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

Gun-Sight Technique With Dual Hepatic Vascular Embolization for Sigmoidal Refractory Biliary Stricture After Living-Donor Liver Transplantation: A Case Report

BACKGROUND

Biliary stricture is a common complication after living-donor liver transplantation (LDLT), but its management is challenging. We herein report a case of successful internal drainage achieved through combination of the gun-sight technique and dual hepatic vascular embolization (DHVE).

CASE PRESENTATION

A 54-year-old woman with primary biliary cholangitis underwent ABO-incompatible LDLT with the right lobe. Duct-to-duct biliary anastomosis was performed, and V5 and V8 of the graft were reconstructed using a vein graft. However, 5 months after surgery, magnetic resonance cholangiopancreatography revealed stricture of the bile duct anastomosis. Endoscopic stenting could not be attempted because of the sigmoidal bending of the bile duct. Instead, percutaneous transhepatic cholangiographic drainage (PTCD) of the anterior and posterior branches was performed. We attempted to remove the PTCD tube by an endofistulization technique. We performed the gun-sight technique, originally employed for transjugular intrahepatic portosystemic shunt procedures, to create a pathway for internal drainage of the posterior segment. The anterior lobe was abandoned by applying DHVE, resulting in no external drainage tubes.

CONCLUSION

Application of the gun-sight technique with DHVE for sigmoidal refractory biliary stricture after LDLT appears to be a feasible treatment.

Initial outcome of external biliary drainage in living donor liver transplantation with pure laparoscopic donor hepatectomy

Biliary complications after living donor liver transplantation (LDLT) are the most common and intractable complications due to both surgical and nonsurgical factors. External biliary drainage (EBD), a surgical option to prevent biliary complications, has recently been adopted in the era of pure laparoscopic donor right hepatectomy, which may result in increased bile duct problems in the recipients. This study retrospectively reviewed the patients who underwent LDLT with duct-to-duct anastomosis between July 2017 and October 2020 to analyze the initial outcomes of EBD and to compare the incidence of biliary complications in adult LDLT recipients who underwent duct-to-duct anastomosis with or without EBD. Only patients who underwent pure laparoscopic donor hepatectomy were included in this study. The patients were divided into 2 groups according to the application of EBD. The median follow-up period was 28.5 months. The overall incidence of Clavien-Dindo grade IIIa biliary complications was 35.0% (n=14) in the EBD group and 50.7% (n=76) in the non-EBD group ( p = 0.08). The incidence of biliary leakage was 0% in the EBD group and 15.3% in the non-EBD group ( p = 0.01). The EBD-related complication rate, that is, involving retraction, accidental removal, and dislocation, was 40.0%. EBD implementation is effective in preventing biliary leakage after LDLT with a graft procured using the pure laparoscopic donor right hepatectomy method with duct-to-duct biliary anastomosis. However, efforts should be made to prevent EBD-related complications. Further studies are needed to establish appropriate selection criteria for EBD.

Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy

AIMS

To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

METHODS

The study protocol was prospectively registered in PROSPERO (registration number: CRD42021286294). A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted (last search: 14th March 2022). All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias was assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters.

RESULTS

Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS: 789, CS: 397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS: 168, CS: 263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD: 14.15 min, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR: 1.34, p=0.11), bile leak (OR: 1.64, p=0.14), biliary stricture (OR: 0.84, p=0.65), cholangitis (OR: 1.54, p=0.35), or liver abscess (OR: 0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR: 0.92, p=0.90), bile leak (OR: 1.70, p=0.28), or biliary stricture (OR: 1.07, p=0.92) compared to CS.

CONCLUSIONS

Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material.

Optimal Intervention for Initial Treatment of Anastomotic Biliary Complications After Right Lobe Living Donor Liver Transplantation

Background: This study evaluated endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) as interventions for patients with anastomotic biliary complications (ABC) after living donor liver transplantation (LDLT).

Methods: Prospectively collected data of patients who were diagnosed with ABC after LDLT between January 2013 and June 2017 were retrospectively reviewed.

Results: There were 57 patients who underwent LDLT with a right liver graft using duct-to-duct biliary reconstruction and experienced ABC. Among the patients with RAD involvement, there were no significant differences in the intervention success (p = 0.271) and patency rates (p = 0.267) between ERCP and PTBD. Similarly, among the patients with RPD involvement, there were no significant differences in the intervention success (p = 0.148) and patency rates (p = 0.754) between the two procedures. Graft bile duct variation (p = 0.013) and a large angle between the recipient and graft bile duct (R-G angle) (p = 0.012) significantly increased the likelihood of failure of ERCP in the RAD. When the R-G angle was greater than 47.5°, the likelihood of ERCP failure increased.

Conclusion: We recommend PTBD when graft bile duct variation is presented in patients with RAD involvement and/or when the R-G angle is greater than 47.5°.

