磁共振胰胆管成像在成人活体右半供肝术前胆道评估中的应用

目的 探讨磁共振胰胆管成像( MRCP)在成人活体右半供肝术前胆道评估中的应用.方法 76例活体肝移植供者,均切取右半肝用于移植.脂肪餐后进行术前MRCP检查,比较MRCP胆管分型与术中胆道造影胆管分型的一致性;在MRCP图像上测量右后肝管汇入部距左右肝管汇合部的距离及相应右后肝管的直径,对相应胆管测量长度及直径与术中胆道重建方式进行二分类Logistic回归分析,并得出术中胆道是否成形的ROC曲线及其长度临界值.结果 MRCP胆管分型与术中胆道造影胆管分型的符合率为97.4％.MRCP所测右后肝管汇入部距左右肝管汇合部的距离和胆管分型是术中胆道重建方式的重要影响因素,而右后肝管直径对术中胆道重建方式的选择无影响.胆道解剖结构变异或Ⅰ型胆管(MRCP分型)中右肝管长度≤4.2mm时,95％的供肝胆道断端数多于1支,且95％行胆道成形术;Ⅲ、Ⅳ型胆管(MRCP分型)所测胆管长度为3.8mm,是选择胆道成形术的分界点.结论 MRCP胆管分型能准确反映胆道解剖结构,MRCP右后肝管汇入部距左右肝管汇合部距离测量值可以指导术中胆道重建方式的选择.     

Reducing Bile Leak Following Segmental Liver Transplantation: Understanding Biliary Anatomy of the Caudate Lobe

Bile leak in split and living donor liver transplantation is not an uncommon postoperative complication with significant morbidity to both donor and recipients. Nonanastomotic bile leaks in these transplants are less well characterized and generally described as cut-surface leaks. A proportion of these leaks may derive from biliary radicles draining the caudate lobe. Based on the caudate lobe biliary anatomy the authors describe measures that may help to reduce such complications after segmental liver transplantation.     

"Hepar divisum"--as a rare donor complication after intraoperative mortality of the recipient of an intended living donor liver transplantation.

In this study, we present our experience with 4 healthy donors having the rare condition of "hepar divisum" after the intraoperative death of the recipient of an intended right adult living donor liver transplantation (LDLT). The study included 4 donors and 4 intended right LDLT recipients affected by neuroendocrine tumor (n = 2), hepatocellular carcinoma (n = 1), and cryptogenic cirrhosis (n = 1). All 4 recipients died intraoperatively. At the time of recipient death, the dissection of the donor liver parenchyma was complete, the vessels intact, and the hepatic duct(s) already divided. In each case, reconstruction of the donor biliary tract was performed: hepaticojejunostomy (HJ) in 2 cases, each with 3 ducts, and duct-to-duct anastomosis in 2. Of the donors receiving the HJ, 1 had a cut surface bile leak and the other experienced an anastomotic leak, treated by percutaneous drainage and reoperation, respectively. The latter patient experienced recurrent HJ stenosis at 44 months and 50 months after the operation and was treated by percutaneous balloon dilatation. One duct-to-duct reconstruction was complicated by early stenosis (postoperative day 6) and treated with endoscopic stenting. In conclusion, in the case of intraoperative death of the recipient of an intended LDLT, when the parenchyma and the hepatic duct of the donor have already been divided, the options are completion of the donor hepatectomy or the status of "fegatum divisum" with reconstruction of biliary tract. The high incidence of biliary complication, however, is of concern. When more than 1 hepatic duct is present, the donor hepatectomy should be completed and the graft reallocated according to the policy of the transplant institution.     

Biliary complications among live donors following live donor liver transplantation

Introduction

In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse.

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.     

Hilar cholangiocarcinoma—surgical anatomy and curative resection

We have studied the surgical anatomy of the intrahepatic bile duct, hepatic hilus, and caudate lobe based on intraoperative findings and selective cholangiography of surgical patients and resected specimens, and have established the cholangiographic anatomy of the intrahepatic subsegmental bile duct. Thorough knowledge of the three-dimensional anatomy of the subsegmental bile duct, hepatic hilus, and caudate lobe is indispensable for curative surgery of hilar cholangiocarcinoma. We designed and actually performed 15 kinds of hepatic segmentectomies with caudate lobectomy and extrahepatic bile buct resection in 100 consecutive patients, with curative resection being possible in 82 patients. Postoperative survival after curative resection of hilar cholangiocarcinoma was better than expected, and the 5-year survival rates for all 82 patients with curative resection and for 55 patients with curative surgery without portal vein resection were 31% and 43%, respectively. Hepatic segmentectomy with caudate lobectomy and extrahepatic bile duct resection should be designed not only in accordance with the preoperative diagnosis of tumor extension into the intrahepatic bile ducts but also so that curative surgery for advanced hilar cholangiocarcinoma can be performed.     

