Synthetic bioabsorbable stent material for duct-to-duct biliary reconstruction

Biliary stricture remains a significant cause of morbidity after liver transplantation. We performed duct-to-duct biliary anastomosis by using an absorbable stent tube with a diameter equal to that of pig common bile duct as an internal stent. The stent tube was constructed using a synthetic biodegradable material-a lactic glycolic acid and epsilon-caprolactone copolymer. Three pigs were alive without cholestasis for 180 d; however, 1 pig died on the 65th postoperative d, and autopsy revealed no cholestasis or biliary sledge in the biliary stent tube. The 3 pigs were euthanized for histological examinations 180 d after surgery; the biliary stent tube was completely absorbed by this time. These experimental results showed the good patency of the absorbable biliary stent tube. In the future, the absorbable biliary stent tube is expected to be clinically developed as a biliary stent for biliary anastomosis, which may protect the biliary anastomotic stricture.     

Biliary complications in orthotopic liver transplantation: experience with a modified technique of duct-to-duct reconstruction

Biliary complications are described as frequent causes of morbidity during the postoperative course of orthotopic liver transplantation (OLTx), even in recent papers. The authors report here on their experience with duct-to-duct anastomosis as their method of choice for biliary reconstruction in a consecutive series of 100 OLTx in adult patients. The original technique, as described by Starzl, was modified by the authors by performing a wide, longitudinal plasty of both the donor and recipient bile ducts, joined together with two polidioxanone running sutures, producing the effect of a side-to-side anastomosis. This technique was used in all procedures, even when a significant discrepancy was evident between the ducts (n=10). Follow-up was completed in 100% of the patients for a period of 2–40 months (mean 13.1 months). Four major complications (4%) occurred including hepatic abscesses due to ascending cholangitis, T-tube dislocation, partial occlusion by a branch of the T-tube at the anastomotic site, and disruption of the bile duct after T-tube removal. In four other patients, transient abdominal pain followed removal of the stent. Neither strictures nor fistulas were observed. Choledochocholedochostomy on a T-tube stent represents, in our experience, the technique of choice for biliary reconstruction in OLTx. The procedure, as described in the present study, proved to be safe in preventing strictures and leakages and appears to be feasible in nearly 100% of all adult patients undergoing OLTx.     

Biliary complications in orthotopic liver transplantation: experience with a modified technique of duct-to-duct reconstruction

Abstract. Biliary complications are described as frequent causes of morbidity during the postoperative course of orthotopic liver transplantation (OLTx), even in recent papers. The authors report here on their experience with duct-to-duct anastomosis as their method of choice for biliary reconstruction in a consecutive series of 100 OLTx in adult patients. The original technique, as described by Starzl, was modified by the authors by performing a wide, longitudinal plasty of both the donor and recipient bile ducts, joined together with two polidioxanone running sutures, producing the effect of a side-to-side anastomosis. This technique was used in all procedures, even when a significant discrepancy was evident between the ducts ( n = 10). Follow-up was completed in 100% of the patients for a period of 2–40 months (mean 13.1 months). Four major complications (4%) occurred including hepatic abscesses due to ascending cholangitis, T-tube dislocation, partial occlusion by a branch of the T-tube at the anastomotic site, and disruption of the bile duct after T-tube removal. In four other patients, transient abdominal pain followed removal of the stent. Neither strictures nor fistulas were observed. Choledochocholedochostomy on a T-tube stent represents, in our experience, the technique of choice for biliary reconstruction in OLTx. The procedure, as described in the present study, proved to be safe in preventing strictures and leakages and appears to be feasible in nearly 100% of all adult patients undergoing OLTx.     

Biliary reconstruction in pediatric live donor liver transplantation: duct-to-duct or Roux-en-Y hepaticojejunostomy

Background

Duct-to-duct biliary reconstruction (DD) is currently a standard procedure in adult live donor liver transplantation (LDLT). Its pediatric feasibility, however, has rarely been reported. The goal of this study is to assess the incidence and treatment of biliary complication after pediatric LDLT with DD or Roux-en-Y hepaticojejunostomy (RY).

Method

Sixty children received LDLT between November 2005 and June 2008, and their database was reviewed.

Results

Biliary reconstruction was achieved with DD in 14 patients and with RY in 46 patients with mean follow-up period of 26.0 and 22.3 months, respectively. The incidence of biliary leakage in the DD and RY groups was 7.1% and 8.7%, respectively, and that of stricture was 28.6% and 10.9%, respectively; but the differences were not statistically significant. Biliary stricture in the DD group tended to require revision surgery with RY and longer treatment with percutaneous transhepatic cholangiodrainage compared with that in the RY group.

