Longterm Analysis of Biliary Complications After Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantations

The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis

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.

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Role of the immune system in liver transplantation and its implications for therapeutic interventions

Liver transplantation (LT) stands as the gold standard for treating end-stage liver disease and hepatocellular carcinoma, yet postoperative complications continue to impact survival rates. The liver's unique immune system, governed by a microenvironment of diverse immune cells, is disrupted during processes like ischemia-reperfusion injury posttransplantation, leading to immune imbalance, inflammation, and subsequent complications. In the posttransplantation period, immune cells within the liver collaboratively foster a tolerant environment, crucial for immune tolerance and liver regeneration. While clinical trials exploring cell therapy for LT complications exist, a comprehensive summary is lacking. This review provides an insight into the intricacies of the liver's immune microenvironment, with a specific focus on macrophages and T cells as primary immune players. Delving into the immunological dynamics at different stages of LT, we explore the disruptions after LT and subsequent immune responses. Focusing on immune cell targeting for treating liver transplant complications, we provide a comprehensive summary of ongoing clinical trials in this domain, especially cell therapies. Furthermore, we offer innovative treatment strategies that leverage the opportunities and prospects identified in the therapeutic landscape. This review seeks to advance our understanding of LT immunology and steer the development of precise therapies for postoperative complications.

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

The role of Roux-en-Y hepaticojejunostomy for the management of biliary complications after living donor liver transplantation

INTRODUCTION

Post living donor liver transplantation (LDLT) biliary complications can be troublesome over the post-operative course of patients, especially those with recurrent cholangitis or choledocholithiasis. Thus, in this study, we aimed to evaluate the risks and benefits of Roux-en-Y hepaticojejunostomy (RYHJ) performed after LDLT as a last option to deal with post-LDLT biliary complications.

METHODS

Retrospectively, of the 594 adult LDLTs performed in a single medical center in Changhua, Taiwan from July 2005 to September 2021, 22 patients underwent post-LDLT RYHJ. Indications for RYHJ included choledocholithiasis formation with bile duct stricture, previous intervention failure, and other factors. Restenosis was defined if further intervention was needed to treat biliary complications after RYHJ was performed. Thereafter, patients were categorized into success group (n = 15) and restenosis group (n = 4).

RESULTS

The overall success rate of RYHJ in the management of post-LDLT biliary complications was 78.9% (15/19). Mean follow-up time was 33.4 months. As per our findings, four patients experienced recurrence after RYHJ (21.2%), and mean recurrence time was 12.5 months. Three cases were recorded as hospital mortality (13.6%). Outcome and risk analysis presented no significant differences between the two groups. A higher risk of recurrence tended to be related to patients with ABO incompatible (ABOi).

CONCLUSION

RYHJ served well as either a rescue but definite procedure for recurrent biliary complications or a safe and effective solution to biliary complications after LDLT. A higher risk of recurrence tended to be related to patients with ABOi; however, further research would be needed.

Initial outcome of external biliary drainage in living donor liver transplantation with pure laparoscopic donor hepatectomy

Biliary complications after living donor liver transplantation (LDLT) are the most common and intractable complications due to both surgical and nonsurgical factors. External biliary drainage (EBD), a surgical option to prevent biliary complications, has recently been adopted in the era of pure laparoscopic donor right hepatectomy, which may result in increased bile duct problems in the recipients. This study retrospectively reviewed the patients who underwent LDLT with duct-to-duct anastomosis between July 2017 and October 2020 to analyze the initial outcomes of EBD and to compare the incidence of biliary complications in adult LDLT recipients who underwent duct-to-duct anastomosis with or without EBD. Only patients who underwent pure laparoscopic donor hepatectomy were included in this study. The patients were divided into 2 groups according to the application of EBD. The median follow-up period was 28.5 months. The overall incidence of Clavien-Dindo grade IIIa biliary complications was 35.0% (n=14) in the EBD group and 50.7% (n=76) in the non-EBD group ( p = 0.08). The incidence of biliary leakage was 0% in the EBD group and 15.3% in the non-EBD group ( p = 0.01). The EBD-related complication rate, that is, involving retraction, accidental removal, and dislocation, was 40.0%. EBD implementation is effective in preventing biliary leakage after LDLT with a graft procured using the pure laparoscopic donor right hepatectomy method with duct-to-duct biliary anastomosis. However, efforts should be made to prevent EBD-related complications. Further studies are needed to establish appropriate selection criteria for EBD.

Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP.

METHODS

We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022.

RESULTS

In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis.

CONCLUSION

Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.

The Role of Microbiota in Liver Transplantation and Liver Transplantation-Related Biliary Complications

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.

