Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation

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.

Living donor liver transplantation in the USA

Living donor liver transplant (LDLT) accounts for a small volume of the transplants in the USA. Due to the current liver allocation system based on the model for end-stage liver disease (MELD), LDLT has a unique role in providing life-saving transplantation for patients with low MELD scores and significant complications from portal hypertension, as well as select patients with hepatocellular carcinoma (HCC). Donor safety is paramount and has been a topic of much discussion in the transplant community as well as the general media. The donor risk appears to be low overall, with a favorable long-term quality of life. The latest trend has been a gradual shift from right-lobe grafts to left-lobe grafts to reduce donor risk, provided that the left lobe can provide adequate liver volume for the recipient.

Risk Factors for Bloodstream Infection After Living-donor Liver Transplantation in Children

BACKGROUND

Postoperative bloodstream infection (BSI) is the most important determinant of recipient morbidity and mortality after liver transplantation (LT). Children who underwent LT are at the highest risk of developing BSI because of the significant surgical intervention, use of multiple devices, and administration of immunosuppressive agents. However, information regarding the risk factors for BSI in children after LT is limited.

METHODS

We retrospectively reviewed 210 children who underwent living-donor LT at the largest pediatric LT center in Japan. Patients' characteristics, blood culture results and clinical outcomes were extracted from electronic medical records. Univariate and multivariate analyses were performed to identify the risk factors for BSI.

RESULTS

Among the 210 LT recipients, 53 (25%) recipients experienced 86 episodes of BSI during the observational period. The source of the BSI was identified only in 38%: catheter-related BSI (27%) peritonitis (7%), urinary tract infection (2%), pneumonia (1%) and infectious endocarditis (1%). A multivariate analysis demonstrated that body weight (P = 0.03), volume of blood loss during LT (P < 0.001) and cytomegalovirus (CMV) antigenemia positivity (P = 0.04) were independently associated with the development of BSI. The risk factors for BSI differed when we analyzed the subjects according to age (≤24 months and >24 months), blood loss and pediatric end-stage liver disease/model for end-stage liver disease versus positive CMV antigenemia.

CONCLUSIONS

The volume of blood loss, postoperative CMV antigenemia positivity and body weight were associated with the development of BSI after LT in pediatric living-donor recipients. To identify the age-specific predictors of BSI in children who underwent LT, age-specific analyses are crucial.

Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation

INTRODUCTION

Long-term biliary complications after living donor liver transplantation (LDLT) are not well described in the literature. This study was undertaken to determine the long-term impact of biliary complications after adult right-lobe LDLT.

METHODS

This retrospective review analyzed an 11-yr experience of 344 consecutive right-lobe LDLTs with at least two yr of follow-up.

RESULTS

Biliary leaks occurred in 50 patients (14.5%), and strictures occurred in 67 patients (19.5%). Cumulative biliary complication rates at 1, 2, 5, and 10 yr were 29%, 32%, 36%, and 37%, respectively. Most early biliary leaks were treated with surgical drainage (N = 29, 62%). Most biliary strictures were treated first with endoscopic retrograde cholangiography (42%). There was no association between biliary strictures and the number of ducts (hazard ratio [HR] 1.017 [0.65-1.592], p = 0.94), but freedom from biliary stricture was associated with a more recent era (2006-2010) (HR 0.457 [0.247-0.845], p = 0.01). Long-term graft survival did not differ between those who had or did not have biliary complications (66% vs. 67% at 10 yr).

CONCLUSIONS

Biliary strictures are common after LDLT but may decline with a center's experience. With careful follow-up, they can be successfully treated, with excellent long-term graft survival rates.

New endoscopic classification system for biliary stricture after liver transplantation

AIM

A new classification system for biliary stricture (BS) after liver transplantation (LT) is proposed, aiming to standardize endoscopic treatment for this condition.

METHODS

Data were retrospectively collected from patients who had undergone endoscopic retrograde cholangiography after LT, and who provided endoscopy images clear enough to reveal the biliary system. Images were classified separately by two endoscopists, who discussed and resolved any disputed findings. From these images, a new classification system is proposed (Ling classification): type A, normal biliary structure; type B, anastomotic stricture and normal intrahepatic biliary structure; type C, narrow and stiff intrahepatic biliary structure or beaded intrahepatic biliary structure or intrahepatic biliary cast without anastomotic stricture; type D, narrow and stiff intrahepatic biliary structure or beaded intrahepatic biliary structure or intrahepatic biliary cast with anastomotic stricture.