Post-Transplant Biliary Strictures: An Updated Review

Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.

Reconstruction of Separated Intrahepatic Ducts Using the Cystic and Common Hepatic Ducts in Right-Lobe Living-Donor Liver Transplantation: Experiences of Surgical Techniques, Biliary Complications, and Outcomes in a Single Institution

BACKGROUND Duct-to-duct biliary reconstruction has been increasingly used in living-donor liver transplantation. Information regarding dual duct-to-duct biliary anastomoses is limited. We present the largest case series to date on the use of the cystic and common hepatic ducts as dual-ductal anastomosis, along with long-term follow-up results. MATERIAL AND METHODS In this study, 740 patients underwent right-lobe living-donor liver transplantation; 56 of them were documented as dual-ductal anastomoses. We analyzed recipient and donor characteristics, surgical procedures, appearance of biliary complications, corresponding interventions, and long-term biliary outcomes. RESULTS Cystic and common hepatic ducts were utilized in 56 cases of dual-ductal biliary reconstruction, which we categorized into 2 types: A (78.6%), in which the right anterior intrahepatic duct was anastomosed to the common hepatic duct and the right posterior intrahepatic duct to the cystic duct; and B (21.4%), which was the reverse of A. After a median follow-up period of 46.4 months, 23 patients (41.1%) experienced complications, including biliary leakage and biliary stricture. However, after aggressive intervention (patent biliary anastomosis in most of them), 50 of 56 patients (89.3%) had patent biliary anastomosis and restored normal liver function at the end of follow-up. A small graft (graft-to-recipient weight ratio <0.9%) was the only predictor of biliary complications after multivariate analysis. CONCLUSIONS Dual-ductal biliary reconstruction in adult right-lobe living-donor liver transplantation is challenging but feasible. Our findings support the use of the cystic duct for reconstruction in selected patients. Good long-term results can be achieved with adequate management of patients with biliary complications.

Biliary complications in recipients of living donor liver transplantation: A single-centre study

BACKGROUND

Biliary complications (BCs) after liver transplantation (LT) remain a considerable cause of morbidity, mortality, increased cost, and graft loss.

AIM

To investigate the impact of BCs on chronic graft rejection, graft failure and mortality.

METHODS

From 2011 to 2016, 215 adult recipients underwent right-lobe living-donor liver transplantation (RT-LDLT) at our centre. We excluded 46 recipients who met the exclusion criteria, and 169 recipients were included in the final analysis. Donors' and recipients' demographic data, clinical data, operative details and postoperative course information were collected. We also reviewed the management and outcomes of BCs. Recipients were followed for at least 12 mo post-LT until December 2017 or graft or patient loss.

RESULTS

The overall incidence rate of BCs including biliary leakage, biliary infection and biliary stricture was 57.4%. Twenty-seven (16%) patients experienced chronic graft rejection. Graft failure developed in 20 (11.8%) patients. A total of 28 (16.6%) deaths occurred during follow-up. BCs were a risk factor for the occurrence of chronic graft rejection and failure; however, mortality was determined by recurrent hepatitis C virus infection.

CONCLUSION

Biliary complications after RT-LDLT represent an independent risk factor for chronic graft rejection and graft failure; nonetheless, effective management of these complications can improve patient and graft survival.

Liver transplantation in pediatric patients under 15 kg; duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses

Back ground. Liver transplantation is an effective treatment for acute or chronic liver failure and metabolic liver disease, which is associated with good quality of life in over 80 percent of recipients. We aimed to evaluate outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in pediatric liver transplant recipients below 15-kg.

Methods. In this single-center retrospective study, all children less than 15 kg that have undergone liver transplantation at Nemazee Hospital Organ Transplant Center affiliated with Shiraz University of Medical Sciences from 2009 till 2019, were enrolled. Over a 10-yr period, 181 liver transplants were performed in patients with two techniques including duct-to-duct (Group 1) vs. Roux-en-Y hepaticojejunostomy biliary anastomoses (Group 2). All data was collected from patients’ medical records, operative notes, and post-transplant follow up notes. Data was analyzed by SPSS software V21.

Results. Overall, 94 patients had duct to duct anastomosis (group 1) and 87 cases had Roux-en-Y hepaticojejunostomy (group 2). The mean age of the patients was 2.46 ± 1.5. The most common underlying diseases was biliary atresia (32%). The most prevalent complication after the surgery was infection in both groups. cardiopulmonary problems were significantly higher in group 2 (24.1% vs 4.3%) (p < 0.001). The rate of infection was significantly higher in group 2, as well.

Conclusion. Our study showed a relatively high rate of post-operative infection which was the most among patients who had undergone Roux-en-Y hepaticojejunostomy. Except from biliary complications which were mostly observed in DD group, other complications were more common among Roux-en-Y group.

