Factors Predicting Ischemic-Type Biliary Lesions (ITBLs) After Liver Transplantation

Among biliary complications, ischemic-type biliary lesions (ITBLs) remain a major cause of morbidity in liver transplant recipients, significantly affecting the chance of survival of both patients and grafts. We retrospectively reviewed 10 years of prospectively collected donor and recipient data from April 2001 to April 2011. We evaluated the incidence of ITBL occurrence, exploring the possible predisposing factors, including donor and recipient data. Two hundred fifty-one grafts were harvested: 222 of them were transplanted at our institution, the remaining 29 (11.6%) discarded by our donor team as showing >40% macrovesicular steatosis. Mild-moderate (20%-40%) macrovesicular steatosis (P < .001) and cold ischemia time (P = .048) significantly increased the risk of ITBL, also as an independent risk factor after multivariate analysis.     

Biliary complications after orthotopic liver transplantation: a 5-year experience

Introduction

Biliary complications, particularly bile duct stenosis or leak, remain the “Achilles' heel” of orthotopic liver transplantation (OLT), significantly increasing the risk of graft loss and recipient death. The aim of the study was to retrospectively analyze biliary complications over a 5-year experience seeking to identify risk factors for these complications.

Material and Methods

Eighty-seven OLT performed in 84 recipients were included in the analysis. In all cases but one, we performed an end-to-end hepatic duct anastomosis with a 7-0 running suture under 2.5× magnification.

Results

Biliary complications developed after 17.2% OLT: anastomosis site stenosis (10.3%), multiple stenoses (5.7%), or bile duct necrosis (1.1%). A bile leak was not observed. Two recipients died from biliary sepsis. Among the patients with biliary complications, there was an higher rate of hepatic artery problems (33.3% vs 2.7%; P < .01), and a longer anhepatic phase (85 vs 72 minutes; P < .01). We performed endoscopic treatment in 73% and percutaneous drainage in 6.6% of recipients. Good treatment results were achieved in 36.4% of cases with biliary complications whereas they were satisfactory in 27.3%. Five patients with biliary complications required re-transplantation.

Conclusions

A bile duct anastomosis performed end-to-end with a running suture under magnification decreased the risk of bile leakage after OLT. A prolonged anhepatic phase or an hepatic artery thrombosis or stenosis increased the risk of biliary complications after OLT.     

Biliary Complications After Orthotopic Liver Transplantation: The Hungarian Experience

Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the incidence and types of biliary complications after OLT in Hungary. We retrospectively analyzed data of 471 adult liver transplant recipients between 1995 and 2011. Biliary complications occurred in 28% of patients. The most frequent BCs were bile duct stricture, stenosis (19%), biliary leakage (12%), and necrosis (BN: 6.4%). Biliary complications were associated with the incidence of acute rejection (51% vs 31%; P = .003), hepatic artery thrombosis (43% vs 11%; P < .001), and hepatic artery stenosis (26% vs 11%; P = .002). When cold ischemic time was longer than 12 hours, leakage (10% vs 3%; P = .043), ischemic type biliary lesion (20% vs 3.4%; P = .05), and BN (12% vs 3%; P = .067) were more often diagnosed post-OLT. Most of the biliary complications were treated by radiologic interventions (70%). Bile duct necrosis was associated with lower graft and patient survival. In conclusion, acute rejection, hepatic artery thrombosis/stenosis and cold ischemic time longer than 12 hours increase the incidence of BCs. Successful management of these risk factors can reduce the incidence of biliary complications and improve mortality.     

Biliary complications after liver transplantation from maastricht category-2 non-heart-beating donors

BACKGROUND: There are unresolved issues regarding the security of liver transplantation with non-heart-beating donors (NHBDs). Recently, an increased incidence of biliary complications, mainly intrahepatic ischemic-type biliary strictures, has been described after controlled NHBDs. METHODS: We studied the incidence and risk factors for biliary complications among uncontrolled NHBDs recipients compared with a large population of HBD recipients. RESULTS: Overall, 16.8% of patients in the HBD group and 41.7% of patients in the NHBD group suffered any type of biliary complication (P=0.66). However, the incidence of nonanastomotic biliary strictures was significantly greater in the NHBD group (P<0.001). Multivariate analysis showed that independent risk factors for nonanastomotic strictures were hepatic artery thrombosis (relative risk; 98.7) and receiving a liver from a NHBD (relative risk; 47.1). CONCLUSIONS: If this type of donors is accepted as a source of liver organs, the high incidence of biliary complications should be considered and efforts should be made to decrease ischemic injury.     