RESULTS

Analysis involved 93 patients: 76 men and 17 women, median age 54 years (range, 12-69 years). Type B was the most commonly observed BS after LT, accounting for 44 cases (47.3%). Type A, the least commonly observed type, accounted for nine (9.7%), type C for 22 (23.7%) and type D for 18 (19.3%) cases.

CONCLUSION

A new endoscopic classification system for BS after LT is proposed, to help determine the most appropriate treatment for patients with each type of stricture.

Quality-of-life assessment in the treatment of iatrogenic bile duct injuries: hepaticojejunostomy versus end-to-end biliary reconstructions

BACKGROUND

Assessment and comparison of quality of life (QOL) in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-en-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE).

METHODS

The Medical Outcomes Study Short Form 36v2 (SF-36v2) Health Survey and the Karnofsky score were used. Comparative analysis of QOL was performed in 41 patients following reconstructive surgery for IBDI between 1990 and 2005: 22 - HJ and 21 - EE.

RESULTS

Seven of eight values were comparable in both analysed groups: role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health index. Physical functioning was significantly better in patients following EE (P = 0.04). Physical component summary (P = 0.11) and mental component summary (P = 0.92) in both groups were comparable. QOL according to the Karnofsky scale was comparable in both groups (P = 0.294).

CONCLUSIONS

Physical functioning was significantly better in patients after EE. Other values of QOF according to the SF-36v2 and the Karnofsky score were comparable in both groups.

Repair of bile duct defect with degradable stent and autologous tissue in a porcine model

AIM: To introduce and evaluate a new method to repair bile duct defect with a degradable stent and autologous tissues.

METHODS: Eight Ba-Ma mini-pigs were used in this study. Experimental models with common bile duct (CBD) defect (0.5-1.0 cm segment of CBD resected) were established and then CBD was reconstructed by duct to duct anastomosis with a novel degradable stent made of poly [sebacic acid-co-(1,3-propanediol)-co-(1,2-propanediol)]. In addition, a vascularized greater omentum was placed around the stent and both ends of CBD. Cholangiography via gall bladder was performed for each pig at postoperative months 1 and 3 to rule out stent translocation and bile duct stricture. Complete blood count was examined pre- and post-operatively to estimate the inflammatory reaction. Liver enzymes and serum bilirubin were examined pre- and post-operatively to evaluate the liver function. Five pigs were sacrificed at month 3 to evaluate the healing of anastomosis. The other three pigs were raised for one year for long-term observation.

RESULTS: All the animals underwent surgery successfully. There was no intraoperative mortality and no bile leakage during the observation period. The white blood cell counts were only slightly increased on day 14 and month 3 postoperatively compared with that before operation, the difference was not statistically significant (P = 0.652). The plasma level of alanine aminotransferase on day 14 and month 3 postoperatively was also not significantly elevated compared with that before operation (P = 0.810). Nevertheless, the plasma level of γ-glutamyl transferase was increased after operation in both groups (P = 0.004), especially 2 wk after operation. The level of serum total bilirubin after operation was not significantly elevated compared with that before operation (P = 0.227), so did the serum direct bilirubin (P = 0.759). By cholangiography via gall bladder, we found that the stent maintained its integrity of shape and was still in situ at month 1, and it disappeared completely at month 3. No severe CBD dilation and stricture were observed at both months 1 and 3. No pig died during the 3-mo postoperative observation period. No sign of necrosis, bile duct stricture, bile leakage or abdominal abscess was found at reoperation at month 3 postoperatively. Pigs had neither fragments of stent nor stones formed in the CBD. Collagen deposit was observed in the anastomosis by hematoxylin and eosin (HE) and Masson’s trichrome stains. No severe cholestasis was observed in liver parenchyma by HE staining. Intestinal obstruction was found in a pig 4 mo after operation, and no bile leakage, bile duct stricture or biliary obstruction were observed in laparotomy. No sign of bile duct stricture or bile leakage was observed in the other two pigs.

CONCLUSION: The novel method for repairing bile duct defect yielded a good short-term effect without postoperative bile duct stricture. However, the long-term effect should be further studied.