Right Lobe Versus Left Lobe Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Donor and Recipient Outcomes

BACKGROUND

Living donor liver transplantation (LDLT) is an established treatment for advanced liver disease. Whether right lobe (RL) or left lobe (LL) LDLT provides the best outcomes for donors and recipients remains contentious.

METHODS

MedLine, Embase, PubMed, and Cochrane Central were searched to identify studies comparing RL- and LL-LDLT and reporting donor and/or recipient outcomes. Effect sizes were pooled using random-effect meta-analysis. Meta-regressions were used to explore heterogeneity.

RESULTS

Sixty-seven studies were included. RL donors were more likely to experience major complications (relative risk [RR] = 1.63; 95% confidence interval [CI] = 1.30-2.05; I2 = 19%) than LL donors; however, no difference was observed in the risk of any biliary complication (RR = 1.41; 95% CI = 0.91-2.20; I2 = 59%), bile leaks (RR = 1.56; 95% CI = 0.97-2.51; I2 = 52%), biliary strictures (RR = 0.99; 95% CI = 0.43-1.88; I2 = 27%), or postoperative death (RR = 0.51; 95% CI = 0.25-1.05; I2 = 0%). Among recipients, the incidence of major complications (RR = 0.85; 95% CI = 0.68-1.06; I2 = 21%), biliary complications (RR = 1.10; 95% CI = 0.91-1.33; I2 = 8%), and vascular complications (RR = 0.79; 95% CI = 0.44-1.43; I2 = 0%) was similar. Although the rate of small for size syndrome (RR = 0.47; 95% CI = 0.30-0.74; I2 = 0%) and postoperative deaths (RR = 0.62; 95% CI = 0.44-0.87; I2 = 0%) was lower among RL-LDLT recipients, no differences were observed in long-term graft (hazard ratio = 0.87; 95% CI = 0.55-1.38; I2 = 74%) and overall survival (hazard ratio = 0.86; 95% CI = 0.60-1.22; I2 = 44%).

CONCLUSIONS

LL donors experience fewer complications than RL donors, and LL-LDLT recipients had similar outcomes to RL-LDLT recipients. These findings suggest that LL-LDLT offers the best outcomes for living donors and similar outcomes for recipients when measures are taken to prevent small for size syndrome.

Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures

BACKGROUND

Biliary strictures frequently occur in living-donor liver transplant (LDLT) recipients. However, long-term clinical outcomes and their associated factors are unclear.

METHODS

We analyzed an historical cohort of 228 recipients who underwent LDLT with post-liver transplantation biliary strictures. Endoscopic retrograde cholangiography or percutaneous transhepatic biliary drainage were performed to treat biliary strictures. Patients that experienced persistent jaundice over 3 mo after the initial treatment were defined as a remission-failure group.

RESULTS

Median observation period was 8.5 y after the diagnosis of biliary stricture. The 15-y graft survival (GS) rate was 70.6%, and 15-y rate of developing portal hypertension (PH) was 26.1%. Remission failure occurred in 25.0% of study participants. In the multivariate analysis, biopsy-proven acute rejection, and portal vein/hepatic artery abnormalities were risk factors for remission failure. Development of PH, retransplantation, and death were significantly more frequent in the remission-failure group. Remission failure and PH were associated with poor GS. In multivariate analyses, hepatic artery abnormality and biloma were common significant factors that were associated with a poor GS and development of PH.

CONCLUSIONS

The insufficient blood supply reflected by hepatic artery abnormality and biloma might be the most important factor that can predict poor long-term survival in LDLT patients with biliary strictures. Future large-scale prospective studies are needed to validate our observations.

Optimal Intervention for Initial Treatment of Anastomotic Biliary Complications After Right Lobe Living Donor Liver Transplantation

Background: This study evaluated endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) as interventions for patients with anastomotic biliary complications (ABC) after living donor liver transplantation (LDLT).

Methods: Prospectively collected data of patients who were diagnosed with ABC after LDLT between January 2013 and June 2017 were retrospectively reviewed.

Results: There were 57 patients who underwent LDLT with a right liver graft using duct-to-duct biliary reconstruction and experienced ABC. Among the patients with RAD involvement, there were no significant differences in the intervention success (p = 0.271) and patency rates (p = 0.267) between ERCP and PTBD. Similarly, among the patients with RPD involvement, there were no significant differences in the intervention success (p = 0.148) and patency rates (p = 0.754) between the two procedures. Graft bile duct variation (p = 0.013) and a large angle between the recipient and graft bile duct (R-G angle) (p = 0.012) significantly increased the likelihood of failure of ERCP in the RAD. When the R-G angle was greater than 47.5°, the likelihood of ERCP failure increased.