Remaining caudate lobe in the right lobe graft in living donor liver transplantation: a blind spot?

The right margin of the caudate lobe is obscure. Therefore, a part of the caudate lobe (a part of the right side of the paracaval portion) seems almost always to remain with the right lobe graft during the standard harvesting procedure. We reviewed the intraoperative findings and the postoperative courses of donors and recipients of 11 consecutive living donor liver transplantations using right lobe grafts. Further, we used computed tomography during the postoperative course to investigate whether the remaining caudate lobe was present in the right lobe graft and whether it produced serious complications. Four recipients displayed an intraoperative bile leak from a remaining part of the caudate lobe after the completion of biliary reconstruction. With the exception of one case who developed repeated bile leakage from the same origin which eventually healed during a long-term postoperative course, Most recipients showed no postoperative biliary complications. Although a remaining caudate lobe was detected on postoperative computed tomography in all recipients, it produced no serious complications. In conclusion, a part of the right side of the paracaval portion of the caudate lobe almost always remains with a right lobe graft during the standard harvesting procedure. However, the implications of this phenomenon seem to be benign.     

Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis

BACKGROUND AND AIMS: Bile duct complications are the modern Achilles' heel of adult-to-adult living donor liver transplantation. A duct-to-duct anastomosis is currently performed in the presence of single graft ducts, while cholangiojejunostomy is used to drain multiple ducts. Our aim is to describe the feasibility of duct-to-duct anastomoses independent of the presence of one or multiple graft bile ducts. METHODS: The probe technique for right bile duct dissection in donors and a proximal hilar bile duct division in recipients are illustrated. The BARIGA LDLT (biliary anastomosis in right graft for adult living donor liver transplantation recipients) with end-to-side or end-to-end hepatico-hepaticostomy was used in five recipients of right grafts (segments 5-8). RESULTS: All donors and recipients are doing well; all grafts are functional at 13 months. Duct-to-duct anastomoses to single, double, or triple graft ducts have been performed. Two early anastomotic stenoses at 5 and 10 weeks were successfully treated endoscopically. CONCLUSION: The duct-to-duct anastomosis represents a valid alternative to the standard hepaticojejunostomy for right living donor liver grafts. Using this method, biliary complications can be treated endoscopically. End-to-side or end-to-end BARIGA LDLT has the potential to become a standard method in segmental transplantation, including split liver.     

Biliary complications in 96 consecutive right lobe living donor transplant recipients

BACKGROUND: Biliary reconstruction represents one of the most challenging parts of right lobe (RL) living donor liver transplantations (LDLTs). Different causes, surgical techniques, and treatments have been suggested but are incompletely defined. METHODS: Between June 1999 and January 2002, 96 RL LDLTs were performed in our center. We reviewed the incidence of biliary complications in all the recipients. RESULTS: Roux-en-Y reconstruction was performed in 53 cases (55.2%) and duct-to-duct was performed in 39 cases (40.6%). Both procedures were performed in 4 cases (4.2%). Multiple ducts (> or =2) were found in 58 grafts (60.4%). Thirty-nine recipients (40.6%) had 43 biliary complications: 21 had bile leaks, 22 had biliary strictures, and 4 had both complications. Patients with multiple ducts had a higher incidence of bile leaks than those patients with a single duct (P=0.049). No significant differences in complications were found between Roux-en-Y or duct-to-duct reconstructions. Freedom from biliary complications was 59% at 1 year and 55% at 2 years. The overall 1-year and 2-year survival rates for patients were 86% and 81%, respectively. The overall 1-year and 2-year survival rates for grafts were 80% and 77%, respectively. Occurrence of bile leaks affected patient and graft survival (76% and 65% 2-year patient and graft survival, respectively, vs. 89% and 85% for those without biliary leaks, P=0.07). CONCLUSIONS: Despite technical modifications and application of various surgical techniques, biliary complications remain frequent after RL LDLT. Patients with multiple biliary reconstructions had a higher incidence of bile leaks. Patients who developed leaks had lower patient and graft survival rates.     