Transhilar passage in right graft live donor liver transplantation: intrahilar anatomy and its impact on operative strategy

The passage through the hilar plate during right graft live donor liver transplantation (LDLT) can have dangerous consequences for both donors and recipients. The purpose of our study was to delineate hilar transection and biliary reconstruction strategies in right graft LDLT, with special consideration of central and peripheral hilar anatomical variants. A total of 71 consecutive donors underwent preoperative three-dimensional (3D) CT reconstructions and virtual 3D hepatectomies. A three-modal hilar passage strategy was applied, and its impact on operative strategy analyzed. In 68.4% of cases, type I and II anatomical configurations allowed for an en block hilar transection with simple anastomotic reconstructions. In 23.6% of cases, donors had "difficult" type II and types III/IV hilar bile duct anatomy that required stepwise hilar transections and complex graft biliary reconstructions. Morbidity rates for our early (A) and recent (B) experience periods were 67% and 39%, respectively. (1) Our two-level classification and 3D imaging technique allowed for donor-individualized transhilar passage. (2) A stepwise transhilar passage was favored in types III and IV inside the right-sided hilar corridor. (3) Reconstruction techniques showed no ameliorating effect on early/late biliary morbidity rates.

Surgical management of biliary complications following living donor liver transplantation

BACKGROUND

Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures.

METHODS

  Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss.

RESULTS

Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05).

CONCLUSIONS

In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.

Biliary complications in 106 consecutive duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation performed in 1 year in a single center: a new surgical technique

OBJECTIVE

Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu.

METHODS

Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis.

RESULTS

All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed.

CONCLUSION

We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.

Bloodstream infection after elective liver transplantation is associated with increased mortality in patients with cirrhosis

PURPOSE

This study aims to investigate what factors predict the development of postoperative bloodstream infection (BSI) in patients transplanted electively for chronic liver disease and compare outcomes in infected transplant recipients (BCLD) with noninfected patients (CLD).

METHODS

A retrospective cohort study of 218 patients who had elective liver transplantation (LT) between January 2003 and July 2005 and admitted to a specialist intensive care unit (ICU) was done.

RESULTS

Fifteen patients had BSI post-LT (BCLD, 29 isolates) while in the ICU, and 203 patients did not (CLD). Thirty-eight percent of isolates were gram negatives; 55%, gram positives; and 7%, fungemia. Median time to first BSI post-LT was 11 days (range, 3-16 days). On admission post-LT to the ICU, patients with BCLD had higher Acute Physiology and Chronic Health Evaluation II scores (23 vs 10, P < .001). While in the ICU, patients with BCLD had greater requirements for renal replacement therapy (73% vs 8%) and days on mechanical ventilation (17 vs 2 days) and longer median ICU stay (21 vs 3 days, P < .001 for all). One-year survival was worse in the BCLD group (40% vs 94%, P < .001). On multivariate analysis, Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.36) post-LT was independently associated with subsequent BSI. Bloodstream infection (hazards ratio, 8.7) was independently associated with mortality.

CONCLUSION

Bloodstream infection post-LT was associated with increased severity of illness on admission, greater requirements for organ support, and increased mortality.

Molecular epidemiology of Escherichia coli bacteremia in liver transplant recipients

The characteristics of Escherichia coli strains causing bacteremia in profoundly immunosuppressed patients such as transplant recipients are undefined. The phylogenetic group and the virulence genotype of 57 distinct E. coli strains that caused bacteremia in 53 liver transplant recipients were investigated, and the association of these characteristics with host factors and in-hospital mortality was examined. Phylogenetic groups A, B1, B2, and D accounted for 39%, 10%, 25%, and 26% of the isolates, respectively. The most prevalent virulence genes were fyuA (yersiniabactin system: 70%) and iutA (aerobactin system: 63%), whereas hlyA (alpha-hemolysin) and cnf1 (cytotoxic necrotizing factor 1) occurred in only 14% and 12% of isolates, respectively. Most virulence genes were significantly more prevalent among group B2 and D isolates, vs. group A and B1 isolates. The overall rate of in-hospital mortality after E. coli bacteremia was 20%. Predictors of mortality included onset of bacteremia within 30 days of transplantation or during the intensive care unit stay, and non-urinary source and cutaneous source, but not E. coli phylogenetic group or virulence profile. Compared with historical E. coli bloodstream isolates from non-transplant patients, those from liver transplant recipients are characterized by a higher prevalence of groups A and B1 isolates and reduced virulence gene content. This finding can be explained by the severely immunocompromised status of the patients and the predominance of abdominal-source bacteremic episodes. Time of onset and source of bacteremia, not bacterial characteristics, predict mortality.

An end-to-end anastomosis model of guinea pig bile duct: A 6-mo observation

AIM: To establish the end-to-end anastomosis (EEA) model of guinea pig bile duct and evaluate the healing process of bile duct.