Conclusion: We recommend PTBD when graft bile duct variation is presented in patients with RAD involvement and/or when the R-G angle is greater than 47.5°.

The biliary microbiome in ischaemic-type biliary lesions can be shaped by stenting but is resilient to antibiotic treatment

This study aims to characterize the biliary microbiome as neglected factor in patients with ischaemic-type biliary lesions (ITBL) after liver transplantation. Therefore, the V1-V2 region of the 16S rRNA gene was sequenced in 175 bile samples. Samples from patients with anastomotic strictures (AS) served as controls. Multivariate analysis and in silico metagenomics were applied cross-sectionally and longitudinally. The microbial community differed significantly between ITBL and AS in terms of alpha and beta diversity. Both, antibiotic treatment and stenting were associated independently with differences in the microbial community structure. In contrast to AS, in ITBL stenting was associated with pronounced differences in the biliary microbiome, whereas no differences associated with antibiotic treatment could be observed in ITBL contrasting the pronounced differences found in AS. Bacterial pathways involved in the production of antibacterial metabolites were increased in ITBL with antibiotic treatment. After liver transplantation, the biliary tract harbours a complex microbial community with significant differences between ITBL and AS. Fundamental changes in the microbial community in ITBL can be achieved with biliary stenting. However, the effect of antibiotic treatment in ITBL was minimal. Therefore, antibiotics should be administered wisely in order to reduce emerging resistance of the biliary microbiome towards external antibiotics.

Biliary complications after adult to adult right-lobe living donor liver transplantation (A-ARLLDLT): Analysis of 245 cases during 16 years period at a single high centre- A retrospective cohort study

Objectives

Biliary complications (BCs) after adult to adult living donor liver transplantation (A-ALDLT) result in poor graft and patient survival. This study aimed to analyze these complications.

Methods

We retrospectively analyzed BCs in 245 recipients who underwent A-ALDLT using the right–lobe graft during 16 years period in our centre. The overall male/female ratio was 215/30.

Results

One hundred fifty-five BCs affected 102 of our recipients (95 early (≤3months) and 60 late (≥3months)). They were classified as 67/245(27.3%) early bile leak, 10/245(4.1%) early biliary stricture, 44/245(17.9%) late biliary stricture, 4/245(1.6%) early cholangitis, 10/245(4.1%) late cholangitis, 14/245(5.7%) early biloma, and 6/245(2.4%) late cholangitic abscesses. Multiple biliary anastomoses were independently correlated with Post liver transplantation (LT) overall BCs; moreover, post LT hepatic artery thrombosis or stenosis (HAT/S) was an independent predictor of overall BCs, strictures and leaks. The mortality affected 96(39.2%) cases mostly due to sepsis, bleeding and multi-organ failure (MOF). On the other hand, the biliary related mortality was 10.6% of cases. Multiple cholangitic hepatic abscesses were significant predictors of poor graft and patient outcomes. Conclusions: Multiple biliary anastomoses and post LT HAT/S lead to a poor biliary outcome, furthermore, cholangitis, cholangitic abscesses and sepsis lead to poor graft and patient outcomes, so proper management of those variables is mandatory to improve outcomes after A-ARLLDLT.

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Multiple biliary anastomoses had negative insult on biliary outcomes after A-ARLLDLT.

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Post LT HAT/S lead to poor biliary outcomes after A-ARLLDLT.

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Cholangitis, and cholangitic abscesses lead to post LT poor graft and patient outcomes.

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Sepsis lead to post LT poor graft and patient outcomes.

Biliary complications in recipients of living donor liver transplantation: A single-centre study

BACKGROUND

Biliary complications (BCs) after liver transplantation (LT) remain a considerable cause of morbidity, mortality, increased cost, and graft loss.

AIM

To investigate the impact of BCs on chronic graft rejection, graft failure and mortality.

METHODS

From 2011 to 2016, 215 adult recipients underwent right-lobe living-donor liver transplantation (RT-LDLT) at our centre. We excluded 46 recipients who met the exclusion criteria, and 169 recipients were included in the final analysis. Donors’ and recipients’ demographic data, clinical data, operative details and postoperative course information were collected. We also reviewed the management and outcomes of BCs. Recipients were followed for at least 12 mo post-LT until December 2017 or graft or patient loss.

RESULTS

The overall incidence rate of BCs including biliary leakage, biliary infection and biliary stricture was 57.4%. Twenty-seven (16%) patients experienced chronic graft rejection. Graft failure developed in 20 (11.8%) patients. A total of 28 (16.6%) deaths occurred during follow-up. BCs were a risk factor for the occurrence of chronic graft rejection and failure; however, mortality was determined by recurrent hepatitis C virus infection.

