Biliary reconstruction,its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence,risk factors and outcome

Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14 359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T‐tube placement was not performed in 82% of duct‐to‐duct reconstruction. The incidence of biliary stricture was 10% with a T‐tube and 13% without a T‐tube and the incidence of leakage was 5% with a T‐tube and 6% without a T‐tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.     

Biliary reconstruction in right lobe living-donor liver transplantation: Comparison of different techniques in 321 recipients

OBJECTIVE: To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction. SUMMARY BACKGROUND DATA: Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported. METHODS: Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed. RESULTS: The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment. CONCLUSIONS: The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.     

Technique and results of biliary reconstruction using side-to-side choledochocholedochostomy in 300 orthotopic liver transplants.

OBJECTIVE: The authors evaluated the complication rate and outcome of side-to-side common bile duct anastomosis after human orthotopic liver transplantation. SUMMARY BACKGROUND DATA: Early and late biliary tract complications after orthotopic liver transplantation remain a serious problem, leading to increased morbidity and mortality. Commonly performed techniques are the end-to-end choledochocholedochostomy and the choledochojejunostomy. Both techniques are known to coincide with a high incidence of leakage and stenosis of the bile duct anastomosis. The side-to-side bile duct anastomosis has been shown experimentally to be superior to the end-to-end anastomosis. The authors present the results of 316 human liver transplants, in which a side-to-side choledochocholedochostomy was performed. METHODS: Biliary tract complications of 370 transplants in 340 patients were evaluated. Three hundred patients received primary liver transplants with side-to-side anastomosis of donor and recipient common bile duct. Thirty-two patients with biliary tract pathology received a bilioenteric anastomosis, and in eight patients, side-to-side anastomosis was not performed for various reasons. Clinical and laboratory investigations were carried out at prospectively fixed time points. X-ray cholangiography was performed routinely in all patients on postoperative days (PODs) 5 and 42. In patients with suspected papillary stenosis, endoscopic retrograde cholangioscopy and papillotomy were performed. RESULTS: One biliary leakage (0.3%) was observed within the early postoperative period (PODs 0 through 30) after liver transplantation. No stenosis of the common bile duct anastomosis was observed during this time. Late biliary stenosis occurred in two patients (0.6%). T tube-related complications were observed in 4 of 300 primary transplants (1.3%). Complications unrelated to the surgical technique, including papillary stenosis (5.7%) and ischemic-type biliary lesion (3.0%), which must be considered more serious in nature than complications of the anastomosis or T tube-related complications, were observed. Papillary stenosis led to frequent endoscopic interventions and retransplantations in 1.3%. CONCLUSIONS: Side-to-side common bile duct anastomosis represents a safe technique of bile duct reconstruction and leads to a low technical complication rate after human orthotopic liver transplantation. Ischemic-type biliary lesion evoked by preservation injury, arterial ischemia, cholestasis, and cholangitis may represent a new entity of biliary complication, which markedly increases the morbidity after human liver transplantation. Therefore, this complication should be the subject of further research.     

Biliary complications in right lateral sector graft live donor liver transplantation.

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.     

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

OBJECTIVE: To assess the feasibility and safety of duct-to-duct biliary anastomosis for living donor liver transplantation (LDLT) utilizing the right lobe. SUMMARY BACKGROUND DATA: Biliary tract complications remain one of the most serious problems after liver transplantation. Roux-en-Y hepaticojejunostomy has been a standard procedure for biliary reconstruction in LDLT with a partial hepatic graft. However, end-to-end choledochocholedochostomy is the technique of choice for biliary reconstruction and yields a more physiologic bilioenteric continuity than can be achieved with Roux-en-Y hepaticojejunostomy. The authors performed right lobe LDLT with end-to-end duct-to-duct biliary anastomosis, and this study assessed retrospectively the relation between the manner of reconstruction and complications. METHODS: Between July 1999 and December 2000, 51 patients (11-67 years of age) underwent 52 right lobe LDLTs with duct-to-duct biliary reconstruction and remained alive more than 1 month after their transplantation. Interrupted biliary anastomosis was performed for 24 transplants and the continuous procedure was used for 28. A biliary tube was inserted downward into the common bile ducts through the recipient's cystic duct in 16 transplants (cystic drainage), or a biliary stent tube was pushed upward into the anastomosis through the cystic duct in four transplants (cystic stent), or upward into the anastomosis through the wall of the common bile duct in 31 transplants (external stent). RESULTS: Biliary anastomotic procedures consisted of 34 single end-to-end anastomoses, 11 double end-to-end anastomoses, and 7 single anastomoses for double hepatic ducts. Overall, 5 patients developed leakage (9.6%) and 12 patients suffered stricture (23.0%). For biliary anastomosis with interrupted suture, the incidence of stricture was significantly higher in the cystic drainage group (53.3%, 8/15) than in the stent group consisting of cystic stent and external stent (0%, 0/8). While the respective incidences of leakage and stricture were 20% and 53.3% for intermittent suture with a cystic drainage tube (n = 15), they were 7.7% and 15.4% for a continuous suture with an external stent (n = 26). There was a significant difference in the incidence of stricture. CONCLUSIONS: Duct-to-duct reconstruction with continuous suture combined with an external stent represents a useful technique for LDLT utilizing the right lobe, but biliary complications remain significant.     