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.     

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.     

Safety of donor right hepatectomy without abdominal drainage: a prospective evaluation in 100 consecutive liver donors.

Although the role of routine abdominal drainage after liver resection for tumors has been questioned, abdominal drainage after donor right hepatectomy for live donor liver transplantation (LDLT) has been a routine practice in most transplant centers. The present study aimed to evaluate the safety of the procedure without abdominal drainage. A prospective study was performed on 100 consecutive liver donors who underwent right hepatectomy for LDLT from July 2000 to September 2003. Biliary anatomy was carefully studied with intraoperative cholangiography using fluoroscopy. The middle hepatic vein was included in the graft in all except 1 patient. Parenchymal transection was performed using an ultrasonic dissector. The right hepatic duct was transected at the hilum and the stump was closed with 6-O polydioxanone continuous suture. Absence of bile leakage was confirmed with methylene blue solution instilled through the cystic duct stump. The abdomen was closed after careful hemostasis without drainage in all donors. The median age of the donors was 36 years (range 18-56 years). Median operative blood loss and operating time were 350 mL (range 42-1,400 mL) and 7.5 hours (range 5.2-10.7 hours), respectively. None of the donors required any blood or blood product transfusion. There was no operative mortality. The median postoperative hospital stay was 8 days (range 5-30 days). Postoperative morbidity occurred in 19 patients (19%), most of which were minor complications. No donor experienced bile leakage, intraabdominal bleeding, or collection. None required surgical, radiologic, or endoscopic intervention for postoperative complications, except for 1 donor who developed late biliary stricture that required endoscopic dilatation. All donors were well with a median follow-up of 32 months (range 11-50 months). In conclusion, with detailed study of the biliary anatomy and meticulous surgical technique, donor right hepatectomy can be safely performed without abdominal drainage. Abdominal drainage is not a mandatory procedure after donor hepatectomy in LDLT.     

成人间活体肝移植体会：附3例报告

目的总结和分析成人间活体肝移植(LDLT)的临床经验。方法对2007年2月—2007年7月的3例成人间活体肝移植的临床资料进行回顾性分析。结果供体为供体右半肝(不带肝中静脉)1例,供体扩大左半肝(带肝中静脉、尾状叶)2例,GV/SLV均≥40%。3对供者及患者术后均恢复良好,无小肝综合征发生,均未出现严重并发症。术后左半肝供者较右半肝供者肝功能恢复更快。结论如左半肝GV/SLV≥40%,可优先选择左半肝作为供肝;胆道重建不必放置胆管引流管;成人间LDLT是治疗终末期肝病的安全有效的手段。     

Hilar early division of the hepatic duct in living donor right hepatectomy: the probe-and-clamp technique.

The division of the hepatic duct is one of the most challenging passages of the donor hepatectomy. We report our experience with the early division, prior to the liver parenchyma resection, of the hepatic duct and the definition of the biliary anatomy with a probe inserted in the proper hepatic duct. From February 2002 to December 2004, 40 donors (25 male, 15 female; mean age 34, range 20-57) underwent right hepatectomy. The yield was a single duct in 24 donors (60%), two ducts in 12 donors (30%), and three ducts in one donor (2.5%), and three donors had aberrant anatomy yielding two ducts (7.5%). By means of a ductoplasty, a single orifice for the recipient biliary anastomosis was obtained in 77.5% of the cases. Three donors (7.5%) suffered a resection surface bile leak. The technique of hepatic duct probing and early division provides a precise definition of the biliary anatomy and facilitates one of the most challenging passages of the donor hepatectomy. This technique should also contribute to maximizing the preservation of the vascular supply of the hepatic duct and the yield of a single orifice for the recipient anastomosis. At a median follow-up of 21 months (range 10-44), neither short- nor long-term complications had been caused by the small donor choledochotomy.     

