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Lapisatepun W, Junrungsee S, Chotirosniramit A, Udomsin K, Ko-Iam W, Lapisatepun W, Siripongpon K, Kiratipaisarl W, Bhanichvit P, Julphakee T. Outcomes of the Initial Phase of an Adult Living vs Deceased Donor Liver Transplantation Program in a Low-Volume Transplant Center: Integration of Hepatobiliary and Transplant Surgery. Transplant Proc 2023; 55:597-605. [PMID: 36990883 DOI: 10.1016/j.transproceed.2023.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/24/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The development of living donor liver transplantation (LDLT) is clinically challenging, especially in a low-volume transplant program. We evaluated the short-term outcomes of LDLT and deceased donor liver transplantation (DDLT) to demonstrate the feasibility of performing LDLT in a low-volume transplant and/or high-volume complex hepatobiliary surgery program during the initial phase. MATERIAL AND METHODS We conducted a retrospective study of LDLT and DDLT in Chiang Mai University Hospital from October 2014 to April 2020. Postoperative complications and 1-year survival were compared between the 2 groups. RESULTS Forty patients who underwent LT in our hospital were analyzed. There were 20 LDLT patients and 20 DDLT patients. The operative time and hospital stay were significantly longer in the LDLT group than in the DDLT group. The incidence of complications in both groups was comparable, except for biliary complications, which were higher in the LDLT group. Bile leakage, found in 3 patients (15%), is the most common complication in a donor. The 1-year survival rates of both groups were also comparable. CONCLUSION Even during the initial phase of the low-volume transplant program, LDLT and DDLT had comparable perioperative outcomes. Surgical expertise in complex hepatobiliary surgery is necessary to facilitate effective LDLT, potentially increasing case volumes and promoting program sustainability.
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Sharma ZD, Karunakaran M, Bansal RK, Gandhi A, Singh MK, Soin AS, Puri R, Sud R. Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy. ANZ J Surg 2022; 93:911-917. [PMID: 36262090 DOI: 10.1111/ans.18123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. METHODS A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. RESULTS Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents. CONCLUSIONS Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.
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Affiliation(s)
- Zubin Dev Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Monish Karunakaran
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.,Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.,College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon, India
| | - Ashish Gandhi
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Rajesh Puri
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Randhir Sud
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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Kim SH, Park JH, An BH. Minimal Surgical Manpower for Living Donor Liver Transplantation. J Clin Med 2022; 11:jcm11154292. [PMID: 35893383 PMCID: PMC9331439 DOI: 10.3390/jcm11154292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Living donor liver transplantation (LDLT) is widely performed with good outcomes in the current era of improved surgical techniques. However, few studies have addressed how many human resources are required in the surgery itself. This study aimed to introduce how to perform LDLT with minimal manpower and evaluate the outcomes in adult patients. Methods: The main surgical procedures of donor and recipient operations of LDLT were performed by a single specialist surgeon who led a team of minimal manpower that only included one fellow, one resident, one intern, and three nurses. He also provided postsurgical care and followed up all the patients as a primary care physician. The outcomes were analyzed from the standpoints of the feasibility and acceptability. Results: Between November 2018 and February 2020, a total of 47 patients underwent LDLT. Ten patients had ABO-incompatible donors. The median age of the overall recipients was 57 years old (36–71); 37 patients (78.7%) were male. The MELD score was 10 (6–40), and the main etiologies were hepatic malignancy (38 patients or 80.9%) and liver failure (9 patients or 19.1%). The median age of the overall donors was 34 years old (19–62); 22 patients (46.8%) were male. All the graft types were right liver except for one case of extended right liver with middle hepatic vein. All donors had an uneventful recovery with no complications. There was one intraoperative mortality due to cardiac arrest after reperfusion in one recipient. Hepatic artery thrombosis was developed in 5 (10.6%) recipients. An acute rejection episode occurred in one patient. The median follow-up period for all the patients was 32.9 months (range, 24.7–39.8). Biliary complications were developed in 11 (23.4%) recipients. In total, 7 (15%) patients died, including 1 intraoperative mortality, 5 from cancer recurrence, and 1 from intracranial hemorrhage. The 1-, 2-, and 3-year overall survival rates in the recipient group were 91.5%, 87.2%, and 85.1%, respectively. Conclusions: LDLT with minimal surgical manpower is feasible under the supervision of a single expert surgeon who has the capacity for all the main surgical procedures in both donor and recipient operations without compromising the outcomes in the present era of advanced surgical management.
