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Chau P, Moses D, Pather N. Normal morphometry of the biliary tree in pediatric and adult populations: A systematic review and meta-analysis. Eur J Radiol 2024; 176:111472. [PMID: 38718450 DOI: 10.1016/j.ejrad.2024.111472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/01/2024] [Accepted: 04/15/2024] [Indexed: 06/17/2024]
Abstract
PURPOSE This study aimed to characterise the normal morphometry of the biliary tree in pediatric and adult populations, through a systematic review and meta-analysis. METHODS This study, conducted using the PRISMA guidelines and registered with PROSPERO, searched MEDLINE, EMBASE, SCOPUS and Web of Science databases up to October 2022, and updated to August 2023. Studies that reported extractable data on diameter and length of the right, left and common hepatic ducts (LHD, RHD and CHD), and common bile duct (CBD) were included. Quality of the included studies were assessed using the Anatomical Quality Assessment (AQUA) tool. Statistical analysis included subgroup analyses according to sex, age, geographical location, and imaging modality. RESULTS In total, 60 studies were included, of which 44 studies reported adequate data for meta-analysis on 23,796 subjects. Overall, the pooled mean diameter of the CBD was 4.69 mm (95 % CI: 4.28-5.11). Significant differences were found between pediatric (1.32 mm, 95 % CI: 1.03-1.61) and adult (4.97 mm, 95 % CI: 4.67-5.27) subjects, as well as US (3.82 mm, 95 % CI: 3.15-4.49) and other imaging modalities, including MRI (6.21 mm, 95 % CI: 4.85-7.57) and ERCP (7.24 mm, 95 % CI: 6.08-8.40). The CBD diameter measured significantly larger distally (5.20 mm, 95 % CI: 4.60-5.80) than proximally (4.01 mm, 95 % CI: 3.51-4.51). CONCLUSIONS The results obtained from this evidence-based study may guide the establishment of standardised reference values and ranges of the normal biliary tree in pediatric and adult populations and aid clinical understanding.
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Affiliation(s)
- Patrick Chau
- Department of Anatomy, School of Biomedical Sciences, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Daniel Moses
- Department of Radiology, Prince of Wales Hospital, Sydney, Australia
| | - Nalini Pather
- Department of Anatomy, School of Biomedical Sciences, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia; Academy of Medical Education, Medical School, Faculty of Medicine, University of Queensland, Australia.
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2
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Choi HJ, Na GH, Chun JH, Choi Y, Park SE, Hong TH, You YK. The Usefulness of High-Magnification Loupe for Reducing Biliary Complications After Liver Transplantation. Transplant Proc 2024; 56:647-652. [PMID: 38320867 DOI: 10.1016/j.transproceed.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Despite advances in surgical techniques, biliary complications are still considered to be a technical "Achilles' heel" of liver transplantation (LT). The purpose of this study was to evaluate the effect of loupe magnification in reducing biliary complications after LT. MATERIALS AND METHODS From April 2017 to February 2022, LT was performed on 307 patients in our center. Among them, except for 3 patients who underwent hepaticojejunostomy, 304 adult patients with LT were enrolled. They were divided into 3 groups according to the loupe magnification: 2.5 times (×2.5 group, n = 105), 3.5 times (×3.5 group, n = 95), and 5.0 times (×5.0 group, n = 105). RESULTS Biliary complications occurred in 63 (20.7%) patients. Anastomosis site leakage occurred in 37 patients (12.2%), and stricture occurred in 52 patients (17.1%). Anastomosis site leakage occurred in 15 patients (14.3%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 7 patients (6.7%) in the ×5.0 group (P = .097). Biliary stricture occurred in 26 patients (24.8%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 11 patients (10.5%) in the ×5.0 group (P = .021). Total biliary complications occurred in 31 patients (29.5%) in the ×2.5 group, 19 patients in the ×3.5 group (20.2%), and 13 patients in the ×5.0 group (12.4%) (P = .009). CONCLUSION The use of a high magnification loupe can reduce biliary complications in liver transplantation. Further large-scale analyses of clinical data or randomized controlled trials are required to support this study.