成人右半肝活体肝移植胆道重建探讨

目的探讨成人右半肝活体肝移植胆道重建的技术问题.方法回顾性分析我院2007年4月至2009年5月完成的21例成人右半肝活体肝移植资料.供肝右肝管与受者肝总管单个吻合10例;供肝两支胆管开口分别与受者两支胆管吻合5例;供肝胆管整形成一个开口与受者胆管吻合5例,其中采用T管支撑2例,Y型管支撑1例;右肝管空肠Roux-en-Y吻合1例.结果4例受者术后1个月内死亡,1例因术后急性肝坏死行再次肝移植.其余受者存活至今,1年存活率为77.65%.受者术后发生胆道并发症7例,其中胆漏5例,胆道狭窄2例,均经外科手术处理痊愈.胆管与胆管单个吻合口组、胆管整形成一个开口与受者胆管吻合组和两支胆管开口分别与受者胆管吻合组比较,胆道并发症发生率差异无统计学意义(x2=0.659,P=0.719).结论根据供受者胆管情况,可以灵活采用单根胆管吻合、胆管整形、分别吻合和肝管空肠吻合等不同重建方式.后壁连续、前壁间断以及显微外科技术的采用可能有助于降低胆道并发症的发生率.     

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.     

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.     

Infraportal bile duct of the caudate lobe: a troublesome anatomic variation in right-sided hepatectomy for perihilar cholangiocarcinoma

OBJECTIVE: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation. SUMMARY BACKGROUND DATA: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported. METHODS: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically. RESULTS: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe. CONCLUSION: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.     

Noninvasive preoperative evaluation of biliary anatomy in right-lobe living donors with mangafodipir trisodium-enhanced MR cholangiography

BACKGROUND: Accurate preoperative radiologic imaging is essential to assess the vascular and biliary anatomy of right-lobe living donors and to ensure their safety. Volumetric magnetic resonance cholangiography (MRCP) using Mangafodipir trisodium (Mn-DPDP) contrast has been recently proposed to evaluate the biliary anatomy of living donor candidates. METHODS: During their preoperative evaluation, 18 right-lobe (RL) living donors underwent 3D Mn-DPDP-enhanced MRCP in addition to the standard thin- and thick-slab MRCP imaging. Immediately prior to hepatectomy all 18 RL donors underwent intraoperative cholangiography (IOC) via the cystic duct. We compared the efficacy of these different radiologic techniques to actual intraoperative IOC findings. RESULTS: Sixty-eight intrahepatic bile ducts were identified on IOC, 67(98.5%) by Mn-DPDP-enhanced 3D MRCP, 41 (60%) by thick-slab SSFSE imaging, and 35 (51%) by thin-slice SSFSE imaging. Mn-DPDP-enhanced 3D MRCP detected 100% (n = 5) of the anomalous origins of the right bile duct, and thick-slab MRCP detected 20% (n = 1) and thin-slab MRCP detected 0%. Anterior and posterior right intrahepatic bile ducts were identified by MnDPDP-enhanced 3D MRCP 100% of the time, by thick-slab SSFSE imaging 35% of the time, and by thin-slice SSFSE imaging only 12% of the time. CONCLUSIONS: Mn-DPDP-enhanced 3D MRCP imaging was highly sensitive and specific in identifying variants of the intrahepatic bile ducts. This technique should be included in the standard protocol of preoperative radiologic evaluation of RL living donor candidates.     

Small Bile Duct Reconstruction of the Caudate Lobe in Living-Related Liver Transplantation

OBJECTIVE: To justify the technique of biliary reconstruction without mucosa-to-mucosa alignment for reconstructing the caudate lobe bile duct. SUMMARY BACKGROUND DATA: The use of a left hepatic lobe graft with the caudate lobe (LHGC) has been introduced to resolve the problem of small-for-size grafts in living-related liver transplantation. The authors have found that the LHGCs occasionally have independent openings of the bile duct of the caudate lobe. METHODS: The graft bile ducts were anastomosed to Roux-en-Y jejunal loops. The main left hepatic ducts were reconstructed in a standard manner. Small bile ducts of the caudate lobe were anastomosed to the intestine without mucosa-to-mucosa alignment, with an external biliary drainage tube, positioned transanastomotically. RESULTS: In 8 of the 19 patients who received LHGCs, nine bile ducts of the caudate lobe (median 1 mm) were reconstructed. After surgery there was no bile leakage. In five of the eight patients, the tubes were removed a median of 92 days after transplantation. Bile duct dilatation had not been observed at a median of 363 days after surgery. CONCLUSIONS: The authors consider their technique of biliary reconstruction without mucosa-to-mucosa alignment useful for the safe reconstruction of small bile ducts of the caudate lobe.