Biliary Complications Following Deceased and Living Donor Liver Transplantation: A Review

Introduction

Biliary complications are the most important source of complications after liver transplantation, and an important cause of morbidity and mortality. With the evolution of surgical transplantation techniques, including living donor and split-liver transplants, the complexity of these problems is increasing. Many studies have shown a higher incidence of biliary tract complications in living donor liver transplantation (LDLT) compared with deceased donor liver transplantation (DDLT). This article reviews biliary complications after liver transplantation and correlations with LDLT and DDLT.

Objective

Provide an overview of biliary complications among LDLT and DDLT.

Results

The incidence of biliary complications is higher among LDLT (28.7%) when compared with DDLT (15.5%). Bile leaks were the most common complication due to LDLT (17.1%); however, stricture was the most common complication due to DDLT (7.5%).     

应用MRCP术前评估活体肝移植供者胆管系统

目的 评价应用MRCP术前评估活体肝移植供者胆管系统的临床意义.方法 60例活体肝移植供者(男50例,女10例,年龄19～60岁,平均32.3岁),于右半肝切取术前行MRCP检查,术中经胆囊管行胆道造影.回顾性分析这些活体肝移植供者术前MRCP和术中胆道造影结果,二者进行比较,对比术中胆道造影结果评价MRCP在活体肝移植供者胆管分型方面的准确性.结果 根据术前MRCP结果,所有60例活体肝移植供者均可以判断出肝内胆管分型情况,1型胆管40例,2型胆管12例,3型胆管5例,其他3例.术中胆道造影显示1型胆管39例,MRCP正确诊断38例,准确率为97.4%;术中胆道造影显示2型胆管12例,MRCP正确诊断出11例,准确率为91%;术中胆道造影显示其他胆管类型为9例,MRCP正确诊断出8例,准确率为89%;MPCP总体准确率为95%(57/60).结论 MRCP可以在术前较为准确地显示活体肝移植供者胆管分型,为临床制定手术方案提供依据.     

"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 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.     

Surgical Complications in 100 Donor Hepatectomies for Living Donor Liver Transplantation in a Single Brazilian Center

The rising demand for liver transplantation has continued to outspace the availability of deceased donor organs, leading to the need for other treatment options including living donor liver transplantation (LDLT). A precise evaluation of surgical complications is the most important issue in this setting. There are controversies about donor morbidity with reports ranging from 13%-75%. The aim of this study was to retrospectively analyze 100 LDLTs performed in a single Brazilian center from December 2002 to August 2008, stratifying the complications according to Clavien's scoring system. None of the donors experienced life-threatening complications or died. The majority of donors (n = 74) did not suffer any complication. Twenty-eight complications were observed in 26 patients. Fifty-seven hepatectomies were performed for adult and 43 for pediatric transplantations. According to the Brisbane classifications, we performed 49 right and 2 left hepatectomies as well as 49 left lateral segmentectomies. According to Clavien, the complications were as follows: grade I (n = 11; 39.2%); grade II (n = 8; 28.5%); and grade III (n = 9; 32.3%). No patient presented with grade IV or V. The most common problem a biliary tract injury, similar to other series. In this Brazilian series, hepatectomy for LDLT was a safe procedure with low morbidity, regardless of the type of liver resection. This practice will probably continue to grow to alleviate the pressure of growing waiting lists.     

活体肝移植22例临床分析

目的 总结开展活体肝移植的临床经验,探讨进一步提高活体肝移植疗效的措施.方法 回顾性分析我院22例活体肝移植供受体的临床资料,总结术前评估过程、手术方法和术后并发症的情况.结果 本组获取的供肝移植物包括左外叶2例、左半肝6例、扩大左半肝1例、右半肝5例和扩大右半肝8例.所有供体术后恢复顺利,未出现严重并发症.22例受体中成年患者13例,儿童患者9例.围手术期发生并发症8例,包括严重腹腔感染1例,肝功能恢复不良合并伤口感染1例,腹腔内出血继发肝动脉血栓形成1例,此3例患者最终均因多器官功能衰竭死亡.1例肝功能衰竭的患儿术后因心肺功能衰竭死亡.另外发生胆漏2例,顽固性腹水1例,右下肢深静脉血栓形成1例,均通过保守疗法治愈.18例受体病愈出院.手术后期发生胆道吻合口狭窄3例,行PTCD并留置支撑管治疗,Oddi括约肌失迟缓引起的梗阻性黄疸1例,行内镜下十二指肠乳头括约肌切开术治疗.此4例患者病情稳定,肝功能均已恢复正常.结论 选择合适的供体、掌握关键的手术技术,才能使供受体都获得良好的预后.     