Conclusion

Theoretical advantages of DD over RY were not confirmed in this study. Duct-to-duct biliary reconstruction tended to encounter more biliary complications, especially stricture, with more difficulty in treating it than RY. Roux-en-Y hepaticojejunostomy seems preferable to DD in the setting of pediatric LDLT, but DD must be considered when making new Roux-en-Y limb seems impossible or troublesome owing to abdominal dense adhesion or short bowel syndrome.     

肝移植围胆道重建环节技巧与细节对胆道并发症的影响研究

目的 探讨肝移植围胆道重建环节技巧与细节对胆道并发症的影响。方法 回顾性分析广州军区广州总医院2003年8月至2006年12月（A组,74例）和2007年1月至2010年3月（B组,131例）两个阶段共205例肝移植病人的临床资料,比较两组围胆道重建环节技巧与细节的差异,统计术后胆道并发症及预后情况。 结果 两组胆管重建方式和围手术期病死率差异均无统计学意义。B组除温缺血时间显著短于A组外,在供肝胆管灌洗、供肝动脉和供受体胆管血供保护、受体胆道下段探查、供受体胆管吻合张力等方面与A组不同。B组胆道并发症发生率为5.3%,显著低于A组（11.0%）。 结论 肝移植围胆道重建环节注意缩短温缺血时间并注重供肝胆管灌洗、供肝动脉和供受体胆管血供保护、受体胆管下端探查、胆管吻合微张力等技巧和细节,可显著降低胆道并发症发生率。     

Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction are associated with postoperative morbidity and mortality. The aims of this study were to evaluate the long-term outcomes of endoscopic deployment of plastic stents, and to investigate factors associated with the stent deployment failure. Between April 2001 and May 2007, 96 patients received LDLT with D-D reconstruction at Okayama University Hospital. Among them, 41 patients (43%) had anastomotic biliary strictures, and all were referred first for endoscopic retrograde cholangiography (ERC). When deployment was unsuccessful, a percutaneous transhepatic procedure was employed. Successful stent deployment was achieved in 35 out of total 41 patients (85%) by both procedures. Among the 35 patients, 28 had their stents removed as a result of strictures resolution. Eight patients underwent ERC and repeated stent deployment as a result of recurrence of the strictures. Finally, 21 out of 41 (51%) patients with biliary stricture were completely treated by endoscopic therapy during the observation period (median 873 days: range 77–2060). By multivariate analysis, biliary leakage was associated with stent deployment failure. Endoscopic deployment of plastic stents is a first-line therapy for patients with biliary stricture after LDLT.     

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目的 探讨肝脏移植胆道重建的外科技巧和影响胆道重建效果的因素。方法 对中山大学附属第一医院器官移植中心2004—2005年施行368例同种原位肝移植病人的临床资料进行分析总结。结果：368例肝移植病人中36例（9．8％）发生与胆道相关的并发症。23例经非手术治疗而愈；13例行开腹手术治疗，其中7例接受再次肝脏移植。5例因胆道并发症导致死亡，死亡原因为严重胆道感染和腹腔感染，病死率为13．9％。结论 保证供、受体胆管断端良好血液供应，正确选择胆道重建方式，精细的显微外科胆管吻合技术和确保胆管通畅性等，是提高胆道重建质量、降低胆道并发症发生率的重要因素。     

Biliary tract reconstruction in liver transplantation

Biliary tract complications are often referred to as the Achilles' heel of liver transplantation and various techniques have been developed to overcome them. The two major methods of bile duct reconstruction currently in use consist of either (1) choledochocholedochostomy over a T-tube or, when duct-to-duct approximation is not feasible, choledochojejunostomy over an internal stent, or (2) interposition of the donor gallbladder as a conduit between the donor bile duct and either the recipient bile duct or a jejunal loop. Although these standardizations of biliary tract reconstruction have resulted in a reduction of biliary complications after liver transplantation, further advancement in the elucidation of ampullary obstruction and viability of the donor bile duct is needed.     

Duct-to-duct biliary reconstruction in adult-to-adult living donor liver transplantation

In living donor liver transplantation (LDLT), Roux-en-Y hepaticojejunostomy has been a standard technique for biliary reconstruction because the majority had been pediatric patients with biliary atresia. Adult-to-adult LDLT using the right lobe graft has recently been developed and we introduced duct-to-duct biliary reconstruction (hepaticohepaticostomy) in such cases. The aim of this study is to evaluate the feasibility of this procedure in adult-to-adult LDLT. From August 2000 to October 2001, five patients underwent adult-to-adult LDLT using the right hepatic lobe and were followed for more than 6 months at our institution. All patients underwent duct-to-duct biliary reconstruction (single hepaticohepaticostomy in one, multiple in four). For the grafts with multiple bile ducts, various techniques were used for reconstruction. In all patients, oral intake could be started early after the operation, and biliary leakage was not encountered. One patient developed two episodes of acute cholangitis who later developed biliary anastomosis stricture which required percutaneous dilatation at 11 months postop. However, otherwise, there were no infectious complications postoperatively. We conclude duct-to-duct biliary reconstruction is feasible and effective in adult-to-adult LDLT.     

Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis

BACKGROUND/PURPOSE: The aims of this study were to characterize the features of the biliary complications that occur after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis, and to evaluate the efficacy of treating biliary complications endoscopically. METHODS: The records of 273 consecutive patients who underwent RL-LDLT with duct-to-duct biliary anastomosis from July 1999 through July 2005 at Kyoto University Hospital were reviewed to determine the overall incidence of postoperative biliary complications and the outcome of endoscopic repair of those complications. RESULTS: Biliary complications occurred in 93 (34.1%) of the patients. These complications were: 80 biliary strictures (75 anastomotic and 5 nonanastomotic) and 16 biliary leakages (5 patients with biliary leakage also had a biliary stricture); most (72%) of the anastomotic strictures were complex (i.e., fork-shaped or trident-shaped). The strictures and leakages were repaired by the endoscopic placement of multiple inside stents above the sphincter of Oddi, and by nasobiliary drainage, respectively. The procedure was successful in repairing 51 (68.0%) of the anastomotic strictures and 8 (50.0%) of the biliary leakages. CONCLUSIONS: Endoscopic stenting of the bile ducts is efficacious in treating biliary complications related to RL-LDLT with duct-to-duct biliary anastomosis and the stenting should be attempted before surgical revision of strictures and leakages.     

Reappraisal of duct-to-duct biliary reconstruction in hepatic resection for liver tumors

BACKGROUND: Duct-to-duct reconstruction is theoretically suitable for short segmental defects of the bile duct. This technique would also be useful, without jeopardizing the curability, in selected cases with hepatic malignancies requiring concomitant liver and bile duct resection. METHODS: For biliary reconstruction after hepatectomy, duct-to-duct reconstruction was performed in 4 patients at our institution between 1994 and 2004. The surgical techniques used are presented, along with the results of evaluation of the outcome, including postoperative and long-term morbidity and survival. RESULTS: Duct-to-duct reconstruction was safely performed in the 4 patients with the defects ranging in size from 10 to 19 mm. None of the cases developed local recurrence at the anastomotic site. None of the cases developed stenosis of the anastomotic site either, but cholangitis occurred in 1 patient. CONCLUSIONS: Duct-to-duct reconstruction for short segmental defects after the removal of hepatic malignant tumors is feasible with less operative and long-term morbidity. It is essential to select patients carefully when thinking of performing duct-to-duct anastomosis without complication and cancer infiltration.     

Spatulated end-to-end bile duct reconstruction in orthotopic liver transplantation

Biliary complications continue to be a major source of morbidity following orthotopic liver transplantation. The aim of this study was to analyze the incidence and management of biliary complications related to the technique of bile duct reconstruction. The patients were stratified into two groups: group I (n = 39) had bile duct reconstruction performed by an end-to-end single interrupted suture choledochocholedochostomy (EE-CDCD) and group II (n = 38) had a spatulated end-to-end CDCD (spEE-CDCD) reconstruction; both groups had an intraductal stent. The groups were similar in age, gender, liver transplant indications and Pugh score. Ten biliary complications (26%), including five bile leaks (13%) and five biliary strictures (13%), were observed in the EE-CDCD group, while one biliary stricture (2.6%) occurred in the spEE-CDCD group (p < 0.05). Subsequent imaging studies and endoscopic retrograde cholangiopancreatography were performed less often in patients undergoing spEE-CDCD reconstruction (p < 0.05). The technique of a spatulated end-to-end bile duct reconstruction provides a significant improvement in lowering biliary complication rates in liver transplant patients. Despite the modest number of cases in this study this technique shows promise and has become the technique of choice in our institution.     