肝移植术后胆道并发症的诊断与治疗

目的 探讨肝移植术后胆道并发症的诊断与治疗.方法 分析2007-2009年肝移植术后不同类型胆道并发症的患者的临床资料,评价胴道并发症的类型,处理方式及术后恢复情况.结果 肝移植术后胆道并发症患者23例,包括胆漏患者12例,计胆管吻合口漏7例,肝断面胆管漏3例,胆囊管漏1例,迷走胆管漏1例;移植术后胆管狭窄患者11例,其中吻合口狭窄4例,非吻合口性狭窄7例.7例吻合口漏患者中,胆管重建2例(Roux-en-Y吻合和胆肠襻式Warren吻合);胆道吻合口修补1例;单纯依靠外引流管引流1例,活体双供肝肝移植的患者剖腹探查纠正胆漏失败后行再次肝移植1例;行经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)植入支架2例.肝断面胆管漏3例中,行肝断面胆管缝扎1例,ERCP联合B超引导下穿刺引流2例,引流2个月后胆漏闭合,拔除引流管,但是随后又出现胆道狭窄,ERCP术后,病情好转.胆囊管漏1例,行胆囊管缝扎.迷走胆管漏1例,行胆囊床缝扎.吻合口狭窄的患者4例,3例经ERCP治愈,1例行胆肠吻合重建胆道后治愈.非吻合口性狭窄的7例,行ERCP治疗3例,ERCP失败后,行经皮肝穿刺胆管引流(percutaneous transhepatic cholangiographic drainage,PTCD)1例;再次肝移植3例,2例患者术后恢复良好,1例死于严重感染.结论 肝移植术后胆道并发症危害大,关键在于预防.     

High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation.

Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation.     

Is Duct to Duct biliary Anastomosis the Rule in Orthotopic Liver Transplantation?

Biliary complications after Liver Transplantation continue to be the major cause of morbidity in 11–25 % of patients. Biliary complications in patients who underwent orthotopic liver transplantation (OLT) at our institute between March 2007 and June 2010 were analyzed retrospectively. 32 patients underwent Deceased Donor Liver Transplantation (DDLT) and in 12 patients Living Donor Liver Transplantation (LDLT) was done. No patients were lost to follow up. Follow up ranged between 4 and 44 months. During the study period, 44 patients underwent orthotopic liver transplantation. Patients were divided into two groups: Biliary Complications group (BC) n = 5 and Non Biliary Complications group (NBC) n = 39. Biliary complications occurred in 15.9 % of patients. Bile leaks accounted for majority of biliary complications. Fifteen variables were analyzed as possible risk factors for biliary complications. Of these, split grafts, duct to duct biliary anastomosis and total blood loss were statistically significant (P < 0.05) for biliary complications. Endoscopic treatment was successful in managing biliary complications in 75 % of patients. Biliary complications are the most common major complications in orthotopic liver transplantation. Significant risk factors are split liver grafts and duct to duct biliary anastomosis. Increased blood loss is a predictor for post operative biliary complications. These complications should be managed by endoscopic interventions. Surgery is indicated following failure of endoscopic interventions.     

Biliary Complications During and After Donor Hepatectomy in Living Donor Liver Transplantation Focusing on Characteristics of Biliary Leakage and Treatment for Intraoperative Bile Duct Injury

Background

Biliary complication is one of the major donor complications during and after hepatectomy in living donor liver transplantation (LDLT). We evaluated risk factors for donor biliary complication in adult-to-adult LDLT.