超声检查在活体肝移植受体术后胆道并发症诊断中的应用

目的探讨超声检查在活体肝移植术后胆道并发症诊断中的临床应用。方法对21例成人右半肝活体移植受体术后进行超声检查,观察移植肝及其胆道声像图表现,与经皮经肝穿刺胆道造影引流(PTCD)等影像学结果相对比。结果 21例病例经PTCD及临床随访证实为胆管吻合口狭窄5例,胆泥1例,胆漏1例。超声检查能够诊断并与之相符5例,为4例吻合口狭窄及1例胆泥,胆漏病例可见肝周积液。其中4例胆管吻合口狭窄病例超声诊断时间均明显早于临床出现黄疸或血清胆红素升高的时间。结论在活体肝移植术后胆道并发症的诊断中,超声检查操作简便、无创、可重复性强、准确性较高,可早期诊断胆管并发症,具有重要的临床应用价值。     

Introduction of microsurgical technique to biliary reconstruction in living donor liver transplantation

OBJECTIVE: High rates of biliary complications continue to be a major concern associated with living donor liver transplantation (LDLT). In this article, we report our experience of applying a microsurgical technique to biliary reconstruction in LDLT. PATIENTS AND METHODS: From January 2001 to December 2005, 32 patients underwent LDLTs (8 children and 24 adults). Biliary reconstruction for 43 hepatic duct orifices in the 32 donor grafts 21 duct-to-duct anastomoses, and 22 cholangiojejunostomies. Nine cholangiojejunostomies in 4 donors used a microsurgical technique under an operative microscope. RESULTS: Biliary complications weren't observed among the cases of cholangiojejunostomy using a microsurgical technique. An anastomotic biliary leakage was found in a recipient with cholangiojejunostomy performed using a surgical loupe and a biliary stricture in another recipient who underwent duct-to-duct anastomoses using a surgical loupe. CONCLUSION: Introduction of a microsurgical technique for biliary reconstruction in LDLT, especially using an operating microscope in the setting of hepatico-jejunostomy for small hepatic duct (< or =2 mm in diameter), showed good results. We believe that using the operative microscope for biliary reconstruction could reduce the incidence of biliary complications associated with LDLT.     

Adult living donor liver transplantation: Perspectives from 100 liver transplant surgeons

The involvement of healthy living donors and the degree of technical difficulty make adult living donor liver transplantation (LDLT) different from any other surgical procedure. We surveyed 100 liver transplant surgeons to assess their views on the complex issues raised by LDLT. Data were collected at meetings on LDLT and by electronic mail. The study instrument was divided into general, donor, surgeon, recipient, and donor and recipient issues. Subjects provided the projected 1-year survival threshold that they would require for the recipient before they would perform LDLT. They listed the three topics that they thought were most critical for transplant fellows to know about LDLT. A majority agreed that transplant programs have a duty to their patients to offer LDLT, that the increasing success of the procedure will expand indications for liver transplantation, and that the risk to the donor causes them a moral dilemma. There was more divergence of opinion regarding who should have the final say about a potential donor's candidacy, whether it is difficult for donors to comprehend the risks of the procedure, and whether repeat cadaveric transplantations should be offered for failed LDLT performed for extended indications. Surgeons' median recipient survival threshold was a conservative 79%. Priorities for educating trainees focused on understanding complications and risks, technical factors, and ethical concerns such as putting the donor first. In conclusion, the findings of this survey indicate that transplant surgeons are working to balance their moral imperative to provide life-saving therapy for transplantation candidates with the risks posed to living donors. (Liver Transpl 2003;9:637-644.)     