CONCLUSION

Biliary complications after RT-LDLT represent an independent risk factor for chronic graft rejection and graft failure; nonetheless, effective management of these complications can improve patient and graft survival.

Risk Factors for Development of Biliary Stricture After Liver Transplant in Adult Patients: A Single-Center Retrospective Study

Identification of risk factors for biliary stricture after liver transplant and its potential prevention is crucial to improve the outcomes and reduce the complications. We retrospectively analyzed donor and recipient characteristics with intraoperative and postoperative parameters to identify the risk factors for development of post-transplant anastomotic and nonanastomotic biliary strictures with additional analysis of the time onset of those strictures. A total of 412 patients were included in this study. Mean (SD) follow-up time was 79 (35) months (range, 1-152 months). Biliary stricture was diagnosed in 84 patients (20.4%). Multivariate analysis indicated that postoperative biliary leakage (odd ratio [OR], 3.94; P = .001), acute cellular rejection (OR, 3.05; P < .001), donor age older than 47.5 years (OR, 2.05; P = .032), preoperative recipient platelet value < 77.5 × 10³/mL (OR, 1.91; P = .023), University of Wisconsin solution (OR, 1.73; P = .041)), recipient male sex (OR, 1.78; P = .072), portal/arterial flow ratio > 4 (OR, 1.76; P = .083), and intraoperative bleeding > 2850 mL (OR, 1.70; P = .053) were independent risk factors for biliary stricture regardless of the time of their appearance. Multiple risk factors for biliary stricture were determined in this study. Some of these risk factors are preventable, and implementation of strategies to eliminate some of those factors should reduce the development of post-transplant biliary stricture.

Archimedes Absorbable Internal Biliary Stent in Liver Transplants to Prevent Bile Leak

BACKGROUND

Biliary complications, especially bile leaks, are an important cause of early postoperative morbidity and, rarely, mortality after liver transplant. The risk is higher in living donor liver transplant (LDLT) compared to deceased donor liver transplant (DDLT). Attempts to reduce bile leaks have included refinements in the biliary anastomosis technique and use of various external and internal stents, with inconsistent benefits. Recent availability and successful use of the absorbable Archimedes stent has prompted its intrabiliary placement across the anastomosis.

METHODS

In this retrospective study, we analyzed the data of 20 adult patients who underwent a liver transplant with duct-to-duct biliary anastomosis using the Archimedes stent. Both DDLT and LDLT were performed using cava-preserving hepatectomy followed by standard implantation methods. Duct-to-duct biliary anastomosis was performed in all cases using interrupted sutures with extracorporeal knots over an absorbable intrabiliary stent. In addition to standard postoperative care, patients were monitored for bile leak.

RESULTS

Nine DDLTs had a single anastomosis over a 10-Fr stent. Out of 11 LDLT patients, 7 had a single anastomosis and 4 patients had 2 anastomoses, all over a 6-Fr stent. Two patients died, 1 as a result of graft primary nonfunction and another because of multidrug-resistant pneumonia. One patient had ascending cholangitis owing to stent migration in the duodenum. This episode was treated with endoscopic stent removal and appropriate antibiotics, with good recovery. None of the other patients had bile leaks, biloma, or stent-related complications.

CONCLUSIONS

Archimedes internal absorbable biliary stents can be safely used in both living and deceased donor liver transplants to prevent bile leaks.

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

BACKGROUND

In 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.

METHODS

We 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.

RESULTS

Ninety-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.

CONCLUSIONS

Multiple 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

BACKGROUND

Biliary 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 2: A 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 3: A 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 4: A 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.

CONCLUSION

BS 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.

[Bilary anastomotic strictures after right lobe living donor liver transplantation: a single-center experience]

OBJECTIVE

To determine the incidence of AS after right lobe living donor liver transplantation with various biliary reconstructions and to identify the predictors of this complication.

MATERIAL AND METHODS

A retrospective and prospective analysis included 245 RLLDLTs for the period 2011-2018 at the Burnazjan Federal Medical Biophysical Center. The results of transplantations in 207 patients aged 19-68 years (median 43 years) were assessed. There were 82 men and 125 women. Follow-up period ranged from 10 to 98 months (median 35 months). We analyzed the relationship between surgical characteristics (preoperative data of recipients and donors, graft parameters, technical features of biliary reconstruction and features of post-transplantation period) and incidence of anastomotic strictures. A total of 58 parameters were analyzed.