Primary Suture of the Common Bile Duct: Continuous or Interrupted?

Objective: To compare the effectiveness and safety of continuous suture and interrupted suture in Laparoscopic Common Bile Duct Exploration (LCBDE) for choledocholithiasis. Materials and Methods: The data of 125 patients with choledocholithiasis treated with LCBDE in our department from January 2017 to January 2019 were retrospectively collected and divided into two subgroups: the continuous suture group (n = 56) and the interrupted suture group (n = 69). The operation duration, time to suture, intraoperative blood loss, extubation time, hospital stay, total hospitalization expenses, preoperative and postoperative diameters of the common bile duct (CBD), and the occurrence rate of postoperative complications were all compared between the two groups. Results: The operative duration, time to suture, and intraoperative blood loss in the continuous suture group were less compared with those in the interrupted suture group (P < .05). There was no statistical significance between the 2 groups considering extubation time, hospital stay, total hospitalization expenses, and the occurrence rate of postoperative complications (P > .05). The postoperative CBD diameters in both groups were significantly larger than the preoperative CBD diameters (P < .05). Conclusions: The continuous suture technique shortened the operative duration, time to suture, and reduced intraoperative blood loss. It proves to be an effective and safe method in patients diagnosed with CBD stones.

Biliary complications after liver transplantation: current perspectives and future strategies

Importance

Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation.

Objective

The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT.

Evidence Review

a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment.

Findings

Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks.

Conclusions and Relevance

BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.

Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.

The high-end range of biliary reconstruction in living donor liver transplant

PURPOSE OF REVIEW

To summarize recent evidence in literature regarding incidence and risk factors for biliary complications in living donor liver transplantation (LDLT), and current concepts in evaluation of donor biliary anatomy and surgical techniques of biliary reconstruction, to reduce the incidence of biliary complications.

RECENT FINDINGS

Advances in biliary imaging in the donor, both before surgery, and during donor hepatectomy, as well as safe hepatic duct isolation in the donor, have played a significant role in reducing biliary complications in both the donor and recipient. Duct-to-duct biliary anastomoses (DDA) is the preferred mode of biliary reconstruction currently, especially when there is a single bile duct orifice in the donor. The debate on stenting the anastomoses, especially a DDA, continues. Stenting a Roux en Y hepaticojejunostomy in children with small ductal orifices in the donor is preferred. With growing experience, and use of meticulous surgical technique and necessary modifications, the incidence of biliary complications in multiple donor bile ducts, and more than one biliary anastomoses can be reduced.

SUMMARY

Biliary anastomosis continues to be the Achilles heel of LDLT. Apart from surgical technique, which includes correct choice of type of reconstruction technique and appropriate use of stents across ductal anastomoses, better imaging of the biliary tree, and safe isolation of the graft hepatic duct, could help reduce biliary complications in the recipient, and make donor hepatectomy safe .

Decreased long-term graft survival in persistent biliary complications after right-lobe living-donor liver transplantation

BACKGROUND

Long-term outcomes after endoscopic treatment of post-transplant biliary complications have not been fully understood. This study aimed to evaluate the impact of biliary complications on graft survival after right-lobe living-donor liver transplantation (R-LDLT).

METHOD

From a single-institutional prospectively maintained database, all patients who underwent R-LDLT between 1999 and 2017 were included. Data on patient demographics, complications, endoscopic treatment, and graft survival were retrieved for analyses.

RESULTS

Among 111 patients who underwent R-LDLT, 33 (29.7%) developed biliary complications; of these, 19 (17.1%) were treated with biliary stenting, and the stent was removed following resolution of biliary complications in 8 of the 19 (42.1%) patients. The graft survival rate was 88.0% and 85.6% at 5- and 10-year follow-up, respectively, in patients without biliary complications, which was similar to that of the patients with resolved biliary complications (81.3% at 5- and 10-year follow-up, P = .68) but higher than that of patients having persistent (unresolved) biliary complications (61.4% and 49.1% at 5- and 10-year follow-up, respectively, P = .04).

CONCLUSION

Post-transplant persistent biliary complications, unresolved after endoscopic management and requiring prolonged biliary stenting, are associated with inferior graft survival. However, patients with resolved biliary complications achieve a favorable long-term survival similar to patients without biliary complications.

Paradigm shift in the management of bile duct strictures complicating living donor liver transplantation

AIM

Validation of new metrics to identify functionally significant obstruction (FSO), to better define biliary strictures complicating living donor liver transplantation (LDLT).