METHODS: Thirty-two male guinea pigs were randomly divided into control group, 2-, 3-, and 6-mo groups after establishment of EEA model. Histological, immunohistochemical and serologic tests as well as measurement of bile contents were performed. The bile duct diameter and the diameter ratio (DR) were measured to assess the formation of relative stricture.

RESULTS: Acute and chronic inflammatory reactions occurred throughout the healing process of bile duct. Serology test and bile content measurement showed no formation of persistent stricture in 6-mo group. The DR revealed a transient formation of relative stricture in 2-mo group in comparation to control group (2.94 ± 0.17 vs 1.89 ± 0.27, P = 0.004). However, this relative stricture was released in 6-mo group (2.14 ± 0.18, P = 0.440).

CONCLUSION: A simple and reliable EEA model of guinea pig bile duct can be established with a good reproducibility and a satisfactory survival rate.

Detection of biliary stenoses in patients after liver transplantation: is there a different diagnostic accuracy of MRCP depending on the type of biliary anastomosis?

PURPOSE

Two different forms of biliary anastomosis can be created in patients undergoing liver transplantation: (a) bilio-digestive anastomoses or (b) choledocho-choledochostomy. Aim of this study was to assess the accuracy of MR cholangiopancreatography (MRCP) for the depiction of biliary stenoses in liver transplant patients depending on the type of biliary anastomosis.

METHOD AND MATERIALS

24 liver transplant patients with clinical suspicion of biliary stenosis were studied (each 12 with bilio-digestive anastomosis/choledocho-choledochostomy). MRCP was performed on a 1.5 T scanner (Magnetom Avanto, Siemens) including 2D single shot RARE, 2D T2w HASTE, TrueFISP and 3D high-resolution navigator corrected sequences. Presence of (a) anastomotic stenoses (AST) and (b) NAS (non-anastomotic strictures) were assessed. Percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP) were performed within 48h after MRCP and served as the standard of reference.

RESULTS

In patients with bilio-digestive anastomoses sensitivities of MRCP for the detection of AST and NAS amounted to 50% and 67%, respectively with specificity values of 83% and 50%. In patients with choledocho-chledochostomy sensitivities (AST: 100%, NAS: 100%) and specificities (AST: 100%, NAS: 88%) were significantly higher.

CONCLUSION

Biliary strictures after liver transplantation can be accurately detected by MRCP in patients after choledocho-chledochostomy. However, the diagnostic value of MRCP is lower if liver transplantation was performed in combination with a bilio-digestive anastomosis. This may be due to the less exact depiction of the anastomosis in the bowel wall. Thus, it is crucial to know the type of biliary anastomosis before choosing a diagnostic procedure.

Hepaticojejunostomy vs. end-to-end biliary reconstructions in the treatment of iatrogenic bile duct injuries

BACKGROUND

Retrospective comparison of short- and long-term results and quality of life in patients treated for iatrogenic bile duct injuries (IBDI) with Roux-Y hepaticojejunostomy (HJ) or end-to-end ductal anastomosis (EE).

METHODS

Between January 1990 and March 2005, 94 patients underwent reconstructive surgery for IBDI: 49, Roux-Y HJ, and 45, EE.

RESULTS

Early postoperative complications were observed in 12 (24.5%) patients undergoing HJ and three (6.7%) undergoing EE (p = 0.0239). Reoperations in the early postoperative period were performed in four (8%) patients after HJ and in zero patients after EE. Following HJ, one (2%) hospital death occurred due to acute circulatory insufficiency. Long-term results were evaluated in 69 (72%) patients. Postoperative mean weight gain was significantly higher after EE than HJ (p = 0.0191). Recurrent stricture was observed in two (5.3%) patients after HJ and three (9.6%) after EE (p = 0.6509). Terblanche long-term results were comparable in both groups (p = 0.3173). Good Karnofsky quality of life was comparable in both groups (p = 0.8377).

CONCLUSIONS

More early complications occurred after HJ than after EE. Long-term results were comparable after both reconstructive methods. After EE, patients achieved a higher weight gain than after HJ. Quality of life in both groups was comparable.