Results of Using the Cystic Duct for Reconstruction of One of the Multiple Bile Ducts in Right Lobe Living Donor Liver Transplantation

BackgroundIn right-lobe liver grafts, variations in the biliary tree anatomy can result in multiple bile duct orifices. We present our experience of 10 patients in which biliary reconstruction was performed with the cystic duct for 1 of the anastomoses with 2 separated ducts. Also, we investigated whether the bile duct anastomosis technique, number of bile duct anastomoses, and use of biliary stents affect the rate of biliary complications.MethodsWe evaluated patients who underwent right-lobe living donor liver transplantation (LDLT) at İstinye University Hospital and İstanbul Aydın University Hospital between December 2017 and June 2020. The patients were divided into 4 groups: duct-to-duct (D-D), duct-to-sheath, double duct-to-duct, and duct-to-duct plus cystic duct-to-duct. Biliary complication rates were compared among these 4 groups, between single- and double-duct groups, and between stent (+) and stent (−) groups.ResultsNinety-three patients who underwent right-lobe LDLT (60 men, 33 women) with a mean age of 51 ± 13 years were included. Mean follow-up time was 18.5 ± 8.3 months. The overall biliary complication rate was 17.2% for all patients, 12.1% for the D-D (single-duct) group (33 patients), 16.1% for the duct-to-sheath group (31 patients), 26.3% for the double duct-to-duct group (19 patients), 20% for the duct-to-duct plus cystic duct-to-duct group (10 patients), 20% for the double-duct group (60 patients), 14.5% for the stent (+) group (69 patients), and 25% for the stent (−) group (24 patients). There were no significant differences among these groups in terms of biliary complication rates. Bile stricture occurred in only 1 cystic duct anastomosis (10%), and no bile leakage was observed.ConclusionsMultiple D-D biliary reconstruction using the cystic duct with external drainage tubes is feasible and safe for LDLT.     

Meta‐analysis of Duct‐to‐duct versus Roux‐en‐Y biliary reconstruction following liver transplantation for primary sclerosing cholangitis

This meta‐analysis aimed to compare outcomes following bile duct reconstruction in patients with primary sclerosing cholangitis (PSC) undergoing liver transplantation depending on whether duct‐to‐duct or Roux‐en‐Y anastomosis was utilized. An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches. Pooled risk ratios and mean difference were calculated using the fixed‐effects and random‐effects models for meta‐analysis. Ten studies including 910 patients met the inclusion criteria. There was no difference in the overall incidence of biliary strictures between the two groups [odds ratio (OR) 1.06 (0.68, 1.66); (P = 0.80)]. The anastomotic stricture rate was similar, [OR 1.18 (0.56, 2.50); (P = 0.67)]. Ascending cholangitis was higher in the Roux–en‐Y group [OR 2.91 (1.17, 7.23); (P = 0.02)]. Anastomotic bile leak rates, graft survival, PSC recurrence and number of patients diagnosed with cholangiocarcinoma following transplantation were comparable between both groups. Duct‐to‐duct and Roux‐en‐Y reconstruction had comparable outcomes. Both techniques are associated with similar incidence of biliary stricture. The bilioenteric reconstruction was associated with a higher risk of cholangitis. The incidence of de novo cholangiocarcinoma was similar in both groups. Duct‐to‐duct reconstruction should be considered when feasible in patients with PSC.     

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.     

Use of the hilar plate looping technique for bile duct dissection in living donor liver transplantation significantly reduces recipient biliary complications

Biliary complications remain a major cause of morbidity after liver transplantation, especially in living donor liver transplantation (LDLT). Maintaining adequate blood supply to the bile duct is important for the prevention of biliary complications. The objective of this study was to analyze the effects of different techniques for bile duct anastomosis on posttransplantation biliary complications. From August 2005 to August 2008, 121 liver transplantations were performed at our center. Among the total 121 liver transplant recipients, 68 patients underwent a LDLT using a right lobe graft and were enrolled in this study. We used classic dissection for the first 38 recipients and the hilar plate looping technique for the next 30 patients. The hilar plate looping technique involves the looping of the complete hilar plate and Glissonian sheath around the hepatic duct after full dissection of the right hepatic artery and portal vein. Biliary complications were defined as bilomas or strictures that developed within 6 months after transplantation and required surgical or radiological intervention. There were no significant demographic differences between the 2 groups. The incidence of complications was 15 (39.5%) for classic dissection and 3 (18.8%) for hilar plate looping. Furthermore, there were no biliary strictures in the hilar plate looping group, and there was a significant difference in the complication rate between the 2 groups (P = .011). In conclusion, the hilar plate looping technique during LDLT significantly reduces recipient biliary complications.     