METHODS

All LDLT recipients who presented with cholestasis were studied. Novel metrics for FSO are as follows: (1) magnetic resonance cholangiopancreatography (MRCP) ductal ratio (MDR): The ratio between hepatic duct and recipient duct diameter on the MRCP taken at presentation; (2) endoscopic retrograde cholangiography (ERC) ductal ratio (EDR): The ratio between hepatic duct and recipient duct diameter on the first ERC done for suspected biliary strictures; (3) delayed contrast drainage (DCD): > 50% contrast retained above the anastomotic site, in more than three consecutive fluoroscopic images taken at least 15 min after contrast instillation. Association between these metrics and endotherapy response was analyzed along with patient demographics, intraoperative variables (cold ischemia time, blood transfusions, biliary anastomosis) and perioperative complications (hepatic artery thrombosis [HAT], bile leak). Favorable response to endotherapy was defined as symptomatic relief with ≥ 80% reduction in total bilirubin/alkaline phosphatase.

RESULTS

A total of 83 LDLT recipients presented with altered liver function tests. Favorable response was seen in 18/39 patients (46.2%). On univariate analysis, HAT, multiple biliary anastomoses, graft-to-recipient weight ratio (GRWR), MDR, EDR and DCD were significant (p value ≤ 0.05). On multivariate analysis, only MDR ≥ 1.15 was an independent predictor of favorable response to endotherapy (OR 48 [95% CI 7.096-324.71]).

CONCLUSION

A paradigm shift in the approach to management of biliary strictures complicating LDLT is proposed whereby a multidimensional definition of FSO can help in reliable patient selection for endotherapy and improve patient outcome as a whole.

Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation

BACKGROUND AND AIMS

The anastomotic biliary stricture is a clinically important complication after living donor liver transplantation (LDLT) with a duct-to-duct anastomosis. Although endoscopic management of post-LDLT biliary strictures using balloon dilation (BD) and plastic stents (PSs) has provided acceptable short-term outcomes, long-term outcomes and prognostic factors for treatment success remain unclear.

METHODS

We included 96 patients with post-LDLT biliary strictures who were endoscopically managed between 2003 and 2016. BD was utilized as a first-line treatment strategy, and PS placement was carried out for refractory cases. Potential prognostic factors for biliary stricture resolution were analysed using logistic regression analyses.

RESULTS

Endoscopic treatment was technically successful in 84 patients (87.5%). The overall rate of biliary stricture resolution was 44.8% (43 of 96 patients) with a median follow-up duration of 90.9 months (interquartile range, 30.9-122.3 months). Bile duct kinking was associated with a lower rate of biliary stricture resolution (odds ratio, 0.33; 95% confidence interval, 0.13-0.87). After successful endoscopic treatment, biliary strictures recurred in 22 patients (57.9%) after BD, and in one patient (4%) after PS treatment.

CONCLUSIONS

Despite a high technical success rate, endoscopic treatment only provided a low rate of resolution of anastomotic biliary strictures among LDLT patients and required prolonged treatment duration. Alternative strategies including the use of a covered metal stent should be evaluated to further improve the treatment outcomes of post-LDLT biliary strictures, particularly in those accompanied by the bile duct kinking.

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

Right lobe (RL) living donor liver transplantation (LDLT) usually includes 2 bile duct anastomosis sites, namely, the right anterior and the right posterior segmental ducts. This study aimed to evaluate the optimal treatment for biliary strictures following RL LDLT with respect to unilateral or bilateral drainage techniques. From January 2005 to December 2017, 883 patients at Seoul National University Hospital underwent RL LDLT. Of these, 110 patients were enrolled who had 2 duct-to-duct anastomosis sites and who were considered at risk of developing biliary anastomotic strictures. Unilateral or bilateral biliary drainage during the follow-up period was identified by endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD). The clinical success, complication, and 180-day mortality rates were compared between the unilateral and bilateral biliary drainage groups according to the initial ERCP findings. The mean age at the time of LDLT was 54.2 ± 8.2 years. The median time from LDLT to initial biliary anastomotic strictures was 177 (interquartile range, 18-1085) days. At the initial ERCP, unilateral drainage was performed in 55 (50.0%) patients, and bilateral drainage was performed in 11 (10.0%) patients. Of the patients who underwent unilateral drainage, 35 (63.6%) patients required conversion to bilateral drainage during follow-up. Overall, 71 (64.5%) patients required bilateral drainage more than once, whereas only 27 (24.5%) patients reached a resolution with unilateral biliary drainage. In this study, most patients required bilateral biliary drainage more than once during follow-up. An active attempt should be made to drain bilaterally in patients with biliary anastomotic strictures following RL LDLT.

Percutaneous Transhepatic Biliary Drainage for Biliary Stricture After Endotherapy Failure in Living Donor Liver Transplantation: A Single-Centre Experience from India

BACKGROUND

In the living donor liver transplant (LDLT) population, postoperative biliary stricture is a common problem. Endoscopic retrograde cholangiography (ERCP) and stenting failures usually occur because of odd angulation of the ducts, particularly in right lobe grafts. Percutaneous transhepatic biliary drainage (PTBD) is helpful in patients where endoscopic intervention is unsuccessful. We report our experience in this particular group of patients from India.