RESULTS

AS occurred in 20 (9.7%) recipients. Median AS-free period was 5 months (range 1-44). In 17 (85%) patients, AC developed within a year after surgery. Cumulative 1-, 2- and 5-year incidence of AS was 8.3%, 8.9%, and 11%, respectively. Significant predictors of AS were impaired arterial blood supply to the graft (HR 7.8, 95% CI 2.3-26.0, p<0.001), biliary leakage ISGLS class B or C (HR 5.0, 95% CI 2.0-12.8, p<0.001), early allograft dysfunction (HR 4.2, 95% CI 1.5-11.6, p=0.006) and female recipient (HR 3.2, 95% CI 1.1-9.9, p=0.04). In our sample, variant biliary anatomy of the graft and recipient liver, as well as technical features of biliary reconstruction did not affect the risk of AS.

CONCLUSION

Variant biliary anatomy of potential donor alone should not be considered as a contraindication for organ donation and right liver lobe transplantation. Precise surgical technique, high transplantation activity, as well as experience of reconstructive interventions on the bile ducts during other operations can significantly reduce the incidence of AS after RLLDLT up to 9.7%.

Bile duct reconstruction using scaffold-free tubular constructs created by Bio-3D printer

Introduction

Biliary strictures after bile duct injury or duct-to-duct biliary reconstruction are serious complications that markedly reduce patients’ quality of life because their treatment involves periodic stent replacements. This study aimed to create a scaffold-free tubular construct as an interposition graft to treat biliary complications.

Methods

Scaffold-free tubular constructs of allogeneic pig fibroblasts, that is, fibroblast tubes, were created using a Bio-3D Printer and implanted into pigs as interposition grafts for duct-to-duct biliary reconstruction.

Results

Although the fibroblast tube was weaker than the native bile duct, it was sufficiently strong to enable suturing. The pigs' serum hepatobiliary enzyme levels remained stable during the experimental period. Micro-computed tomography showed no biliary strictures, no biliary leakages, and no intrahepatic bile duct dilations. The tubular structure was retained in all resected specimens, and the fibroblasts persisted at the graft sites. Immunohistochemical analyses revealed angiogenesis in the fibroblast tube and absence of extensions of the biliary epithelium into the fibroblast tube's lumen.

Conclusions

This study's findings demonstrated successful reconstruction of the extrahepatic bile duct with a scaffold-free tubular construct created from pig fibroblasts using a novel Bio-3D Printer. This construct could provide a novel regenerative treatment for patients with hepatobiliary diseases.

Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation

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.

Optimizing biliary outcomes in living donor liver transplantation: Evolution towards standardization in a high-volume center

Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation. While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction, our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors, in particular, our surgical protocols. We present herein, the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts. Over this period of transition, our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0% to 10.2%.

Novel Method for Reconstructing Multiple Graft Bile Ducts During Right Lobe Living Donor Liver Transplant: Dunking With Mucosal Eversion Technique

BACKGROUND

Multiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy.

METHODS

Here, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique.

RESULTS

Overall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624).

CONCLUSIONS

Our novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.

Biliary Stricture: The Achilles Heel of Pediatric Living Donor Liver Transplantation

Since a 1989 report demonstrating successful living donor liver transplantation (LDLT), living donors have been increasingly used to overcome the disparity between organ supply and demand, especially in the cases of pediatric patients. Although short-term graft outcomes after LDLT have improved significantly because of progress in surgical techniques and immunosuppression, biliary stricture (BS) remains the Achilles heel of pediatric LDLT and is the major cause of significant long-term morbidity. BS results in poor quality of life or even in graft loss after LDLT, with a reported incidence of BS after pediatric LDLT of 10% to 35%. The suggested risk factors for BS after LDLT are hepatic arterial thrombosis, bile duct ischemia, acute cellular rejection, older donor age, and ABO incompatibility. Duct-to-duct biliary reconstruction, which enables an endoscopic approach to be attempted after BS, is the preferred technique for LDLT. Endoscopic approaches are less invasive and more convenient for recipients than surgical and percutaneous interventions. However, the major cause of end-stage liver disease in pediatric recipients is biliary atresia, and hepaticojejunostomy is needed to reconstruct the bile duct because of the lack of recipient bile duct. Endoscopic approaches for BS are usually less favorable in patients with hepaticojejunostomy than in those with duct-to-duct biliary reconstruction. Treatment options for BS after hepaticojejunostomy at many centers thus involve interventional radiology or surgical reintervention. Although endoscopic approaches remain controversial in pediatric recipients, several reports have shown them to be safe and less invasive.

The high-end range of biliary reconstruction in living donor liver transplant

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 .