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Affiliation(s)
- Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Gun Hyung Na
- Department of Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jin Ha Chun
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoonyoung Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Eun Park
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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3
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Hou TY, Komorowski AL, Lin TS, Lin YC, Sng YP, Yeh CH, Li WF, Lin CC, Wang CC. The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis. HPB (Oxford) 2024:S1365-182X(24)01229-2. [PMID: 38556407 DOI: 10.1016/j.hpb.2024.03.1160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/10/2024] [Accepted: 03/15/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Uncontrolled massive bleeding and bowel edema are critical issues during liver transplantation. Temporal intra-abdominal packing with staged biliary reconstruction (SBR) yields acceptable outcomes in deceased donor liver transplantation; however, data on living donor liver transplantation (LDLT) are scarce. METHODS A retrospective analysis of 1269 patients who underwent LDLT was performed. After one-to-two propensity score matching, patients who underwent LDLT with SBR were compared with those who underwent LDLT with one-stage biliary reconstruction (OSBR). The primary outcomes were graft survival (GS) and overall survival (OS), and the secondary outcomes were postoperative biliary complications. RESULTS There were 55 and 110 patients in the SBR and OSBR groups, respectively. The median blood loss was 6500 mL in the SBR and 4875 mL in the OSBR group. Patients receiving SBR-LDLT had higher incidence of sepsis (69.0% vs. 43.6%; P < 0.01) and intra-abdominal infections (60.0% vs. 30.9%; P < 0.01). Biliary complication rates (14.5% vs. 19.1%; P = 0.47) and 1-and 5-year GS (87.27%, 74.60% vs. 83.64%, 72.71%; P = 0.98) and OS (89.09%, 78.44% vs. 84.55%, 73.70%; P = 0.752) rates were comparable between the two groups. CONCLUSIONS SBR could serve as a life-saving procedure for patients undergoing complex critical LDLT, with GS, OS, and biliary outcomes comparable to those of OSBR.
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Affiliation(s)
- Teng-Yuan Hou
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Andrzej L Komorowski
- Department of Surgery, College of Medicine, University of Rzeszów, Rzeszów, Poland
| | - Tsan-Shiun Lin
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Cheng Lin
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Ping Sng
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Hsi Yeh
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Feng Li
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Che Lin
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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4
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The Role of Microbiota in Liver Transplantation and Liver Transplantation-Related Biliary Complications. Int J Mol Sci 2023; 24:ijms24054841. [PMID: 36902269 PMCID: PMC10003075 DOI: 10.3390/ijms24054841] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Liver transplantation as a treatment option for end-stage liver diseases is associated with a relevant risk for complications. On the one hand, immunological factors and associated chronic graft rejection are major causes of morbidity and carry an increased risk of mortality due to liver graft failure. On the other hand, infectious complications have a major impact on patient outcomes. In addition, abdominal or pulmonary infections, and biliary complications, including cholangitis, are common complications in patients after liver transplantation and can also be associated with a risk for mortality. Thereby, these patients already suffer from gut dysbiosis at the time of liver transplantation due to their severe underlying disease, causing end-stage liver failure. Despite an impaired gut-liver axis, repeated antibiotic therapies can cause major changes in the gut microbiome. Due to repeated biliary interventions, the biliary tract is often colonized by several bacteria with a high risk for multi-drug resistant germs causing local and systemic infections before and after liver transplantation. Growing evidence about the role of gut microbiota in the perioperative course and their impact on patient outcomes in liver transplantation is available. However, data about biliary microbiota and their impact on infectious and biliary complications are still sparse. In this comprehensive review, we compile the current evidence for the role of microbiome research in liver transplantation with a focus on biliary complications and infections due to multi-drug resistant germs.
