Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation

Normal morphometry of the biliary tree in pediatric and adult populations: A systematic review and meta-analysis

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.

Application of cholecystic duct plasty in the prevention of biliary complications following orthotopic liver transplantation

Background

The purpose was aimed to evaluate the safety and effectiveness of cholecystic duct plasty (CDP) and biliary reconstruction techniques preventing biliary complications following orthotopic liver transplantation (OLT) first proposed by our center.

Methods

127 enrolled patients who underwent LT in our center from January 2015 to December 2019 were analyzed retrospectively. According to the mode of biliary tract reconstruction, patients were divided into CDP group (Group 1, n = 53) and control group (Group 2, n = 74). The differences of perioperative general data, biliary complications and long-term prognosis between two groups were compared and analyzed.

Results

All patients completed the operation successfully, the incidence of perioperative complications was 22.8%. There was no significant difference in perioperative general data and complications between the two groups. Follow-up ended in June 2020, with a median follow-up period of 31 months. During the follow-up period, biliary complications occurred in 26 patients, with an overall incidence of 20.5%. The overall incidence of biliary complications and anastomotic stenosis in Group 1 was lower than that in Group 2 (P < 0.05). There was no significant difference in overall prognosis between the two groups (P = 0.274), however, the cumulative incidence of biliary complications in Group 1 was lower than that in Group 2 (P = 0.035).

Conclusion

Reconstruction of common bile duct by CDP represents considerable safety and practicability, particularly for patients with small diameter of common bile duct or wide discrepancy of bile duct size between donor and recipient.

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.

Anastomotic Biliary Stricture Development after Liver Transplantation in the Setting of Retained Prophylactic Intraductal Pediatric Feeding Tube: Case and Review

The biliary anastomosis remains a common site of postoperative complications in liver transplantation (LT). Biliary complications have indeed been termed the "Achilles' heel" of LT, and while their prevention, diagnosis, and treatment have continued to evolve over the last two decades, various challenges and uncertainties persist. Here we present the case of a 33-year-old man who, 10 years after undergoing LT for idiopathic recurrent intrahepatic cholestasis, was noted to have developed pruritus and abnormalities in serum liver biochemistries during routine post-liver transplant follow-up. Abdominal ultrasound revealed a linear, 1.5 mm hyperechoic filling defect in the common bile duct; magnetic resonance cholangiopancreatography demonstrated a curvilinear filling defect at the level of the choledochocholedochostomy, corresponding to the ultrasound finding, as well as an anastomotic biliary stricture (ABS). On endoscopic retrograde cholangiography (ERC), a black tubular stricture with overlying sludge was encountered and extracted from the common bile duct, consistent with a retained 5 Fr pediatric feeding tube originally placed at the time of LT. The patient experienced symptomatic and biochemical relief and successfully underwent serial ERCs with balloon dilatation and maximal biliary stenting for ABS management. With this case, we emphasize the importance of ensuring spontaneous passage or removal of intraductal prostheses placed prophylactically at the time of LT in order to minimize the risk of chronic biliary inflammation and associated sequelae, including cholangitis and ABS formation. We also provide herein a brief review of the use of prophylactic internal transanastomotic prostheses, including biliary tubes and stents, during LT.