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.     

Intractable Biliary Strictures After Living Donor Liver Transplantation: A Case Series

BackgroundBiliary stricture (BS) is a severe complication after liver transplantation. It is difficult to treat, especially after living donor liver transplantation (LDLT). We successfully treated 4 patients for intractable BS after LDLT. All patients had developed cholangitis with stenosis of bile ducts anastomosis.Case 1. A 65-year-old woman underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Internal plastic stents inserted by endoscopic retrograde cholangiography (ERC) were changed quarterly for the next 2 years.Case 2A 55-year-old man underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Insertion of internal plastic stents by ERC was attempted; however, the posterior bile duct branch showed complete obstruction. After percutaneous transhepatic biliary drainage (PTCD), the stents were inserted using the rendezvous technique of ERC and were changed by ERC quarterly for the next 3 years.Case 3A 22-year-old man underwent LDLT with left lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and stents were changed quarterly for the next 2 years.Case 4A 60-year-old man underwent LDLT with right lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and changed to a metallic stent after 1 year. Three months later the stent was extracted using the rendezvous technique of double balloon enteroscopy.ConclusionBS of complete obstruction type after LDLT is difficult to treat. Appropriate procedures should be chosen based on the types of strictures and biliary reconstruction methods.     

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.     

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.     

活体肝移植术后胆管并发症的处理与预防

目的 探讨活体肝移植术后胆管并发症的防治.方法 84例活体肝移植,成人56例.小儿28例;良性终末期肝病66例,肝细胞肝癌18例.供受体胆管端端吻合重建50例,供体肝管与受体肝管端端和胆总管端侧吻合重建1例,供体肝管与受体肝管和胆囊管吻合1例,供体胆管与受体空肠Roux-en-Y吻合重建32例,所有胆管莺建后均置入4Fr或6Fr内支架管从受体胆总管前壁或空肠袢肓端侧肠壁引出体外.结果 术后发生胆管并发症24例,发生率为28.5%,胆管胆管吻合与肝管空肠Roux-en-Y吻合胆漏发牛率差异显著(8.3%νs16.7%,P＜0.05).胆管胆管吻合与肝管空肠Roux-en-Y吻合胆管狭窄发生率差异显著(50%νs 16.7%,P＜0.05).单支胆管与多支胆管发生胆管并发症差异湿著(20.8%νs 79.2%,P＜0.05).胆漏者保守治疗治愈4例,再次手术治疗治愈4例;胆管狭窄内镜下球囊扩张和鼻胆管引流治疗治愈4例,好转2例,再次手术胆管空肠Roux-en-Y吻合治疗治愈6例,经皮肝脏穿刺胆管狭窄球囊扩张治疗支架管引流治疗好转4例.该组资料无因胆管并发症死亡病例.结论 良好的胆管血供和吻合技术,选择恰当的胆管重建方式,是降低活体肝移植术后胆管并发症的重要措施.     

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.     

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.     

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.     

Feasibility of using the cystic duct for biliary reconstruction in right-lobe living donor liver transplantation.

Duct-to-duct biliary reconstruction has been introduced in adult living donor liver transplantation (LDLT). In right-lobe grafts, however, the presence of two or three separated bile duct orifices is not rare and makes an alternative approach for reconstruction necessary. We used the cystic duct for one of the anastomoses in biliary reconstruction for 5 right-lobe living donor liver transplants with two separated ducts. Before the anastomosis, the inside lumen of the cystic duct was straightened with a metal probe. Two external drainage tubes were placed in all recipients, and posttransplant cholangiography through the tubes approximately one month after transplantation showed no leakage or stricture at any of the anastomotic sites. The drainage tubes were removed between 17 and 37 weeks after transplantation. All of the patients except one who died of chronic rejection have been doing well without any late biliary complications during follow-up periods ranging from 10 to 28 months after transplantation. In conclusion, our results indicate that biliary reconstruction using the cystic duct is feasible and safe for living donor liver transplantation and that external drainage tubes may be effective for prevention of complications.     

Bile duct anastomotic stricture after pediatric living donor liver transplantation

Background/PurposeHepaticojejunostomy is a well-accepted method, whereas duct-to-duct anastomosis is gaining popularity for bile duct reconstruction in pediatric living donor liver transplantation (LDLT). Biliary complications, especially biliary anastomotic stricture (BAS), are not clearly defined. The aim of the present study is to determine the rate of BAS and its associated risk factors.MethodsThe study included 78 pediatric patients (<18 years old) who underwent LDLT during the period from end of September 1993 to end of November 2010. The diagnosis of BAS was based on clinical, biochemical, histologic, and radiologic results.ResultsAll patients received left-side grafts. Thirteen patients (16.7%) developed BAS after LDLT. Among them, 3 patients (23.1%) had duct-to-duct anastomosis during LDLT. The median follow-up period for the BAS group and the non-BAS group was 57.8 and 79.5 months, respectively (P = .683). Ten of the patients with BAS required percutaneous transhepatic biliary drainage with or without dilatation for treating the stricture. Multivariable analysis showed that hepatic artery thrombosis and duct-to-duct anastomosis were 2 risk factors associated with BAS.ConclusionIn pediatric LDLT, hepaticojejunostomy is the preferred method for bile duct reconstruction, but more large-scale research needs to be done to reconfirm this result.     