Graft Steatosis as a Risk Factor of Ischemic-Type Biliary Lesions in Liver Transplantation

Ischemic-type biliary lesions (ITBLs) are now a discussed cause of morbidity and mortality in liver transplant recipients, even if not definitively characterized. We reviewed 13 years of donor and recipient data between April 2001 and April 2013. We evaluated the incidence of ITBL occurrence, exploring the possible predisposing factors, focusing on the relationship between severe macrovesicular steatosis of the graft and incidence of ITBL. A total of 445 grafts were harvested: 416 of them were transplanted at our institution, the remaining 29 were discarded by our donor team as showing more than 40% macrovesicular steatosis. Mild-moderate (20% to 40%) macrovesicular steatosis (P < .001) and cold ischemia time (P = .048) significantly increased the risk of ITBLs, also resulting in independent risk factors at multivariate analysis.     

Liver transplantation using non-heart-beating donors: Belgian experience

Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short. PURPOSE: To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers. RESULTS: Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months. CONCLUSION: This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.     

Biliary Complications After Liver Transplantation Using Side-to-Side Choledochocholedochostomy Reconstruction With or Without T-Tube

Background

Biliary complications are a frequent cause of morbidity, graft loss, and death after orthotopic liver transplantation (OLT). The choledochocholedochostomy anastomosis without a T-tube is controversial, as it has been related to more biliary complications.

Aims

The aims of this study were to determine the incidence and to identify the risk factors of post-OLT biliary complications after reconstruction with or without a T-tube.

Materials and Methods

Ninety-five consecutive adult patients with deceased donor liver transplantations (overall survival rate, 86.3%; mean follow-up, 22.2 months) were analyzed to determine the incidence and type of biliary complications in 2 groups: choledochocholedochostomy with (45 patients, Group I) or without a T-tube (50 patients, Group II). The incidence of biliary complications in Groups I and II was 40% (18/45) and 30% (15/50), respectively (P > .05). In Group I, 49% of the complications were directly related to the T-tube. Biliary anastomosis stricture was more frequent in Group II (28% vs 8.9% in Group I; P = .018). Endoscopic retrograde cholangiopancreatography (ERCP) was the most common therapeutic procedure for the resolution of biliary complications in both groups (Group I, 66.5%; Group II, 58.2%). Arterial thrombosis, high pretransplantation Model for End-Stage Liver Disease (MELD) score, and donor obesity were identified as risk factors for biliary complications after OLT.

Conclusion

OLT biliary reconstruction without a T-tube is not related to an increased risk of biliary complications, although stricutre of the anastomosis is more frequent in this group of patients. Donor obesity, arterial thrombosis, and high pretransplantation MELD score are associated with a higher incidence of biliary complications after OLT.     

Ischemic cholangiopathy after liver transplantation from controlled non-heart-beating donors-a single-center experience

BACKGROUND: Previous reports have shown that livers from controlled non-heart-beating-donors (NHBD) are associated with higher rates of primary failure and ischemic cholangiopathy of orthotopic liver transplantation (OLT) as a complication of the prolonged warm ischemia. METHODS: This retrospective review of activities from 1999 to 2006 examined donor characteristics of age, liver function tests, warm ischemic time before (1WITa) and after cardiac arrest (1WITb), cold ischemic time (CIT) and transplant results. RESULTS: Eleven NHBD retrieved livers were transplanted from "ideal" donors except for one elderly donor (73 years). Of the 11 recipients, 3 developed biliary cholangiopathy (27%). There were no episodes of primary graft nonfunction, but one recipient displayed primary graft dysfunction. Two recipients died: one due to biliary complications with sepsis (long CIT >10 hours, fatty liver), and the other due to aspiration pneumonia and hypoxic brain damage with normal liver function. One recipient required retransplantation owing to ischemic cholangiopathy (1WITb 45 min) at 6 months after OLT with a good result. The other eight recipients are alive (observation period 72 to 14 months) including six with normal liver function, one with biopsy-proven biliary ischemia and one with recurrent primary sclerosing cholangitis without biliary ischemic changes on biopsy. Among 164 heart-beating donors recipients transplanted in the same period, biliary complications occurred in 27 patients (16%), of whom 12 were leaks and 15 anastomotic strictures. CONCLUSION: NHBD were a good source for livers with reasonable early results. To avoid late complications especially ischemic cholangiopathy, caution is urged with the use of these organs as well as strict donor and ischemic time criteria.     