METHODS

We analysed retrospective data of 932 patients who underwent LDLT at our centre. Data collected include basic demographics, technical and clinical success rate of PTBD, postprocedure complications and overall outcome.

RESULTS

Of the 932 patients, 81 (8.7%) developed biliary stricture and required endoscopic or percutaneous interventions; out of whom, 75 patients underwent ERCP, and 6 patients had hepaticojejunostomy. Right posterior sector graft recipients had the highest incidence of biliary stricture (29.16%), followed by the right lobe grafts (8.57%), whereas stricture rate was less among left lobe and left lateral lobe graft recipients (3.77% and 3.7%, respectively). Failure of ERCP was common among the ductoplasty group (80%). The failure rate of ERCP did not differ significantly among patients who had single-duct, two-duct or three-duct anastomoses (44%, 36% and 50%, respectively, p > 0.05). PTBD was technically successful in 34 patients (87%) The mortality rate following PTBD was 2.5%, and morbidity was 15%. For the 5 patients in whom PTBD could not be performed, open hepaticojejunostomy was performed successfully.

CONCLUSIONS

Right lobe liver grafts have high incidence of biliary stricture compared with left lobe grafts. The failure of ERCP was not dependent on the number of biliary anastomoses; however, the ductoplasty group had a higher failure rate. PTBD is technically successful in a majority of patients albeit with a morbidity of 15%. Open hepaticojejunostomy is a good therapeutic option following PTBD failure.

Efficacy of a Biliary Splint at the Anastomosis in Living Donor Liver Transplantation−With a Special Reference to Postoperative Endoscopic Treatment for Biliary Stricture

Objective:

For successful biliary anastomosis in living donor liver transplantation (LDLT), the efficacy of a biliary splint at the anastomosis remains controversial. In the case of biliary anastomotic stricture (BAS), endoscopic intervention is mostly performed as the initial treatment. In this study, we evaluated the efficacy of endoscopic treatment for BAS in patients with placement of splints.

Methods:

A retrospective study was conducted with 148 adult patients who underwent LDLT with duct-to-duct biliary anastomosis from 2005 to 2015. A biliary splint was placed in all cases; the splint was removed 3 months after the LDLT. Patients who postoperatively underwent endoscopic treatment for BAS were divided into successful and failed groups.

Results:

A total of 24 patients (16.2%) underwent endoscopic treatment postoperatively. The successful group included 14 patients (63.6%) and the failed group included 8 (36.4%). Comparison between the 2 groups in terms of demographic, pretransplant, intraoperative, and posttransplant data did not show any significant differences. Two patients developed BAS within 3 months after LDLT. In these 2 patients, the splint was dislocated, and endoscopic intervention was not successful. Twenty patients developed BAS later than 3 months after LDLT. In contrast to the success rate of endoscopic intervention of 73.3% in patients without splint dislocation (n = 15), it was 60% in the patient with dislocation of the splint (n = 5).

Conclusion:

The prevention of early biliary stricture by placing a splint may lead to an improved success rate of endoscopic intervention, since endoscopic intervention was difficult in the cases of early biliary stricture within 3 months.

Living Donor Liver Transplantation Using Selected Grafts With 2 Bile Ducts Compared With 1 Bile Duct Does Not Impact Patient Outcome

The outcome after living donor liver transplantation (LDLT) using grafts with multiple bile ducts (BDs) remains unclear. We analyzed 510 patients who received an adult-to-adult right lobe LDLT between 2000 and 2015 and compared outcome parameters of those receiving grafts with 2 BDs (n = 169) with patients receiving grafts with 1 BD (n = 320). Additionally, patients receiving a graft with 3 BDs (n = 21) were analyzed. Demographic variables and disease severity were similar between the groups. Roux-en-Y reconstruction was significantly more common in the 2 BD group (77% versus 38%; P < 0.001) compared with the 1 BD group. No difference was found in biliary complication rates within 1 year after LDLT (1 BD versus 2 BD groups, 18% versus 21%, respectively; P = 0.46). In the 2 BD group, 82/169 (48.5%) patients were reconstructed with 2 anastomoses. The number of anastomoses did not negatively impact biliary complication rates. Recipients' major complication rate (Clavien ≥ 3b) was similar between both groups (1 BD versus 2 BD groups, 21% versus 24%, respectively; P = 0.36). Furthermore, no difference could be found between the 1 BD, the 2 BD, and the 3 BD groups in the frequency of developing biliary complications within 1 year (18%, 21%, 14%, respectively; P = 0.64), BD strictures (15%, 15%, 5%, respectively; P = 0.42), or BD leaks (10%, 11%, 10%, respectively; P = 0.98). In addition, the 1-year (90% versus 91%), 5-year (82% versus 77%), and 10-year (70% versus 66%) graft survival rates as well as the 1-year (92% versus 93%), 5-year (84% versus 80%), and 10-year (75% versus 76%) patient survival rates were comparable between the 1 BD and the 2 BD groups (P = 0.41 and P = 0.54, respectively). In conclusion, this study demonstrates that selected living donor grafts with 2 BDs can be used safely without negatively impacting biliary complication rates and graft or patient survival rates.