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Khot R, Morgan MA, Nair RT, Ludwig DR, Arif-Tiwari H, Bhati CS, Itani M. Radiologic findings of biliary complications post liver transplantation. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:166-185. [PMID: 36289069 DOI: 10.1007/s00261-022-03714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.
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Affiliation(s)
- Rachita Khot
- Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
| | - Matthew A Morgan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Rashmi T Nair
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Chandra S Bhati
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Malak Itani
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
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6
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Duct Division "Before or After Clipping" in Laparoscopic Liver Donors: Overcoming the Dilemma to Quintessential Approach. Transplantation 2022; 106:e317-e318. [PMID: 35616913 DOI: 10.1097/tp.0000000000004079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Yamaguchi N, Matsuyama R, Kikuchi Y, Sato S, Yabushita Y, Sawada Y, Homma Y, Kumamoto T, Takeda K, Morioka D, Endo I, Shimada H. Role of the Intramural Vascular Network of the Extrahepatic Bile Duct for the Blood Circulation in the Recipient Extrahepatic Bile Duct Used for Duct-to-Duct-Biliary-Anastomosis in Living Donor Liver Transplantation. Transpl Int 2022; 35:10276. [PMID: 35592448 PMCID: PMC9110655 DOI: 10.3389/ti.2022.10276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 11/15/2022]
Abstract
A duct-to-duct-biliary-anastomosis is the preferred biliary reconstruction technique in liver transplantation; biliary complications remain the major concerns for the technique. We examined the significance of the intramural vascular network of the extrahepatic bile duct (EBD) and its relevant vessels. We microscopically examined the axial sections of the EBD with 5 mm intervals of 10 formalin-fixed deceased livers. The luminal-areas of the 3 and 9 o’clock arteries correlated significantly and positively with the distance from the bifurcation of the right and left hepatic ducts (the 3 o’clock artery, r = 0.42, p < 0.001; the 9 o’clock artery, r = 0.39, p < 0.001); the ratios of the numbers of the intramural vessels to the areas of the corresponding sections of the EBD significantly correlated positively with the distance from the bifurcation of the right and left hepatic ducts (total vessels, r = 0.78, p < 0.001; arterioles, r = 0.52, p < 0.001; venules, r = 0.45, p < 0.001). This study demonstrated that there is a significant locoregional distributional heterogeneity of the intramural vessels among the EBD. The hepatic arteries neighboring the EBD primarily supply the blood flow to the EBD; thus, when the broader isolation of the EBD from the neighboring arteries is necessary, this locoregional distributional heterogeneity of the intramural vessels may render the EBD likely to suffer ischemia of the anastomotic site.
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Affiliation(s)
- Naotaka Yamaguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yutaro Kikuchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Sho Sato
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yu Sawada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kazuhisa Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Daisuke Morioka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Hiroshi Shimada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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8
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Su WL, Yu FJ, Huang JW, Shih MC, Hsu WH, Shih HY, Huang YL, Chen LA, Wu PH, Wu CJ, Chen CY, Kuo KK, Lee KT, Chang WT. The experience of use of percutaneous transhepatic biliary drainages for early biliary complications after liver transplantation. Kaohsiung J Med Sci 2022; 38:486-493. [PMID: 35199937 DOI: 10.1002/kjm2.12519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/06/2022] [Accepted: 01/24/2022] [Indexed: 12/19/2022] Open
Abstract
This study aimed to describe our experience and discuss the results, controversies, and the use of percutaneous transhepatic biliary drainage (PTBD) in patients with biliary complications after liver transplantation (LT). Between November 2009 and August 2020, 76 consecutive patients who underwent 77 LTs (44 deceased donor LTs and 33 living donor LTs [LDLT]) were enrolled retrospectively. Endoscopic therapy as initial approach and PTBD as rescue therapy were used for patients with biliary complications. There were 31 patients (31/76, 40.8%) with biliary complications, and two of them died (2/31, 6.5%). Clinical success rate of endoscopic therapy alone was 71.0% (22/31). The remaining nine patients received salvage PTBD and their clinical results were observed according to whether their intrahepatic bile ducts (IHBDs) was dilated (group A, n = 5) or not (group B, n = 4). In group A, the technical and long-term clinical success rates of PTBD were 100% and 20%, respectively. These five patients received PTBD ranging from 75 to 732 days after their LTs, and no procedure-related complications were encountered. In group B, the technical and long-term clinical success rates of PTBD were 50% and 25%, respectively. Three group B patients (75%) underwent PTBD within 30 days after LDLT and had lethal complications. One patient had graft laceration and survived after receiving timely re-transplantation. The other two patients died of sepsis due to PTBD-related bilioportal fistula or multiple liver abscesses. Our experience showed salvage PTBD played a limited role in biliary complications without dilated IHBDs within 1 month after LT.