Duct-to-duct biliary reconstruction for living donor liver transplantation: experience of 92 cases

Bile duct-to duct reconstruction is now performed in living donor liver transplantation (LDLT) for adult patients. To confirm the feasibility, the results after the reconstruction were retrospectively analyzed. The subjects were 92 adult patients who underwent LDLT at the University of Tokyo Hospital. During the observation period (median 546 days), biliary complications were observed in 28 cases (30%). The complications included bile juice leakage in 11, stenosis at the anastomotic site in 9, and tube trouble in 8. Of these, 20 patients required surgical revision. The results suggest that duct-to-duct reconstruction provides satisfactory results, although long-term observation will be necessary.     

胆肠吻合术在肝移植中的作用

目的 探讨胆肠Roux-en-Y吻合术在原位肝移植胆道重建以及术后胆道并发症治疗中的作用.方法 回顾性分析佛山市第一人民医院从2003年3月到2006年12月所实施28例原位肝移植胆道重建两种方式与术后并发症发生情况,胆管对端吻合组20例(占76.9%),胆肠吻合组8例(占23.1%),术后胆道并发症包括狭窄、胆漏、结石或胆泥以及广泛胆管坏死.结果 2例病人围手术期死亡,余26例病人总的胆道并发症发生率为19.2%(5/26),胆管对端吻合组发生率为27.8%(5/18),胆肠吻合组为0(0/8),胆肠吻合组胆道并发症发生率明显低于胆管对端吻合组(P<0.05),5例胆道并发症包括胆道狭窄3例,胆漏2例,治疗包括放置鼻胆管引流1例,放置金属内支架1例,行胆肠吻合术2例,行再次肝移植1例,其中2例死亡.结论 根据笔者的经验,胆肠Roux-en-Y术胆道并发症发生率明显低于胆管对端吻合组,无论是在肝移植胆道重建还是移植后胆道并发症处理方面,胆肠Roux-en-Y吻合术均非常有用,尤其是在重建胆管血运欠佳或内镜治疗失败时.     

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 reconstruction and complications of right lobe live donor liver transplantation

OBJECTIVE: To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications. SUMMARY BACKGROUND DATA: Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined. METHODS: From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors. RESULTS: The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered. CONCLUSIONS: With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.     

Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers

Melcher ML, Pomposelli JJ, Verbesey JE, McTaggart RA, Freise CE, Ascher NL, Roberts JP, Pomfret EA. Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01189.x.
© 2009 John Wiley & Sons A/S. Abstract: Adult living‐donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow‐up <180 d. Biliary reconstructions were performed using either duct‐to‐duct (DD) or Roux‐en‐Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.     

Surgical management of biliary complications following living donor liver transplantation

Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation.
Clin Transplant 2011: 25: 504–510. © 2010 John Wiley & Sons A/S. Abstract: 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.     

Duct-to-Duct Biliary Reconstructions and Complications in 100 Living Donor Liver Transplantations

Objective

We evaluated the risk factors for biliary complications and surgical procedures for duct-to-duct reconstructions in adult living donor liver transplantation (LDLT).

Patients and Methods

From February 2005 to March 2008, we performed 100 cases of adult LDLT with duct-to-duct biliary reconstruction, using 64 right lobe grafts, 33 left lobe grafts, and 3 right lateral grafts. We employed 4 types of duct-to-duct procedures: all interrupted 6-0 Prolene suture (group 1, n = 9); continuous posterior and interrupted anterior wall 6-0 Prolene suture (group 2, n = 49); all continuous 7-0 Prolene suture (group 3, n = 26); and all continuous 7-0 Prolene suture with external stent (group 4, n = 16). Biliary complications were defined as an anastomosis stricture or a leakage.

Results

Thirty-four patients experienced biliary complications during the follow-up period (median, 27 months). The incidence of stricture was 27% and that of leakage, 8%. There were no perioperative, intraoperative, or anatomic risk factors for biliary complications, except the type of duct-to-duct procedure. Group 1 and 2 patients showed higher incidences of biliary strictures than groups 3 and 4 (43.1% vs 4.7%; P = .00). Group 3 patients experienced a higher incidence of bile leakage than the other groups (23.1% vs 2.7%; P = .004).

Conclusions

The type of biliary reconstruction is a factor affecting biliary complications following duct-to-duct anastomosis in LDLT. Duct-to-duct biliary anastomosis with 7-0 monofilament suture and a small external stent is a feasible procedure in LDLT that significantly reduces the incidence of biliary complications.