Duct-to-duct biliary reconstruction in orthotopic liver transplantation for primary sclerosing cholangitis: a viable and safe alternative

Roux-en-Y loop is considered the reconstruction method of choice in Orthotopic Liver Transplantation (OLT) for Primary Sclerosing Cholangitis (PSC). We have adopted an approach of duct-to-duct (D-D) reconstruction when recipient common bile duct is free of gross disease. Patients were divided into two groups: patients who underwent a Roux-en-Y choledochojejunostomy and patients who had a D-D anastomosis. Morbidity, mortality, disease recurrence and graft and patient survival were compared between the two groups and analyzed. Ninety-one patients had OLT for PSC. Sixty-three patients underwent a D-D biliary reconstruction, whereas 28 patients had a Roux-en-Y loop. Biliary leak complicated 8% from the D-D group, and 14% from the Roux-en-Y group (P = 0.08), whereas biliary strictures were identified in 10% vs. 7% patients from the D-D and Roux-en-Y group, respectively (P = 0.9). Actuarial 1, 3 and 10 year survival for D-D and Roux-en-Y group was (87%, 80% and 62%) and (82%, 73% and 73%), respectively (P = 0.7). The corresponding 1, 3 and 10 year graft survival was (72%, 58% and 42%) and (67%, 58% and 53%), respectively (P = 0.6). No difference was seen in disease recurrence rates. D-D biliary reconstruction in OLT for selected PSC patients remains our first option of reconstruction.     

Duct-to-duct biliary reconstruction following liver transplantation for primary sclerosing cholangitis

The biliary complications in patients undergoing biliary reconstruction by duct-to-duct (D-D) anastomosis or with a Roux-en-Y loop (RL) at the time of liver transplantation for primary sclerosing cholangitis (PSC, 16 D-D, 10 RL) or primary biliary cirrhosis (PBC, 31 D-D, 1 RL) were reviewed and compared. Patients were followed up for a mean period of 32 months. Extrahepatic biliary strictures occurred in 18.7%, 10% and 9.7% of DD-PSC, RL-PSC and DD-PBC patients, respectively, leaks in 6.2%, 20% and 6.4% DD-PSC, RL-PSC and DD-PBC patients, respectively (P=NS). Four intrahepatic biliary abnormalities developed in the PSC group. Duct-to-duct anastomosis did not significantly increase the risk of stricture formation or bile leaks in PSC patients compared to PBC patients. We conclude that duct-to-duct biliary reconstruction following liver transplantation for PSC is satisfactory unless the distal common bile duct is strictured.     

Two-step biliary external stent removal after living donor liver transplantation.

Biliary stenting plays an important role in living donor liver transplantation (LDLT) as the rate of biliary complication is higher in LDLT than in diseased donor whole LT. We use a 2-mm tube for stenting at the biliary anastomosis, externalize it through the lower common bile duct, and fistulize it using duodenal serosa. After 3 months without biliary complications ensured by a cholangiogram, the stent tube is removed in a two-step manner, allowing bile to drain under a fluoroscope. The incidence of local peritonitis was lower, and the hospital stay was shorter with the two-step procedure. We herein report on the method of the two-step removal and its efficacy.     

经胆囊管胆道引流在肝移植胆道重建中的临床应用价值Meta分析

[摘要] 目的 评价经胆囊管胆道引流（transcytic bile drainage,TBD）对肝移植术后胆道并发症的预防作用。方法 计算机检索PubMed、EMbase、sinoMed、Web of Science、the Cochrane Central Register of Controlled Trials（CENTRAL）、万方数据库、中国知网以及维普数据库等。查找并筛选出所有比较经胆囊管胆道引流（transcytic bile drainage,TBD）与T管引流（T-tube,T-T）或non-TBD对肝移植术后胆道并发症影响的随机对照试验（randomized controlled trial,RCT）,同时手动检测纳入文献的参考文献,检索时间均为建库至2017年2月28日。主要结局指标：胆道并发症总的发生率、胆道狭窄、胆漏以及拔管相关性胆漏。按纳入、排除标准由2位评价者独立进行RCT的筛选、资料提取和质量评价后,采用RevMan（5.30版） 软件进行Meta分析,并采用GRADE pro3.6软件进行证据质量评价。结果 共纳入文献6篇,其中TBD与T管引流（T-T）对照研究3篇,TBD与胆管直接吻合（primary closure）对照研究文献1篇,TBD、T-T与直接吻合三者对照研究2篇。纳入病例542例,其中TBD组347例,T-T组102例,non-TBD组133例。Meta分析结果显示：与T-T组相比,TBD虽然不能降低胆道并发症总的发生率和总的胆漏发生率（7.3% vs 10.8%,RR=1.27,95% CI =0.50～1.16, P =0.21;23.9% vs 30.4%,RR=1.03,95% CI =0.30～1.45, P =0.30）,但是能显著降低肝移植术后胆道狭窄和拔管后胆漏的发生率（14.3% vs 30.2%,RR=3.37,95% CI =0.33～0.75, P =0.0008;1.7% vs 18.8%,RR=2.48,95% CI =0.05～0.70, P =0.01）。与胆管直接吻合相比,TBD能降低肝移植术后胆道并发症总的发生率以及胆道狭窄的发生率,但差异没有统计学意义（25.8% vs 39.2%,RR=0.29,95% CI =0.58～1.50, P =0.77;14.0% vs 19.2%,RR=0.61,95%CI=0.54～3.24, P =0.54）,并且不会明显增加胆漏的发生率（17.4% vs 15.8%,RR=0.47,95% CI =0.47～1.59, P =0.64）。结论 在肝移植术后胆道并发症的预防上,TBD与胆管直接吻合相当,优于T管引流。因此,TBD在肝移植胆管重建中是可行的,并且具有一定的临床价值。     