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Affiliation(s)
- Wen-Lung Su
- Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jian-Wei Huang
- Department of Surgery, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Ming-Chen Shih
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hung Hsu
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Ling Huang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ling-An Chen
- Department of Surgery, Ministry of Health and Welfare Pingtung Hospital, Pingtung, Taiwan
| | - Po-Hsuan Wu
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chia-Jen Wu
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chiao-Yun Chen
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Kung-Kai Kuo
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - King-Teh Lee
- Department of Surgery, Park One International Hospital, Kaohsiung, Taiwan
| | - Wen-Tsan Chang
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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9
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Abstract
Content available: Audio Recording.
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Affiliation(s)
- Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative MedicineMedanta The MedicityGurugramIndia
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10
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The Need to Update Endpoints and Outcome Analysis in the Rapidly Changing Field of Liver Transplantation. Transplantation 2021; 106:938-949. [PMID: 34753893 DOI: 10.1097/tp.0000000000003973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation (LT) survival rates have continued to improve over the last decades, mostly due to the reduction of mortality early after transplantation. The advancement is facilitating a liberalization of access to LT, with more patients with higher risk profiles being added to the waiting list. At the same time, the persisting organ shortage fosters strategies to rescue organs of high-risk donors. This is facilitated by novel technologies such as machine perfusion. Owing to these developments, reconsideration of the current and emerging endpoints for the assessment of the efficacy of existing and new therapies is warranted. While conventional early endpoints in LT have focused on the damage induced to the parenchyma, the fate of the bile duct and the recurrence of the underlying disease have a stronger impact on the long-term outcome. In light of this evolving landscape, we here attempt to reflect on the appropriateness of the currently used endpoints in the field of LT trials.
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11
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Pamecha V, Sasturkar SV, Sinha PK, Mohapatra N, Patil N. Biliary Reconstruction in Adult Living Donor Liver Transplantation: The All-Knots-Outside Technique. Liver Transpl 2021; 27:525-535. [PMID: 37160038 DOI: 10.1002/lt.25862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/15/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022]
Abstract
Biliary complications (BCs) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of the all-knots-outside technique (AKOT) of biliary reconstruction (BR) and its impact on BCs. A retrospective analysis was performed using prospectively collected data of 330 consecutive adult patients undergoing LDLT from July 2011 to February 2018 with a minimal follow-up of 24 months. Only 2.8% required hepaticojejunostomy and were excluded. In an initial 122 patients, BR was performed with the standard technique (ST), and AKOT was performed in the subsequent 208 patients. In the AKOT group, a single anastomosis was attempted even for multiple ducts whenever feasible. A major BC was defined as requiring endoscopic, percutaneous, or surgical interventions. In the AKOT group, significantly more patients received a left lobe graft (5.7% versus 18.3%; P = 0.001), had shorter warm ischemia time (44.6 versus 27 minutes; P < 0.001), and had a left hepatic artery (LHA) in the right lobe that was used for arterial reconstruction (48 [39.3%] versus 122 [58.6%]; P = 0.003). The incidence of BCs in the entire cohort was 47 (14.2%). For the ST versus AKOT groups, the overall BCs (27/122 [22.1%] versus 20/208 [9.6%]; P = 0.003) and major BCs (20.5% versus 6.7%; P < 0.001) decreased significantly. In the multivariate analysis, the number of bile ducts (hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78; P = 0.003), number of anastomoses (HR, 2.03; 95% CI, 1.03-4.02; P = 0.04), and technique of anastomosis (HR, 0.36; 95% CI, 0.19-0.68; P = 0.002) predicted BCs. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomoses, and AKOT for BR significantly decreased the incidence of BCs.
