sano K, Ohkubo T, Kaneko J, Takayama T. Duct-to-duct biliary reconstruction in living-related liver transplantation. Transplantation 2002; 73:1348-50. [PMID: 11981435 DOI: 10.1097/00007890-200204270-00029] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bile duct-to duct reconstruction is now used in living-related liver transplantation for adult patients. However, the feasibility remains controversial. METHODS Bile duct-to-duct reconstruction was performed in 25 adult patients. In the total hepatectomy of the patients, the hilar plate was dissected at the second-order branch of the bile ducts. The anastomosis was performed using an interrupted suture with an external stent tube. A C tube was inserted from the stump of the cystic duct and introduced into the duodenum. RESULTS All of the patients survived the operation. During the observation period ranging from 34 to 345 days, biliary complications were observed in 8% cases. Dilation of the bile ducts and an absence of bile output were recognized in one patient each, and necessitated surgical revision. CONCLUSIONS Our preliminary experience in biliary reconstruction seems to warrant its long-term observation in the postoperative period.
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Affiliation(s)
- Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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