The role of Intraoperative cholangiography (IOC) and methylene blue tests in reducing bile leakage after living donor hepatectomy

AimLiver transplantation remains the only curative treatment in end stage liver disease. Biliary complications remain the most common major morbidity causes in hepatic resection. We aimed to determine and eliminate the bile leakage in donor hepatectomy of LDLT.Material and methodsThis study was conducted retrospective and one center study. The study population included 110 consequential liver donors with major liver resection (more than three segments). The population was divided into three groups for data analyses. Primary study groups included 40 donors subjected to methylene blue test starting in April 2013 and 40 donors subjected to intraoperative cholangiography started in March 2014.ResultsA total of 110 liver donors (42.7% women) were included in the study. Postoperative biliary complications were less in methylene blue and intraoperative cholangiography (IOC) groups. Bile leakage was significantly higher in control group (23.3%) compared to methylene blue (5%) and IOC groups (2%) Average duration of hospital stay and duration of operation were significantly higher in control group compared to methylene blue and IOC groups.ConclusionIn our study we conducted to establish biliary leakage in living donor hepatectomy which intraoperative cholangiography test was used to determine. Many intraoperative methods have been introduced to prevent biliary leakage and development of complications. We have showed that IOC test used in the present study could be easily applied in both living liver donor hepatectomy and other major hepatectomy cases. IOC test reduced postoperative biliary leakage incidence and did not increase incidence of other complications.     

Safety of donor right hepatectomy for adult-to-adult living donor liver transplantation

The purpose of this study was to ascertain the usefulness of preoperative evaluations of donors by computed tomography (CT) volumetry and CT cholangiography for prevention of unexpected liver failure and biliary complications after donor right hepatectomy for adult-to-adult living donor liver transplantation. Fifty-two donors who underwent right hepatectomy without the middle hepatic vein were enrolled in this study. The values of graft weight (GW) were significantly correlated with those of estimated graft volume (GV; P < 0.0001). GW was predicted by the following formula: GW = 155.25 + 0.658 x GV; r(2) = 0.489. CT cholangiography revealed anatomical variants of biliary structure in one-third of the donors and also clearly showed one or two small biliary branches from the caudate lobe to the right hepatic ducts or the confluence in 58% of the donors. Biliary leakage, which was treated by conservative therapy, occurred in only one donor (1.9%). No donors received homologous blood transfusion. Hyperbilirubinemia (serum total bilirubin >5 mg/dl) occurred in 5.8% of the donors during their early postoperative periods. Precise evaluations of liver remnant volume by CT volumetry and biliary variation by CT cholangiography are essential for performing safe donor hepatectomy, preventing hepatic insufficiency and minimizing the risk of biliary tract complications.     

Psychosomatische Aspekte der Leberlebendspende

Living donor liver transplantation (LDLT) offers the option to reduce organ scarcity and thereby waiting list mortality. The crucial ethical problem of LDLT is the fact that the well being of a donor is being jeopardized for the improvement of quality of life of the recipient. To preserve mental health of the donors, psychosomatic evaluation should be conducted including examination of the coping capacity, the mental stability of the donor and the voluntary nature of the donation. Thus a comprehensive disclosure of information to donors is necessary. Realistic outcome expectations, family relationships without extreme conflicts, sufficient autonomy of the donor-recipient relationship and social and familiar support are predictors facilitating a favorable psychosocial outcome for the donor. Before and after LDLT the health-related quality of life of the donors is similar or increased in comparison to the general population. Psychiatric complications following LDLT can occur in 13% of the donors. Female donors, donors who have surgical complications themselves and donors with unrealistic outcome expectations should be given psychotherapeutic support before they are admitted to living liver donation. Urgent indications in the case of acute liver failure and the donation by adult children for their parents are particular stress factors. For the safety of the donor, these combinations should be avoided whenever possible.     

Biliary Complications in 108 Consecutive Recipients With Duct-to-Duct Biliary Reconstruction in Living-Donor Liver Transplantation

Background

Biliary complications remain the leading cause of postoperative complications after living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy. The aim of this study was to analyze the causes of these complications.