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Affiliation(s)
- Viniyendra Pamecha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar Vasantrao Sasturkar
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Kumar Sinha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nilesh Patil
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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12
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Venous outflow reconstruction using a polytetrafluoroethylene (PTFE) graft in right lobe living donor liver transplantation: A single center study. Surgery 2021; 169:1500-1509. [PMID: 33642052 DOI: 10.1016/j.surg.2021.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous outflow reconstruction is very important especially in right lobe living donor liver transplantation without middle hepatic vein. Various interposition (venous or synthetic) grafts have been recommended for reconstruction of anterior sector tributaries. METHODS We aimed to describe our surgical technique and analyze anterior sector venous reconstruction using expanded polytetrafluroethylene graft. Retrospective analysis of prospectively collected data for 760 primary right lobe living donor liver transplantations performed at our institute between December 2011 and June 2018. Reconstruction of anterior sector: expanded polytetrafluroethylene (group A, n = 705) and autologous vein (group B, n = 55). RESULTS Pretransplant characteristics were comparable among both groups. Group A has significantly lower cold ischemia time (68.7 ± .3.5 minutes vs 127.8 ± 7.2 minutes; P < .001) and anhepatic time (116.3 ± 5.5 minutes vs 190.81 ± 9.35 minutes; P < .001) compared with group B. There was no difference in recovery pattern of liver functions, morbidity, and mortality between the 2 groups. One- and 6-month patency rates of interposition grafts were 97.6% and 84.4% (group A) and 96.4% and 78.1% (group B), respectively. CONCLUSION In centers with limited access to homologous or autologous vascular grafts, use of expanded polytetrafluroethylene graft for anterior sector venous outflow reconstruction in right lobe living donor liver transplantation is a viable option with excellent patency and patient outcomes.
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13
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Lin J, Ko CJ, Lin KH, Lin PY, Hsieh CE, Chou CT, Chen YL, Hung YJ. Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation. Asian J Surg 2021; 44:742-748. [PMID: 33468384 DOI: 10.1016/j.asjsur.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/13/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND /Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. METHODS Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. RESULTS At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p = 0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p = 0.018). CONCLUSION This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.
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Affiliation(s)
- Joseph Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Jan Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Hua Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chia-En Hsieh
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chen-Te Chou
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Molecular Biotechnology, College of Biotechnology and Bioresources, Dayeh University, Changhua City, Taiwan; Department of Radiology, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yao-Li Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan; College of Nursing and Health Sciences, Dayeh University, Changhua City, Taiwan.
| | - Yu-Ju Hung
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.
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Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy. HPB (Oxford) 2021; 23:144-153. [PMID: 32646806 DOI: 10.1016/j.hpb.2020.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD. METHODS This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database. RESULTS 241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique. CONCLUSION Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.