Longterm Analysis of Biliary Complications After Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantations

Biliary complication (BC) is still regarded as the Achilles' heel of a living donor liver transplantation (LDLT). This study aims to evaluate the longterm outcomes of the duct-to-duct (DD) biliary reconstruction using 7-0 suture and to identify the risk factors of BCs after LDLTs. Data of 140 LDLTs between 2006 and 2015 were analyzed. All biliary reconstructions were performed as DD anastomoses using 7-0 suture: 102 for the right lobe, 20 for the left lobe, and 18 for right posterior sector grafts. BC was defined as a bile leakage (BL) or a biliary stricture (BS), and the median follow-up time after LDLT was 65 months. A total of 19 recipients (13.5%) developed BCs (8 BLs and 16 BSs) after LDLT. The survival rates between recipients with and without BCs were 83% and 86.7%, respectively (P = 0.88). In univariate analyses, the risk factors for BC were small diameter of the graft's bile duct, long warm ischemic time, small graft-to-recipient weight ratio, and no use of external biliary stent (EBS). The graft's bile duct diameter ≤ 3 mm and no use of EBS were determined as independent risk factors (hazard ratios of 9.74 and 7.68, respectively) in multivariate analyses. The 116 recipients with EBS had no BL, 11 had BSs (9%), while 24 without EBS had 8 BLs (33%) and 5 BSs (21%). After a propensity score match between the recipients with and without EBS, the EBS group (24) developed only 1 BS (4%). In conclusion, DD anastomosis using 7-0 suture combined with EBS could provide favorable longterm outcomes after LDLT, which should thus be considered the surgical technique of choice for LDLTs.

Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions

Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.

Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial

BACKGROUND

Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT.

STUDY DESIGN

Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak.

RESULTS

Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003).

CONCLUSIONS

Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications.

Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004

BACKGROUND AND AIM

In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications.

METHODS

During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively.

RESULTS

The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%.

CONCLUSION

Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.

Endoscopic management of biliary strictures after living donor liver transplantation

Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.

Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up

BACKGROUND

Biliary complications are important during liver transplantation because of their effect on recipient and graft survival, incidence, and the long treatment period. These complications are associated with 50% morbidity and 30% mortality rates in recent studies. One of the most important reasons for biliary anastomosis complications is arterial ischemia. We present the results of our telescopic biliary anastomosis technique performed on the mucosa of the main biliary duct.

PATIENTS AND METHODS

Fifty-six cases of telescopic biliary reconstruction were performed in 203 patients during 2015. Fifty cases and 52 patients who underwent standard reconstruction were chosen and compared. All patients had been scanned retrospectively. Statistical analyses were conducted with χ2 and Mann-Whitney U tests for the complications that occurred during the first 3 months. A P value <.05 was considered significant.

RESULTS

No clinical or demographic differences were detected between the groups. About 90% of both groups were living donor liver transplantation cases. Five (10%) anastomotic leaks occurred in telescopic reconstruction group (n = 50), and 13 (25%) occurred in the standard reconstruction group (n = 52; P < .05).

CONCLUSION

The arterial blood supply is better if the biliary anastomosis is made on the mucosal side of the main biliary duct. Early period anastomotic leaks may decrease significantly.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Advisability of biliary drainage in liver fragments reconstruction]

AIM

to estimate the effect of decompressive stented drainage of biliary anastomosis on incidence of biliary complications.

MATERIAL AND METHODS

294 patients aged from 5 months to 61 years (mean 13.8±0.81) were enrolled. They underwent liver fragments transplantation in the Department of Liver Transplantation of Petrovsky Russian Research Center of Surgery for the period from March 1997 to January 2016. Decompressive stented drainage tubes were used in 28 (9.5%) patients. Reconstruction without drainage was applied in 266 (90.5%) cases. In the group of biliobiliary reconstruction drainage was used in 18 out of 89 cases (20.2%), in the group of biliodigestive reconstruction - in 10 out of 202 cases (4.9%). Incidence of specific biliary complications was assessed.

RESULTS

There was significant direct correlation of stented drainage of biliodigestive anastomosis with various biliary complications including bile leakage (r= -0,1253; p=0.06), obturation of anastomosis (r=0.045; p=0.501), stricture of anastomosis (r= -0.0665; p=0.320), other strictures of intrahepatic bile ducts (r= -0.0291; p=0.664), hepatolithiasis (r=0.0857; p=0.199). However significant direct correation was observed between stented drainage and incidence of intrahepatic bile ducts strictures (r=0.2117; p=0.046) and anastomosis obturation (r=0.2330; p=0.028) in case of biliobiliary reconstruction. Significant correation with other biliary complications was absent (p>0.05).