Methods

One hundred eight patients who underwent LDLT with duct-to-duct biliary reconstruction at Mie University Hospital were enrolled in this study. The mean follow-up time was 58.4 months (range, 3–132). The most recent 18 donors underwent indocyanine green (ICG) fluorescence cholangiography for donor hepatectomy. The development of biliary complications was retrospectively analyzed. Biliary complications were defined as needing endoscopic or radiologic treatment.

Results

Biliary leakages and strictures occurred in 6 (5.6%) and 15 (13.9%) of the recipients, respectively, and 3 donors (2.7%) experienced biliary leakage. However, since the introduction of ICG fluorescence cholangiography, we have not encountered any biliary complications in either donors or recipients. Biliary leakage was an independent risk factor for the development of biliary stricture (P = .013). Twelve (80%) of the 15 recipients with biliary stricture had successful nonoperative endoscopic or radiologic management, and 3 patients underwent surgical repair with hepaticojejunosotomy.

Conclusions

Biliary leakage was an independent factor for biliary stricture. ICG fluorescence cholangiography might be helpful to reduce biliary complications after LDLT in both donors and recipients.     

成人间双供体活体肝脏移植成功2例报告

目的供肝短缺是影响肝脏移植发展的主要因素之一，活体供肝是解决这一矛盾的重要措施，供者提供足够的肝脏是影响活体肝脏移植的重要因素。方法施行成人间双供体活体肝移植2例，1例由受者的两位姐姐分别提供左半肝作为供肝，另1例由受者母亲提供右半肝，由无心跳供者提供左半肝(采用劈裂方式，其另一部分肝脏同时为另一成人受者实施肝脏移植)作为供肝。结果术后供、受者肝功能均恢复良好。结论成人问双供肝活体肝脏移植可以为受者提供更大重量的肝脏，又可减少供者提供较多肝脏所带来的风险；双供肝一受者肝脏移植手术操作复杂。     

Living donor liver transplantation, adult to adult

AIM: Since living donor liver transplantation (LDLT) can offer a viable response to the lack of transplantable cadaveric organs, our center instituted an LDLT program in 2001. METHODS: The authors report their experience with the first 35 LDLT procedures successfully completed at the Liver and Multiorgan Transplant Center of the University of Modena between 9 May 2001 and 21 May 2003. The case series comprised 35 patients, 7 of which received a left-half liver and 1 a left lobe. RESULTS: The global survival rate was 77.2% (27 out of 35 patients), with a mean follow-up period of 295 days; the survival rate at 1 year was 81%. In 4 cases (11%) retransplantation was performed. The donor demographics are described; all donors returned to their normal activities before transplantation, after a mean follow-up period of 373 days. No intraoperative complications were experienced by the donors, whereas during the postoperative period, 2 donors (5.7%) developed major complications (1 biliary fistula on the cut surface, 1 stenosis of the main bile duct). CONCLUSION: Our study shows that LDLT can be safely completed in the donor, with good results achieved in the recipient as well. Underlying these results is the accurate pretransplant assessment that continued into the operation itself. Even more important was the demonstrated ability and experience of the surgical team to attain results in the donor which we believe are necessary for carrying forth a LDLT program.     

One thousand fifty-six hepatectomies without mortality in 8 years

BACKGROUND: Despite improvements in diagnostic and surgical techniques, operative mortality associated with liver resection is still greater than 2% in most of the recent studies. HYPOTHESIS: By refining preoperative and postoperative care and surgical skills, liver resection mortality can be decreased to zero. DESIGN: Retrospective cohort study to analyze postoperative morbidity and mortality in 1056 consecutive hepatectomies performed at a single medical center during 8 years. SETTING: Tertiary referral center. PATIENTS: A total of 915 patients who underwent 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign diseases. MAIN OUTCOME MEASURES: Operative mortality and morbidity rates. RESULTS: No operative mortality occurred. Major complications, as defined by postoperative radiologic or surgical intervention, occurred in 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary malignancy, and 5% of living donor liver transplantation donors. Using multiple logistic regression, independent risk factors associated with major complications were operative blood loss of 1000 mL or greater for hepatocellular carcinoma and total bilirubin level of 1.0 mg/dL or greater (>or=17 micro mol/L) and operative time greater than 6 hours for other liver malignancy. No independent factors associated with major complications were identified for biliary malignancy or for living donor liver transplantation donors among the variables investigated in this study. CONCLUSIONS: Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.     