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15
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Biliary reconstruction and complications in living donor liver transplantation. Int J Surg 2020; 82S:138-144. [DOI: 10.1016/j.ijsu.2020.04.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
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16
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The high-end range of biliary reconstruction in living donor liver transplant. Curr Opin Organ Transplant 2020; 24:623-630. [PMID: 31397730 DOI: 10.1097/mot.0000000000000693] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To summarize recent evidence in literature regarding incidence and risk factors for biliary complications in living donor liver transplantation (LDLT), and current concepts in evaluation of donor biliary anatomy and surgical techniques of biliary reconstruction, to reduce the incidence of biliary complications. RECENT FINDINGS Advances in biliary imaging in the donor, both before surgery, and during donor hepatectomy, as well as safe hepatic duct isolation in the donor, have played a significant role in reducing biliary complications in both the donor and recipient. Duct-to-duct biliary anastomoses (DDA) is the preferred mode of biliary reconstruction currently, especially when there is a single bile duct orifice in the donor. The debate on stenting the anastomoses, especially a DDA, continues. Stenting a Roux en Y hepaticojejunostomy in children with small ductal orifices in the donor is preferred. With growing experience, and use of meticulous surgical technique and necessary modifications, the incidence of biliary complications in multiple donor bile ducts, and more than one biliary anastomoses can be reduced. SUMMARY Biliary anastomosis continues to be the Achilles heel of LDLT. Apart from surgical technique, which includes correct choice of type of reconstruction technique and appropriate use of stents across ductal anastomoses, better imaging of the biliary tree, and safe isolation of the graft hepatic duct, could help reduce biliary complications in the recipient, and make donor hepatectomy safe .
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Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK. Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study. Br J Radiol 2020; 93:20191046. [PMID: 31971831 DOI: 10.1259/bjr.20191046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. RESULTS Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). CONCLUSION Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). ADVANCES IN KNOWLEDGE (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.
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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Swati Das
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Pancreatic surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
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Leal-Leyte P, McKenna GJ, Ruiz RM, Anthony TL, Saracino G, Testa G, Klintmalm GB, T W Kim P. Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation. Liver Transpl 2018; 24:1011-1018. [PMID: 29637692 DOI: 10.1002/lt.25075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022]
Abstract
Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.
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Affiliation(s)
- Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Greg J McKenna
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Richard M Ruiz
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Tiffany L Anthony
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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19
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Makki K, Chorasiya V, Srivastava A, Singhal A, Khan AA, Vij V. Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation - a single centre prospective study. Transpl Int 2018; 31:1041-1049. [PMID: 29722074 DOI: 10.1111/tri.13272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/03/2018] [Accepted: 04/23/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Kausar Makki
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vishal Chorasiya
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ajitabh Srivastava
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Arif Ali Khan
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vivek Vij
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
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20
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Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10:297-311. [PMID: 28600688 DOI: 10.1007/s12328-017-0754-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
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Affiliation(s)
- Takeshi Tsujino
- Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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21
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DaVee T, Geevarghese SK, Slaughter JC, Yachimski PS. Refractory anastomotic bile leaks after orthotopic liver transplantation are associated with hepatic artery disease. Gastrointest Endosc 2017; 85:984-992. [PMID: 27623104 DOI: 10.1016/j.gie.2016.08.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/27/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Anastomotic bile leaks are common after orthotopic liver transplant (OLT), and standard treatment consists of placement of a biliary endoprosthesis. The objectives of this study were to identify risk factors for refractory anastomotic bile leaks and to determine the morbidity associated with refractory bile leaks after OLT. METHODS Consecutive adult patients who underwent ERCP for treatment of post-OLT biliary adverse events between 2009 and 2014 at a high-volume transplant center were retrospectively identified. A refractory leak was defined as a bile leak that persisted after placement of a plastic biliary endoprosthesis and required repeat endoscopic or surgical intervention. RESULTS Forty-three subjects met study inclusion criteria. Median age was 57 years, and 36 (84%) subjects were men. Refractory bile leaks were diagnosed in 40% of subjects (17/43). Time-to-event analysis revealed an association between refractory bile leaks and the combined outcome of death, repeat transplant, or surgical biliary revision (hazard ratio, 3.78; 95% confidence interval, 1.25-11.45; P = .01). Hepatic artery disease was more common with refractory compared with treatment-responsive bile leaks (53% vs 8%, P = .001). CONCLUSIONS Refractory anastomotic bile leaks after liver transplantation are associated with decreased event-free survival. Hepatic artery disease is associated with refractory leaks. Large-scale prospective studies should be performed to define the optimal management of patients at risk for refractory bile leaks.