Isolated liver transplantation for decompensated end-stage liver disease in children with intestinal failure

Cholestasis progressing to end-stage liver disease (ESLD) is common in intestinal failure (IF) in infants. Isolated liver transplantation (OLT) is performed when eventual enteral sufficiency is expected. We reviewed our experience with OLT for ESLD in patients with residual IF. From 1998 to 2004, four IF patients underwent OLT for ESLD at our institution. Three were performed as UNOS status I for acute decompensation of chronic liver failure; one other with severe cholestasis with a living donor. The living donor recipient died within months after OLT of chronic respiratory failure despite normal liver function. One recipient remains on parenteral nutrition (PN) and continues to receive partial enteral feeds with normal liver function. Two other recipients became enterally sufficient after the OLT. Biliary complications occurred in two patients, one with late hepatic artery thrombosis. Resolution was achieved with serial balloon dilatations and the other by conversion from duct-to-duct anastomosis to a choledochoduodenostomy. The morbidity of OLT for this indication is higher than for others likely because of comorbidities like sepsis and pulmonary insufficiency. OLT is complicated further by the attempt to maximally preserve residual bowel length for the biliary reconstruction. OLT can be an emergent life-saving procedure in IF patients despite higher morbidity. Improved liver function and diminished portal pressures may shorten the time to enteral sufficiency. Management of parenteral nutrition after OLT can avoid ESLD and eliminate small bowel transplantation in selected patients.     

Delayed hepatic artery thrombosis in adult orthotopic liver transplantation-a 12-year experience.

BACKGROUND: Although the clinical features of early hepatic artery thrombosis (HAT) are well defined, the features of delayed (more than 4 weeks after transplantation) hepatic artery thrombosis are less clearly defined. The aim of our study was to identify risk factors, clinical presentation, and outcome of management of delayed hepatic artery thrombosis (HAT) after liver transplant (LTx). METHODS: An analysis of prospectively collected data of all patients transplanted from 1986 to 1998 was performed. The importance of recipient (age, sex, primary indication for LTx, cytomegalovirus status, and intraabdominal sepsis) and donor factors (donor age, cold ischemia time, and donor cytomegalovirus status), modes of presentation, and outcome of treatment (biliary reconstruction/stenting, regraft, vascular reconstruction, observation) were analyzed. RESULTS: Delayed HAT was seen in 31/1097 adult LTx recipients (incidence 2.8%). No recipient or donor factors were identified as risk factors. A total of 16 patients were symptomatic at presentation (HAT diagnosed on abdominal ultrasound). Six patients had recurrent episodes of cholangitis, four had cholangitis with a stricture, four had cholangitis and intrahepatic abscesses, and two had bile leaks. Biliary reconstruction was done in six patients (all of whom subsequently required a regraft), vascular reconstruction was performed in two patients (one regrafted and one died shortly after), four patients with cholangitis and stricture on presentation had a biliary stent (all four were later regrafted). A total of 16 patients were regrafted, 9 are alive, 5 died within 6 months (septic at time of LTx), 1 died after 1 year, and 1 died after 2 years. Fifteen patients were asymptomatic and detected on routine screening. 5 have remained asymptomatic and are still alive, 1 developed a biliary stricture that was stented and is alive 105 months later, 4 had recurrence of the original disease, 3 developed progressive graft failure and were listed for transplant but died before regraft due to overwhelming sepsis and hepatic encephalopathy. Two patients died due to nonbiliary sepsis. CONCLUSIONS: Delayed HAT is a rare complication of LTx that may present with biliary sepsis, or remain asymptomatic. Biliary or vascular reconstructions do not increase graft survival. Of the patients who were clinically silent on presentation, 20% developed progressive graft failure requiring a second transplant. A total of 33% survived in the long-term without a second transplant. Ongoing severe sepsis at the time of regraft results in poor survival.     