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.     

Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation

BACKGROUND: The aims of this study were to characterize the features of the biliary strictures that occur after duct-to-duct biliary reconstruction during right-lobe living-donor liver transplantation (LDLT) and to evaluate the feasibility of correcting such stricture endoscopically by inserting an "inside stent," that is, a short internal stent, above the sphincter of Oddi. METHODS: Biliary stricture occurred in 26 (35.6%) of 73 consecutive patients who underwent right-lobe LDLT with duct-to-duct biliary reconstruction from July 1999 through October 2001 and survived for more than 3 months. Of the 26 patients who had biliary stricture, 22 were referred for endoscopic retrograde cholangiography (ERC) and 4 for percutaneous cholangiography. RESULTS: ERC disclosed biliary stricture in 19 (86.4%) of the 22 patients who underwent the procedure. One patient had an unbranched stricture, 16 had a fork-shaped stricture, 1 had a trident-shaped stricture, and 1 had a stricture with more than three branches. Fourteen (73.7%) of the patients with strictures were treated endoscopically by inserting inside stents ranging from 7 F to 12 F in size, three underwent a Roux-en-Y hepaticojejunostomy to repair their stricture, and two were closely observed as outpatients. Of the 14 patients who were treated with the inside-stent, only 1 had acute cholangitis immediately after the procedure and underwent a Roux-en-Y hepaticojejunostomy. The other 13 patients who were treated with the inside stent have not required surgical repair for as long as an average of 586 days. CONCLUSION: Endoscopic placement of an inside stent is useful for treating biliary strictures in patients who have undergone right-lobe LDLT with duct-to-duct reconstruction.     

Intrahepatic artery pseudoaneurysm associated with a metallic biliary stent after living donor liver transplantation: report of a case

An intrahepatic artery pseudoaneurysm (IHAA) is a very rare but potentially lethal complication occurring after liver transplantation. This report presents a case of an IHAA associated with a metallic biliary stent after liver transplantation. A 40-year-old male underwent living donor liver transplantation (LDLT) using a left lobe graft. The bile duct reconstruction was performed with Roux-en-Y hepaticojejunostomy. He developed obstructive jaundice 5 years after LDLT, and had biliary stricture of the anastomosis area, therefore, the two metallic biliary stents were finally positioned at the stricture of the biliary tract. He suddenly developed hematemesis 8 years after LDLT, and computerized tomography scan showed an IHAA. Although seven interlocking detachable coils were placed at the neck of the aneurysm, hematemesis recurred 3 days after the initial embolization. Therefore, retransplantation was successfully performed 25 days after the embolization of IHAA using a right lobe graft from his son. In conclusion, metal stent insertion can lead to the fatal complication of HAA. The placement of a metallic stent could have been avoided in this case. Percutaneous metallic stent insertion for biliary stenosis after liver transplantation should therefore only be performed in carefully selected patients.     

Severe outflow block syndrome caused by compression by the swollen caudate lobe after living donor liver transplantation: report of a case

A 50-year-old man with primary biliary cirrhosis underwent living-donor liver transplantation (LDLT) using a graft of a left hemiliver with a left caudate lobe and duct-to-duct hepaticocholedochostomy. Postoperative bile leakage necessitated percutaneous drainage 22 days after LDLT. The patient presented to our hospital 205 days after the LDLT with abdominal distension and fever. Computed tomography showed ascites and a diffusely mottled pattern in the graft. The caudate lobe was swollen, and its bile ducts were dilated. The inferior vena cava was forced to the right by the swollen caudate lobe, and the root of the hepatic vein was stretched. The hepatic vein was not contrasted. Endoscopic retrograde cholangiography showed a biliary anastomotic stricture. Based on these findings, we diagnosed a severe outflow block of the hepatic vein and biliary anastomotic stricture. We performed balloon dilation of the biliary anastomosis and implanted a metallic stent in the hepatic vein. Thereafter, his clinical symptoms improved dramatically.     

Duct-to-duct biliary reconstruction without a stent in pediatric living-donor liver transplantation

Purpose

In pediatric liver transplantation, Roux-en-Y hepaticojejunostomy is often preferred for biliary reconstruction, especially in living-donor liver transplantation (LDLT). Limited numbers of duct-to-duct biliary reconstructions have been presented in pediatric recipients. We retrospectively reviewed our experiences with duct-to-duct biliary reconstruction without a stent in pediatric LDLT recipients.

Materials and Methods

Since September 2006, 32 LDLTs were performed using a duct-to-duct biliary reconstruction without a stent in 31 children (16 boys and 15 girls; overall mean age, 8.3 ± 5.1 years). We transplanted 19 left lobe grafts, 11 left lateral segments, 1 monosegment, and 1 reduced-size right lobe graft. Twenty-eight grafts had a single bile duct; the remaining 4, two bile ducts. We created a single orifice at the back table for the grafts that had 2 bile ducts.