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目的探讨原位肝移植术后非吻合口胆管狭窄(NABS)的预防和治疗措施。方法对2004年1月至2006年12月中山大学附属第一医院收治的516例同种原位肝移植病人的临床资料进行回顾性分析。总结肝移植术后发生NABS的情况。结果共发生NABS18例(3.5%),其中肝门部胆管狭窄9例,肝内胆管多发狭窄6例,肝内外胆管多发狭窄3例。18例病人采用给予反复的介入、内镜治疗、外科重建胆道及再次肝移植治疗。该组近期临床治愈率为55.6%(10/18),与NABS相关的再次肝移植率为38.9%(7/18),与NABS相关病死率为22.2%(4/18)。结论肝移植术后发生NABS临床处理棘手,应注重预防。NABS的治疗主要包括介入治疗和手术治疗,其中胆管介入治疗在NABS的临床处理中仍占重要地位,对于介入治疗、外科手术重建胆道等措施均无法控制其进行性发展的重度NABS病人,应把握好时机行再次肝移植。     

Technique of bile duct reconstruction and management of biliary complications in right lobe living donor liver transplantation

From December 1999 to January 2002, 50 right lobe living donor liver transplantations were performed. The donor operations included an intraoperative cholangiography to elicit variations in bile duct anatomy. The biliary reconstruction was done whenever possible as an end-to-end microanastomosis of the donor right hepatic duct with the recipient's bile duct. As a result of the early segmental branching of the donor biliary tree, two segment bile ducts had to be anastomosed in 20 patients and three segment bile ducts in three patients. In 12 patients, a Roux-en-Y hepaticojejunostomy was performed. All anastomoses were drained externally. We observed two leakages at the resection surface which could be treated successfully by an external drainage. Six leaks occurred at the site of end-to-end biliary anastomoses. Twice the problem could be conservatively solved placing a stent percutaneously. In two patients a hepaticojejunostomy was performed after a bile duct necrosis. In two patients with an anastomotic leak, occurring 3 d, respectively, 3 month after the original transplantation, the bile duct could be directly reconstructed over a T-tube. Two anastomotic stenoses were observed, one in combination with a leak treated by percutaneous stent implantation and the second, 3 month after transplantation which was treated surgically. Biliary reconstruction after living donor liver transplantation requires microsurgical techniques and can be performed as a direct end-to-end anastomosis in most cases. Biliary complications were treated by percutaneous drainage or surgical revision in all cases.     

In adult-to-adult living donor liver transplantation hepaticojejunostomy shows a better long-term outcome than duct-to-duct anastomosis.

Roux-en-Y hepaticojejunostomy (RYHJ) has been the standard biliary reconstruction in adult-to-adult living donor liver transplantation (ALDLT). Recently, duct-to-duct anastomosis (DD) has been introduced. This study compared the outcomes of RYHJ and DD. For 4 years, 74 recipients underwent ALDLT and were followed up for at least 2 years. The patients were divided into three groups, RYHJ group (n = 18), DD with a stent (DD + S) group (n = 35), and DD without a stent (DD - S) group (n = 21). Overall, biliary complications were developed in 32.4% patients. The biliary complication rate was 11.1%, 48.5% and 33.3% in RYHJ, DD + S and DD - S groups, respectively (P = 0.047). Bile leaks occurred in 28.5% of DD + S group. The incidence of biliary stricture was 5.3%, 20.2% and 28.6% in RYHJ, DD + S and DD - S group, respectively. Most complications (83.3%) were resolved nonsurgically. RYHJ has a better long-term outcome than DD in ALDLT. Subgroup analysis of DD group showed that DD - S group had no bile leaks, but still had a higher incidence of bile duct strictures. However, because this study was a retrospective review there are limitations in analyzing the data and confirming the conclusion. A randomized-prospective study will be needed to confirm these findings.