Liver transplantation using donors older than 80 years: a single-center experience

AIM: The shortage of organs for orthotopic liver transplantation (OLT) has forced transplantation centers to expand the donor pool by using donors traditionally labeled as "extended criteria donors." One such example is OLT using a donor with advanced age. MATERIALS AND METHODS: We retrospectively evaluated 10 patients who received a liver graft from cadaveric donors older than 80 years. We analyzed pretransplantation donor and recipient characteristics, as well as the evolution of the recipients. RESULTS: All 10 donors were older than 80 years (median age, 83.5; range, 80-93). No steatosis (>30%) was accepted in the older donor group. Medium follow-up was 19.5 months. The most frequent cause for OLT was hepatitis C virus (HCV) cirrhosis (8/10 patients). We had 1 case of primary nonfunction, 1 patient died immediately after surgery because of extrahepatic complications (cardiac arrest), and 2 other patients had a severe HCV recurrence and died after 1 and 2 years from OLT, respectively. Five patients had HCV recurrence and biliary complications were present in 60% of the patients. No cases of acute or chronic rejection were described. Overall survival rates after 1 and 3 years were 80% and 40%, respectively. CONCLUSIONS: Old donor age is not an absolute contraindication to OLT. Liver grafts from donors older than 80 years can be used knowing that there is a high risk of postoperative complications. Furthermore, the increased risk of developing severe HCV recurrence, related to older donor age, suggests that such livers should be used in HCV-negative recipients.     

肝移植后胆道并发症的诊断和处理

目的 研究肝移植后胆道并发症的诊断和处理及分析相关因素。方法 回顾性研究Pittsburgh移植中心96例肝移植病人。结果 94例（97次移植）存活2d以上的病人，92例为端端＋T管的胆道吻合，随访时间为5.8个月（0.3-10.2个月）。分析发现92例病人中8例有胆道并发症（8.51%）；T管拔除时胆漏2例，术后早期胆漏2例，狭窄2例。75％胆道并发症有诱因，诱因：肝动脉狭窄2例，其中1例合并严重排斥反应；肝动脉血栓3例；供一受体胆管直径不匹配1例。冷缺血时间无显著性差异。5例有肝动脉血栓和（或）狭窄＞50％行再移植，另3例无肝动脉血栓和（或）狭窄＜50％经皮穿刺和内窥镜＋支架或行气囊扩张，所有病人均获得良好疗效。结论 肝移植术后胆道并发症发生率为8.51％（胆－胆端端吻合＋T管），胆道狭窄晚于胆漏，肝动脉检塞和（或狭窄是最重要的相关因素；无肝动脉栓塞和（或）狭窄，则无需手术治疗，若有肝动脉栓塞和（或）狭窄＞50％，应尽早做再次肝移植。     

再次肝移植治疗移植肝失功的经验分析

目的 总结再次肝移植治疗移植肝失功的临床经验。方法 回顾分析1993年4月至2005年4月期间施行的9例再次肝移植受者临床资料。再次肝移植的原因包括肝动脉血栓（2／9）,门静脉血栓（1／9）,胆道并发症（6／9）;9例再次肝移植均为尸肝移植,3例采用经典原位肝移植,6例采用背驮式肝移植,6例采用Roux-en-Y胆肠内引流,1例供受体门静脉间用供体脾静脉搭桥,1例供体肝动脉与供体腹主动脉之问用供体脾动脉搭桥。结果 全组无手术死亡,5例术后未出现并发症,1例术后门静脉吻合口狭窄,3例术后6个月内死亡。结论 首次肝移植后由于胆道和血管并发症导致移植肝失功是再次肝移植的主要适应证,不失时机地进行再次肝移植是治疗移植肝失功惟一有效的方法。     

Liver Transplantation Using University of Wisconsin or Celsior Preserving Solutions in the Portal Vein and Euro-Collins in the Aorta

Introduction

Orthotopic liver transplantation (OLT) is today the gold standard treatment of the end-stage liver disease. Different solutions are used for graft preservation. Our objective was to compare the results of cadaveric donor OLT, preserved with the University of Wisconsin (UW) or Celsior solutions in the portal vein and Euro-Collins in the aorta.

Methods

We evaluated retrospectively 72 OLT recipients, including 36 with UW solution (group UW) and 36 with Celsior (group CS). Donors were perfused in situ with 1000 mL UW or Celsior in the portal vein of and 3000 mL of Euro-Collins in the aortia and on the back table managed with 500 mL UW or Celsior in the portal vein, 250 mL in the hepatic artery, and 250 mL in the biliary duct. We evaluated the following variables: donor characteristics, recipient features, intraoperative details, reperfusion injury, and steatosis via a biopsy after reperfusion. We noted grafts with primary nonfunction (PNF), initial poor function (IPF), rejection episodes, biliary duct complications, hepatic artery complications, re-OLT, and recipient death in the first year after OLT.