Living liver donation: preoperative assessment,anatomic considerations,and long-term outcome

BACKGROUND: A major prerequisite for living donor liver transplantation (LDLT) as an acceptable treatment modality is thoughtful consideration of the donor. However, there has been no comprehensive audit of living liver donation focusing on issues such as donor selection, anatomic surveys, and long-term outcome. METHODS: Between June 1990 and January 2002 at our institution, 160 LDLTs were performed and 177 patients were referred for LDLT. For these patients, a total of 203 potential donors were screened. The process of donor selection, safety of donor hepatectomy, and postoperative morbidity were investigated. Additionally, an anonymous questionnaire was administered to 100 donors who had undergone LDLT more than 3 years previously. RESULTS: Thirty-eight (19%) of the 203 donor candidates were excluded. Precise estimation of the hepatic anatomy was indispensable for donor safety. None of the donors showed prolonged postoperative liver dysfunction nor developed complications requiring reoperation or readmission. There was no donor mortality. The responses to the questionnaire indicated that 95% of the living donors had not felt coerced to donate and that 5% were neutral about coercion pressure. There were no severe postoperative aftereffects, but minor problems were reported by 51% of the respondents. CONCLUSIONS: Our appraisal of the perioperative and long-term postoperative course of LDLT donors revealed that although most donors are satisfied after undergoing LDLT, there is a need for strict attention to the process of donor selection and long-term postoperative follow-up. The outcome of the present series seems to confirm the safety of donor hepatectomy.     

Selection of Safe Donors for Living Donor Liver Transplant Using Extended Right Lobe Graft

Extended right lobectomy (ERL) for living donor liver transplant (LDLT) is selectively performed in many transplant centers and has shown excellent recipient outcomes as reported in previous studies. Yet, there is no universally accepted indication for ERL in respect to donor safety. Current study was designed to stratify risk factors of adverse donor outcome after ERL. A total of 79 living donors who underwent ERL for LDLT were included in analysis. Donors were classified as safety and hazard donor groups according to postoperative findings relevant to posthepatectomy liver failure classification by the International Study Group for Liver Surgery. On multivariable analysis, left lateral section volume <20% of total liver volume and nonpreservation of segment 4a venous drainage were the independent risk factors impairing postoperative outcomes. Despite the short-term impairment of liver function in hazard donor groups, all donors recovered and showed satisfactory remnant liver regeneration. However, these findings have implications in establishing selection criteria of donors eligible for ERL donation. In conclusion, LDLT using ERL graft can be safely performed provided so that left lateral section volume/total donor liver is ≥20% besides conventional donor selection criteria. Also, efforts to preserve segment 4a vein must be made in performing ERL graft procurement in LDLT donors.     

Quality of life of living donors before and after living donor liver transplantation

Living donor liver transplantation (LDLT) is becoming an established method for treatment of terminal liver disease in adults. After resection of the right hepatic lobe, postoperative complications can arise in healthy donors, and even individual cases of death have been recorded. There remains, however, little research on the psychosocial aspects in living donors before and after LDLT. Using the WHOQOL questionnaire, this prospective study investigates the quality of life (QoL) in a sample of 28 living donors, including the relationship between postoperative complications and QoL before and 6 months after donation. Before LDLT, the donor QoL is high, above that of the general healthy population. After LDLT, a significant reduction in the QoL appears in the areas of "physical health" and "living conditions." Nevertheless, the QoL remains above the level of the general population. Only two donors showed general QoL values below those of the general population. The postoperative complications had no significant influence on the QoL after transplantation. The high QoL of donors following LDLT indicates a positive psychosocial outcome for the majority of donors, irrespective of donation-related complications. Additional psychosocial studies will be necessary to disclose predictors for an unfavorable psychosocial outcome following LDLT.     

Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation – a single centre prospective study

Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post‐operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage. This single‐centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left‐to‐right crossover drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and in recipients was 2.2%. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.