Endoscopic treatment for biliary stricture after adult living donor liver transplantation

Endoscopic intervention is considered to be the primary treatment for biliary stricture after adult living donor liver transplantation (LDLT) with duct-to-duct biliary reconstruction. The aim of this study was to investigate the risk factors of biliary stricture and the clinical outcomes and predictors of failure after endoscopic retrograde cholangiography with balloon dilation (ERC-D). We enrolled 239 adult patients who underwent LDLT between 2000 and 2006. Sixty-eight patients (28.4%) developed biliary stricture. Twenty-nine patients with anastomotic biliary stricture were treated with ERC-D and stenting. We retrospectively analyzed the risk factors of biliary stricture and the clinical outcomes of ERC-D. The median follow-up period was 31 months. The risk factors of biliary stricture on multiple logistic regression analysis were a graft with multiple bile ducts, a previous history of bile leakage, and hepatic artery stenosis. The overall success rate of ERC-D was 64.5%. On simple logistic regression, the failure of primary ERC-D was associated with late biliary stricture over 24 weeks and more than 8 weeks between a 2-fold increase of serum alkaline phosphatase from the stable level and ERC-D, even though these were not statistically significant on multiple logistic regression. The relapse rate of stricture after successful ERC-D was 30%. The duration of stenting in the recurrence group was shorter than that in the nonrecurrence group (11.8 +/- 5.03 versus 29.0 +/- 11.6 weeks, P = 0.004). ERC-D is effective for the management of anastomotic biliary stricture. However, the failure rate of primary ERC-D may be high in patients with late onset and delayed diagnosis of biliary stricture. The recurrence seems to occur frequently in patients with a short duration of stenting.

Early regular examination of biliary strictures by endoscopic retrograde cholangiography for duct-to-duct biliary reconstruction after adult living donor liver transplantation

In September 2006, we initiated regular screening of biliary strictures (BS) by endoscopic retrograde cholangiography (ERC) within 6 months after removal of external stents among duct-to-duct biliary reconstructed adult living donor liver transplantations (LDLT). From March 2000 to January 2008, we retrospectively evaluated 45 primary adult LDLTs who had survived >1 month. We separated the cases into 2 groups-the early cases (March 2000 to August 2006: n = 34) and the late cases (September 2006 to January 2008: n = 11)-to compare the incidences of BS and the success rates of endoscopic treatments. Median follow-up of the late cases (8.0 months) was shorter than that of the early cases (38.5 months; P = .0003). The overall incidence of BS was 36% (16/45), with 32% (11/34) among the early and 45% (5/11) among the late cases (P = .18). BS was successfully treated by endoscopic management in 4/5 (80%) late cases and 3/11 (27%) early cases (P = .049). Two early patients required operative biliary reconstructions. Endoscopic procedure-related complications developed in 2 patients among the early cases. Early postoperative regular screening of BS by ERC for duct-to-duct biliary reconstructions may be effective to avoid surgical interventions after adult LDLT. However, repeat ERCs have a risk for pancreatitis and other complications. Further investigations and longer follow-up are needed to confirm the efficacy and safety of a regular examination by ERC for duct-to-duct biliary reconstructions in LDLT.

Endoscopic management of biliary complications after adult right-lobe living donor liver transplantation without initial biliary decompression

OBJECTIVES

We sought to examine biliary complications in adult right-lobe living donor liver transplantation (LDLT) with duct-to-duct anastomosis (RL-LDLT-DD), evaluating the efficacy of endoscopic retrograde cholangiography (ERC) in the diagnosis and management of biliary complications following LDLT.

METHODS

Ninety adult RL-LDLT-DD were performed from June 2004 to August 2007, including 21 (23.3%) cases of biliary complications.

RESULTS

The endoscopic retrograde cholangiopancreatiography (ERCP) findings were stricture only (n = 8), stricture plus leakage (n = 9), and leakage only (n = 4). In the overall 13 cases of leakage, nine patients recovered after treatment by stent or endoscopic nasobiliary drainage. The time to resolution was 3.0 +/- 1.3 months with 2.2 +/- 1.3 endoscopic examinations. All bile duct complications were treated by ERC first. Among 17 cases with stricture, seven cases were successfully treated by endoscopy and three cases by percutaneous transhepatic cholangiography plus stent (PTCS). In the other seven cases, the treatment was still ongoing in five cases and two subjects died during treatment. The mean time to stricture resolution 7.2 +/- 3.3 months with 3.9 +/- 1.4 endoscopic examinations. The results of 21 cases were 5/21 mortalities (23.8%), successful ERC treatment in 9/21; (42.9%), successful PTCS treatment in 3/21 (14.3%), and ongoing ERC treatment in 5/21, (23.8%), including one case with successful ERC treatment who died of lung infection postoperatively. During follow-up (13.1 +/- 9.9 months), there was no recurrence in the stricture or leak.

CONCLUSIONS

When compared with the literature, RL-LDLT-DD without biliary drainage does not increase the incidence of biliary complications. From our study, ERC and PTC play a complementary roles in the treatment of bile duct complications.