CONCLUSION

Unconstrained stented drainage during primary biliary reconstruction is associated with increased incidence of biliary complications and should not be indicated routinely. Clear need for drainage should be determined in further investigations.

Biliary complications in right lobe living donor liver transplantation

Living donor liver transplantation is an alternative to deceased donor liver transplantation in the face of insufficient deceased donor liver grafts. Unfortunately, the incidence of biliary complication after living donor liver transplantation is significantly higher than that after deceased donor liver transplantation using grafts from non-cardiac-death donations. The two most common biliary complications after living donor liver transplantation are bile leakage and biliary anastomotic stricture. Early treatment with endoscopic and interventional radiological approaches can achieve satisfactory outcomes. If treatment with these approaches fails, the salvage measure for prompt rectification will be surgical revision, which is now seldom performed. This paper also discusses risk factors in donor biliary anatomy that can affect recipients.

Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management

Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.

[The results of biliary reconstructions after liver fragments transplantation]

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.

Management of Biliary Strictures After Liver Transplantation

Strictures of the bile duct are a well-recognized complication of liver transplant and account for more than 50% of all biliary complications after deceased donor liver transplant and living donor liver transplant. Biliary strictures that develop after transplant are classified as anastomotic strictures or nonanastomotic strictures, depending on their location in the bile duct. The incidence, etiology, natural history, and response to therapy of the 2 types vary greatly, so their distinction is clinically important. The imaging modality of choice for the diagnosis of biliary strictures is magnetic resonance cholangiopancreatography because of its high rate of diagnostic accuracy and limited risk of complications. Biliary strictures that develop after liver transplant may be managed with endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), or surgical revision, including retransplant. The initial treatment of choice for these strictures is ERC with progressive balloon dilation and the placement of increasing numbers of plastic stents. PTC and surgery are generally reserved for failures of endoscopic therapy or for anatomic variants that are not suitable for ERC. In this article, we discuss the classification of biliary strictures, their diagnosis, and the therapeutic strategies that can be used to manage these common complications of liver transplant.

External biliary drainage in living donor liver transplantation using duct-to-duct anastomosis

PURPOSE

This study compared the incidence of biliary complication (BC) in adult living donor liver transplant recipients who underwent right-lobe duct-to-duct anastomosis (DDA) with or without external biliary drainage (EBD) and intended to optimize EBD tube clamping.

METHODS

This study consisted of a retrospective assessment of EBD effect and a prospective trial for EBD tube-clamping optimization. The retrospective study included the EBD group (n = 208) and the non-EBD group (n = 145). The prospective study included 60 patients with EBD.

RESULTS

In the retrospective study, single DDA was performed in 83.7% of the EBD group and 80.7% of the non-EBD group (P = .47). One-year overall incidence of BC was 14.4% in the EBD group and 16.8% in the non-EBD group (P = .48). The incidence of early anastomotic bile leakage was 1.0% in the EBD group and 4.8% in the non-EBD group (P = .036). In the prospective study, there was no difference in tube-clamping success rates between low- and high-output EBD groups. There was also no statistical difference between the success and failure groups in terms of graft duct size, liver function tests, and post-transplant days at tube clamping.

CONCLUSIONS

The size of our EBD tube was too small for the graft duct size, therefore its main role appeared to be early biliary decompression, which helped prevent bile leakage and also simplified the route of cholangiogram in detecting early BC. Hence, EBD is worthy of performing in selected patients with a high risk of anastomotic bile leak.

Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients

The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.

End-to-end ductal anastomosis in biliary reconstruction: indications and limitations

End-to-end ductal anastomosis is a physiologic biliary reconstruction that is commonly used in liver transplantation and less frequently in the surgical treatment of iatrogenic bile duct injuries. Currently, end-to-end ductal anastomosis is the biliary reconstruction of choice for liver transplantation in most adult patients. In recent years, it has also been performed for liver transplantation in children and in select patients with primary sclerosing cholangitis. The procedure is also performed in some patients with iatrogenic bile duct injuries, as it establishes physiologic bile flow. Proper digestion and absorption as well as postoperative endoscopic access are possible in patients who undergo end-to-end ductal anastomosis. It allows endoscopic diagnostic and therapeutic procedures in patients following surgery. This anastomosis is technically simple and associated with fewer early postoperative complications than the Roux-en-Y hepaticojejunostomy; however, end-to-end ductal anastomosis is not possible to perform in all patients. This review discusses the indications for and limitations of this biliary reconstruction, the technique used in liver transplantation and surgical repair of injured bile ducts, suture types and use of a T-tube.