Results

Two recipients developed bile leakage in the early postoperative period; 3 bile duct stenoses occurred in the late postoperative period. All biliary complications were successfully treated with interventional radiologic or endoscopic approaches. There was no morbidity and no graft loss owing to biliary complications. During a mean follow-up of 23.5 ± 13.6 months (range, 4-44), 4 children died and the remaining 27 (88%) are doing well with satisfactory liver function.

Conclusion

Our results showed that duct-to-duct biliary reconstruction without a stent was a safe technique for biliary reconstruction even among pediatric cases.     

Duct-to-duct Biliary Reconstruction in Living-donor Liver Transplantation for Primary Sclerosing Cholangitis: Report of a Case

Although Roux-en Y hepaticojejunostomy was previously recommended for the biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC), some recent reports showed no difference in the graft survival between Roux-en Y and duct-to-duct anastomosis in deceased-donor liver transplantation. On the other hand, considering the risk of recurrence and the short length of the bile duct of the graft, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor liver transplantation (LDLT) for PSC. A 45 year-old male underwent LDLT using a left-lobe graft donated from his brother. Cholangiography showed no lesion in his common bile duct and duct-to-duct anastomosis was chosen for him. Fifteen months later, he suffered cholangitis due to PSC recurrence and endoscopic retrograde cholangiography was performed. The stents were inserted into his B2 and B3, and he remains well. Because of the ability to easily manage biliary complication, duct-to-duct biliary reconstruction may become the first choice in LDLT for PSC without common bile duct lesions.     

Evolving strategies to prevent biliary strictures after living donor liver transplantation

Introduction

The optimal surgical technique has not been elucidated that reduces the occurrence of biliary strictures after living donor liver transplantation (LDLT).

Method

We performed retrospective analysis of 193 consecutive LDLTs, including 78 right and 115 left lobe grafts. An external biliary stent was used for all of the cases.

Results

The overall 1-, 3-, and 5-year biliary stricture-free survival rates were 87.5%, 85.3%, and 85.3%, respectively. The 1- and 3-year biliary stricture-free survival rates for duct-to-duct reconstruction were 86.9% and 84.9%, and those for hepaticojejunostomy were 90.1% and 80.8%, respectively. A multivariate analysis revealed that the original number of graft bile ducts greater than the number of external stents, right lobe grafts, bile leaks, and recipient age older than 60 years represented the significant risk factors (P < .05) to develop a biliary stricture after LDLT. All cases with biliary strictures (n = 61) were initially managed nonsurgically, but 4 patients ultimately required interventions.

Conclusions

Biliary reconstruction in LDLT using an appropriate number of external stents resulted in fairly acceptable outcomes. However, not only the proper use of stents or graft selection, but also nonsurgical factors, are important factors that determine the incidence of biliary strictures after LDLT.     

活体肝移植的胆道重建技术及并发症分析

目的 探讨活体肝移植的胆道重建方法及并发症防治措施.方法 回顾性分析77例活体肝移植临床资料,其中74例行右半肝移植(带肝中静脉29例,不带肝中静脉45例),左半肝带肝中静脉1例,左外叶切取2例.胆道重建采用胆肠吻合或供肝肝管与受体肝管端端吻合.结果 供肝断面1个胆管开口为54例,多个胆管开口为23例;胆肠吻合2例,胆管端端吻合75例,63例留置T管;术后总体胆道并发症发生率为36.4%(28/77),其中胆漏为10.4%(8/77),胆道狭窄为26.0%(20/77).供肝单支胆道以及单个吻合口术后胆道狭窄的发生率明显低于多支胆道及多个吻合口(P<0.05).8例胆漏病人经过B超指引穿刺引流全部治愈,20例吻合口狭窄病人经T管窦道放置支撑管或通过ERCP进行扩张,肝功能全部或部分好转.结论 活体肝移植供肝切取术中注意对断面胆管血供的保护以及尽可能获得单一的肝管开口可有效减少术后胆道并发症的发生;内镜和放射介入技术是治疗胆道并发症的有效手段.     

Transhepatic biliary catheterization before graft implant in living donor liver transplantation

AIM: Despite the evolution in surgical technique, the biliary anastomosis remains the technical Achilles' heel of liver transplantation, especially in living donor liver transplantation. Interventional radiology or endoscopic procedures constitute the most common options to treat complications from the biliary anastomosis. We report a novel technique to prevent biliary complications following the transplant. METHODS: During the donor procedure a wire guide was introduced in the severed duct, left or right, in retrograde fashion. The liver surface was then perforated and the wire guide exposed. A 4F catheter was then attached to the wire guide and pulled into the bile duct passing through the end-to-end duct-to-duct anastomosis or hepaticojejunostomy. RESULTS: This technique was performed in six living donor grafts: one right lobe, two left lobes, and three left lateral segments. All patients had no complications from the stent placement, biliary strictures, or leaks. One developed a hepatic artery thrombosis on the posttransplant day 14 with no major biliary complications.     

Rendezvous Technique Using Double Balloon Endoscope for Removal of Multiple Intrahepatic Bile Duct Stones in Hepaticojejunostomy After Living Donor Liver Transplant: A Case Report

Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts.Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope.Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.