Results

The average age was 33.6 years in the UW group versus 41 years in the CS group (P = .048). There was a longer duration of surgery in the UW group (P = .001). The other recipient characteristics, ischemia-reperfusion injury, steatosis, PNF, IPF, rejection, re-OLT, and recipient survival were not different. Stenosis of the biliary duct occured in 3 (8.3%) cases in the UW group and 8 (22.2%) in the CS (P = .19) with hepatic artery thrombosis in 4 (11.1%) CS versus none in the UW group (P = .11).

Conclusion

Cadaveric donor OLT showed similar results with organs preserved with UW or Celsior in the portal vein and Euro-Collins in the aorta.     

Late biliary complications in pediatric liver transplantation

PURPOSE: The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children. METHODS: The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge. RESULTS: Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001). CONCLUSIONS: Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.     

原位肝脏移植术后肝动脉并发症的诊治

目的：探讨肝脏移植术后肝动脉并发症的诊断和处理。方法：回顾性总结107例肝脏移植患者的临床资料,分析肝脏移植手术中可能影响术后肝动脉并发症发生的危险因素,以及肝动脉并发症的预防、诊断和处理措施。结果：肝脏移植术后肝动脉并发症的发生与外科手术方式相关。供肝动脉的质量和供体-受体动脉的重建方式是两个重要因素。术后共发生动脉相关的并发症7例,发生率6．54％;其中死亡6例,死亡率85．7％;主要是肝动脉血栓形成和肝动脉狭窄。结论：供肝动脉的质量和动脉的重建方式是影响术后肝动脉并发症发生的主要因素。早期诊断、早期治疗是处理肝动脉相关并发症,挽救植入器官和患者生命的关键。     

BILIARY COMPLICATIONS AFTER LIVER TRANSPLANT: THE VICTORIAN EXPERIENCE

Background: Biliary complications remain a continuing problem in liver transplantation. The goals of this study were to document the frequency of biliary complications following orthotopic liver transplantation in the Victorian programme. and to examine associations with suspected risk factors with reference to biliary stenosis. Methods: Data were collected from 129 consecutive transplants in 123 patients (106 adults, 17 children) at the Austin Hospital, Melbourne during the period 1988–94. The 2 year actuarial survival was 88%. Biliary reconstruction was by end-to-end anastomosis in 89 patients and Roux-en-Y in 40. Complications were suspected on clinical, biochemical or microbiological evidence. Biliary stenoses were considered to be radiological evidence of duct narrowing. Results: Biliary complications occurred in 19% and biliary stenosis in 8.5%. Of the stenoses, 1/35 occurred in the first 20 month period, 9/47 in the second and 1/47 in the third. There was a significant difference between the middle period and other periods (P < 0.05, Chi-square test). This change may be related to incomplete flushing of bile from the donor liver. Recurrence of the original disease was suspected for one stenosis. The length of the donor bile duct from hilum to anastomosis, cold ischaemia time and total hepatic artery flow at transplant did not relate to stenosis. Cholangitis was not diagnosed in patients without strictures. Strictures were managed by dilatation (5/11) and by operative repair (6). Conclusions: Stenoses were not related to the length of the donor bile duct, cold ischaemia time or total hepatic artery flow. Meticulous adherence to the protocol for flushing out bile at the donor operation was associated with a significant reduction in frequency of biliary stenoses.     

Biliary complications in pediatric liver transplantation. A comparison of reduced-size and whole grafts.