Biliary complications in 108 consecutive recipients with duct-to-duct biliary reconstruction in living-donor liver transplantation

BACKGROUND

Biliary complications remain the leading cause of postoperative complications after living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy. The aim of this study was to analyze the causes of these complications.

METHODS

One hundred eight patients who underwent LDLT with duct-to-duct biliary reconstruction at Mie University Hospital were enrolled in this study. The mean follow-up time was 58.4 months (range, 3-132). The most recent 18 donors underwent indocyanine green (ICG) fluorescence cholangiography for donor hepatectomy. The development of biliary complications was retrospectively analyzed. Biliary complications were defined as needing endoscopic or radiologic treatment.

RESULTS

Biliary leakages and strictures occurred in 6 (5.6%) and 15 (13.9%) of the recipients, respectively, and 3 donors (2.7%) experienced biliary leakage. However, since the introduction of ICG fluorescence cholangiography, we have not encountered any biliary complications in either donors or recipients. Biliary leakage was an independent risk factor for the development of biliary stricture (P = .013). Twelve (80%) of the 15 recipients with biliary stricture had successful nonoperative endoscopic or radiologic management, and 3 patients underwent surgical repair with hepaticojejunosotomy.

CONCLUSIONS

Biliary leakage was an independent factor for biliary stricture. ICG fluorescence cholangiography might be helpful to reduce biliary complications after LDLT in both donors and recipients.

Interventional treatment of a biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis

BACKGROUND

[corrected] A biliary stricture is the most common complication after living-donor liver transplantation (LDLT). The present study was performed to examine treatment methods and outcomes after treatment for a biliary stricture after LDLT.

METHODS AND RESULTS

From January 2000 to December 2010, 488 patients underwent LDLT using the right lobe with duct-to-duct anastomosis at our transplantation centre. Overall biliary strictures were detected in 160 patients (32.8%), and the majority occurred within 2 years after LDLT. Biliary strictures were related to bile leakage (P < 0.001) and the urgency of the surgery (P = 0.012) in a multivariate analysis. All biliary strictures were treated with interventional modalities including an endoscopic or a percutaneous approach. Failure of interventional treatment was demonstrated in 13 patients (8.5%), among them, four (2.6%) underwent re-transplantation and nine (5.9%) died of sepsis and biliary cirrhosis during the follow-up period. A biliary stricture was not related to the survival rate (P = 0.586).

CONCLUSION

The incidence of overall biliary stricture was related to bile leakage and the urgency of the surgery. All biliary strictures could be treated by interventional modalities. These approaches are effective, complementary and help to avoid the need for surgery for a biliary stricture.

Single-center experience and long-term outcomes of duct-to-duct biliary reconstruction in infantile living donor liver transplantation

The indications for duct-to-duct (DD) biliary reconstruction in living donor liver transplantation (LDLT) for small children are still controversial. In this study, the feasibility of DD biliary reconstruction versus Roux-en-Y (RY) biliary reconstruction was investigated in terms of long-term outcomes. Fifty-six children who consecutively underwent LDLT with a weight less than or equal to 10.0 kg were enrolled. Biliary reconstruction was performed in a DD fashion for 20 patients and in an RY fashion for 36 patients. During a minimum follow-up of 2 years, the incidence of biliary strictures was 5.0% in the DD group and 11.1% in the RY group. Cholangitis during the posttransplant period was observed in the RY group only. There were no deaths related to biliary problems. This study shows that DD reconstruction in LDLT for small children (weighing 10.0 kg or less) is a feasible option for biliary reconstruction.

Outcome of routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation

OBJECTIVE

Microsurgical techniques, initially used for hepatic artery reconstruction, have been extended to biliary reconstruction to decrease biliary complications. The routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation (LDLT) has not been elucidated.

METHODS

Sixty-seven pediatric patients underwent primary LDLT. All biliary reconstructions were performed by a single microsurgeon using microsurgical techniques. A biliary stent was not used. The minimum follow-up was 12 months. Thirty-four patients had a minimum follow-up of 36 months. The outcomes of those who underwent microsurgical biliary reconstruction were compared with the outcomes of a cohort of 67 patients who underwent conventional biliary reconstruction.

RESULTS

The demographical and clinical profiles of the two groups were not significantly different. There were 5 anastomotic complications in the conventional and 2 anastomotic complications in the microsurgical reconstruction groups. All complications developed within 90 days after transplant. There were no late biliary complications. Further analysis showed that conventional reconstruction increased the risk of biliary complications by 2.4 times (relative risk: 2.42; attributable risk: 4.5).

CONCLUSION

The routine use of microsurgical biliary reconstruction in pediatric LDLT is a technical innovation that led to decreased anastomotic biliary complications.