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Affiliation(s)
- Tomas DaVee
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick S Yachimski
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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22
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Karakas S, Sarici K, Ozdemir F, Ersan V, Ince V, Baskiran A, Kayaalp C, Kutlu R, Yilmaz S. Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up. Transplant Proc 2017; 49:562-565. [DOI: 10.1016/j.transproceed.2017.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rammohan A, Govil S, Vargese J, Kota V, Reddy MS, Rela M. Changing pattern of biliary complications in an evolving liver transplant unit. Liver Transpl 2017; 23:478-486. [PMID: 28152569 DOI: 10.1002/lt.24736] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/23/2016] [Accepted: 01/14/2017] [Indexed: 01/11/2023]
Abstract
Biliary complications (BCs) remain a significant cause of morbidity following liver transplantation (LT). This series of 640 LT recipients with a blend of living and deceased donor transplants was analyzed to determine the incidence, risk factors, management protocol, and outcomes in these patients. Review of a prospectively collected database of transplant recipients operated between August 2009 and June 2016 was performed. Patients were divided into those with and without BCs and data analyzed. The 640 LT recipients from both living (n = 481) and deceased donors (n = 159) were evaluated for BCs. The overall incidence of BCs was 13.7%. It reduced from 23% to 5% (P = 0.003) over a 6-year period. Risk factors for BCs on multivariate analysis were living donor liver transplantation, prolonged time to rearterialization, recipient age above 16 years, prolonged cold ischemia time (CIT) after deceased donor liver transplantation, and biliary reconstruction performed by anyone but the senior author. One-fifth of bile leaks progressed to strictures, and 40% of strictures followed leaks. Endoscopic therapy resolved 60% of the strictures. Surgical repair of strictures was successful in 90% of those in whom endoscopy failed, those who could not undertake the follow-up schedules endoscopic therapy entails, and those presenting with late strictures. BCs significantly prolonged hospital stay but did not alter survival after LT. BCs affect 1 in 7 recipients, although they are not associated with increased mortality. The frequency of these complications is influenced by potentially modifiable factors like evolving surgical expertise and CIT. Liver Transplantation 23 478-486 2017 AASLD.
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Affiliation(s)
- Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Sanjay Govil
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Joy Vargese
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Venugopal Kota
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Mettu S Reddy
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India.,Institute of Liver Studies, King's College Hospital, London, United Kingdom
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Eversion Technique to Prevent Biliary Stricture After Living Donor Liver Transplantation in the Universal Minimal Hilar Dissection Era. Transplantation 2017; 101:e20-e25. [DOI: 10.1097/tp.0000000000001533] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Vij V, Makki K, Chorasiya V, Sood G, Singal A, Dargan P. Reply. Liver Transpl 2016; 22:864-5. [PMID: 27101779 DOI: 10.1002/lt.24455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/25/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Vivek Vij
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Kausar Makki
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Vishal Chorasiya
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Gaurav Sood
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Ashish Singal
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Puneet Dargan
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
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26
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Soin A, Pahari H, Goja S, Bhangui P, Rastogi A. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:862-3. [PMID: 27061449 DOI: 10.1002/lt.24444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 03/10/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Arvinder Soin
- Medanta-the Medicity, Medanta Liver Institute, Haryana, India
| | - Hirak Pahari
- Medanta-the Medicity, Medanta Liver Institute, Haryana, India
| | - Sanjay Goja
- Medanta-the Medicity, Medanta Liver Institute, Haryana, India
| | | | - Amit Rastogi
- Medanta-the Medicity, Medanta Liver Institute, Haryana, India
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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Vij V. Reply. Liver Transpl 2016; 22:561. [PMID: 26824627 DOI: 10.1002/lt.24409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/15/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and HPB Surgery, Fortis Hospital, Noida, India
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29
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Li M, Jiang L, Yan L, Yang J. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:559-60. [PMID: 26821573 DOI: 10.1002/lt.24404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/15/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Ming Li
- Department of Liver Surgery Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Department of Liver Surgery Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lunan Yan
- Department of Liver Surgery Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jiayin Yang
- Department of Liver Surgery Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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