One of the major changes in liver transplantation has been the application of reduced-size liver transplants(RLT). RLT has the great advantage of expanding the donor pool up to ten times the weight of the recipient, thereby decreasing pretransplant mortality in the pediatric age group. It has been suggested that RLT is a risk factor for biliary complications. To analyze the role of RLT and biliary complications, the results of 213 consecutive liver transplants in 164 pediatric patients over a 6-year period will were reviewed. These included 113 whole-liver transplants and 100 reduced-size liver transplants (49 reduced cadaveric liver transplants (RCLT), 38 split-liver transplants (SLT) and 13 living-related liver transplants (LRLT). The average weight and age were significantly higher in recipients receiving whole-size grafts (average weight 18.4 mg, average age 4.9 years) than in those receiving reduced size grafts (average age 2.3 years, average weight 11.1 kg). Biliary reconstruction consisted of Roux-en-Y, cholangiojejunostomy (n = 203) or choledochocholedochostomy (n = 10). There were 29 total biliary complications, (13.6%) with no significant difference in the complication rate between the whole (n = 13, 11.5%) or reduced livers (n = 16, 16%). Biliary leakage was the most common complication (n = 20), and it occurred at the biliary enteric anastomoses (n = 10), the roux limb (n = 7), or at the cut edge (n = 3). Of the leaks occurring at the biliary enteric anastomoses, 50% were caused by hepatic artery thrombosis. Biliary obstruction accounted for their remaining complications (n = 9) or 4.2%. Actuarial survival from 6 years to a minimum of two months of follow-up was 73% in the whole-size and 70% in reduced-size liver transplants. This series demonstrates that the incidence of biliary complications is similar in reduced-size and full-size grafts. No grafts were lost to biliary complications in the absence of hepatic artery thrombosis.     

Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient, and technical factors.

Biliary complications remain a significant problem following liver transplantation in the Model for End-Stage Liver Disease (MELD) era. We hypothesized that donor, recipient, and technical variables may differentially affect anastomotic biliary complications in MELD era liver transplants. We reviewed 256 deceased donor liver transplants after the institution of MELD at our center and evaluated these variables' association with anastomotic biliary complications. The bile leak rate was 18%, and the stricture rate was 23%. Univariate analysis revealed that recipient age, MELD, donor age, and warm ischemia were risk factors for leak, whereas a Roux limb or stent was protective. A bile leak was a risk factor for anastomotic stricture, whereas use of histidine tryptophan ketoglutarate (HTK) versus University of Wisconsin (UW) solution was protective. Additionally, use of a transcystic tube/stent was also protective. Multivariate analysis showed that warm ischemia was the only independent risk factor for a leak, whereas development of a leak was the only independent risk factor for a stricture. HTK versus UW use and transcystic tube/stent use were the only independent protective factors against stricture. Use of an internal stent trended in the multivariate analysis toward being protective against leaks and strictures, but this was not quite statistically significant. This represents one of the first MELD era studies of deceased donor liver transplants evaluating factors affecting the incidence of anastomotic bile leaks and strictures. Donor, recipient, and technical factors appear to differentially affect the incidence of anastomotic biliary complications, with warm ischemia, use of HTK, and use of a stent emerging as the most important variables.     

Surgical management of anatomical variations of the right lobe in living donor liver transplantation

OBJECTIVE: To review the anatomical variations of the right lobe encountered in 40 living liver donors, describe the surgical management of these variations, and summarize the results of these procedures. SUMMARY BACKGROUND DATA: Anatomical variability is the rule rather than the exception in liver and biliary surgery. To make effective use of liver segments from living donors for transplantation, surgical techniques must be adapted to the anomalies. METHODS: Donor evaluation included celiac and mesenteric angiography with portal phase, magnetic resonance angiography, and intraoperative ultrasonography and cholangiography. Arterial anastomoses were generally between the donor right hepatic artery and the recipient main hepatic artery. Jump-grafts were constructed for recipients with hepatic artery thrombosis, and double donor arteries were joined to the bifurcation of the recipient hepatic artery. The branches of a trifurcated donor portal vein were isolated during the parenchymal transection, joined in a common cuff, and anastomosed to the recipient main portal vein. Significant accessory hepatic veins were preserved, brought together in a common cuff if multiple, and anastomosed to the recipient cava. The bile ducts were individually drained through a Roux-en-Y limb, and stents were placed in most patients. RESULTS: Forty right lobe liver transplants were performed between adults. No donor was excluded because of prohibitive anatomy. Seven recipients had a prior transplant and five had a transjugular intrahepatic portosystemic shunt (TIPS). Arterial anomalies were noted in six donors and portal anomalies in four. Arterial jump-grafts were required in three. Sixteen had at least one significant accessory hepatic vein, and one had a double right hepatic vein. There were no vascular complications. Multiple bile ducts were found in 27 donors. Biliary complications occurred in 33% of patients without stents and 4% with stents. CONCLUSIONS: Anatomical variations of the right lobe can be accommodated without donor complications or complex reconstruction. Previous transplantation and TIPS do not significantly complicate right lobe transplantation. Microvascular arterial anastomosis is not necessary, and vascular complications should be infrequent. Biliary complications can be minimized with stenting.