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Affiliation(s)
- Seoung Hoon Kim
- Correspondence: or ; Tel.: +82-31-9201647; Fax: +82-31-9201138
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Parlak E, Simsek C, Koksal AS, Eminler AT, Unal E, Ciftci TT, Akinci D, Yilmaz S. The Classification of Biliary Strictures in Patients With Right-Lobe Liver Transplant Recipients and Its Relation to Traversing the Stricture With a Guidewire. Transplantation 2022; 106:328-336. [PMID: 33724243 DOI: 10.1097/tp.0000000000003738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traversing the stricture with a guidewire is a prerequisite for the endoscopic treatment of biliary strictures after living donor liver transplantation. We aimed to evaluate the effect of variations in the biliary anastomosis and strictures on the success of endoscopic treatment and suggest a cholangiographic classification. METHODS The 125 strictures among the 104 patients with right-lobe living donor liver transplantation were reviewed. The strictures were classified by the anastomosis pattern according to the number (1, 2, or >2), location (common bile, hepatic, or cystic duct), the angle between the proximal and distal sites of the anastomosis, and the contrast enhancement pattern. The relationship between the success rate of traversing the anastomosis and the classification was evaluated. RESULTS Of the 125 biliary strictures, 86 (68.8%) could be passed via endoscopically. Thirty-three strictures were managed either percutaneously (n = 13) or by magnetic compression anastomosis (n = 20). Compared with the round, the triangular (odds ratio [OR], 6.5), the intermediate form (OR, 17.7), and the end-to-side anastomosis (OR, 5.1) were associated with an increased chance of traversing. The contrast enhancement pattern of the strictures and the bile ducts was also related to the successful rate of the endoscopic treatment (P < 0.001). The success rate was higher in the patients with the angle between the proximal and distal sites of the anastomosis approximated was small (0°-30° = 74%, 30°-60° = 69%, 60°-90° = 63%, >90° = 41%). CONCLUSIONS The type of biliary anastomoses and stricture affect the success rate of endoscopic treatment. These data may play role in making decision about the type of anastomosis during the surgery.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cem Simsek
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Aydin Seref Koksal
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Emre Unal
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Turkmen Turan Ciftci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Devrim Akinci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezai Yilmaz
- Department of Surgery, Faculty of Medicine, Liver Transplant Institute, Inonu University, Malatya, Turkey
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Lee AY, Lehrman ED, Perito ER, Kerlan RK, Kohi MP, Kolli KP, Taylor AG, Ostroff JW, Kang SM, Roberts JP, Rhee S, Rosenthal P, Fidelman N. Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience. Pediatr Transplant 2021; 25:e14028. [PMID: 33951255 DOI: 10.1111/petr.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/05/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. METHODS Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. RESULTS Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). CONCLUSIONS Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.
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Affiliation(s)
- Andrew Y Lee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Evan D Lehrman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Emily R Perito
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Robert K Kerlan
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Kanti P Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - James W Ostroff
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Sang-Mo Kang
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sue Rhee
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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Karatoprak S, Kutlu R, Yılmaz S. Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience. ACTA ACUST UNITED AC 2021; 27:546-552. [PMID: 33599206 DOI: 10.5152/dir.2021.20523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. METHODS A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. RESULTS A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. CONCLUSION Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.
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Affiliation(s)
- Sinan Karatoprak
- Department of Radiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Ramazan Kutlu
- Department of Radiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery, Inonu University Faculty of Medicine, Malatya, Turkey
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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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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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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A Worldwide Survey of Live Liver Donor Selection Policies at 24 Centers With a Combined Experience of 19 009 Adult Living Donor Liver Transplants. Transplantation 2019; 103:e39-e47. [PMID: 30308575 DOI: 10.1097/tp.0000000000002475] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abu-Gazala S, Olthoff KM. Current Status of Living Donor Liver Transplantation in the United States. Annu Rev Med 2019; 70:225-238. [DOI: 10.1146/annurev-med-051517-125454] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Adult-to-adult living donor liver transplantation (LDLT) was introduced in response to the shortage of deceased donor liver grafts. The number of adult living donor transplants is increasing due to improved outcomes and increasing need. Advantages of LDLT include optimization of the timing of transplant, better organ quality, and lower rates of recipient mortality compared to staying on the wait list for deceased donor liver transplant. Donor safety remains the major focus when considering LDLT. Recent advancements have supported the increased use of LDLT to help decrease wait list death and improve long-term survival of transplant recipients.
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Affiliation(s)
- Samir Abu-Gazala
- Transplantation Unit, Department of Surgery, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Kim M. Olthoff
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4283, USA
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12
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Dar FS, Bhatti ABH, Qureshi AI, Khan NY, Eswani Z, Zia HH, Khan EU, Khan NA, Rana A, Shah NH, Salih M, Nazer R. Living Donor Liver Transplantation in South Asia: Single Center Experience on Intermediate-Term Outcomes. World J Surg 2018; 42:1111-1119. [PMID: 28936685 DOI: 10.1007/s00268-017-4259-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is paucity of data on intermediate-term post liver transplant outcomes from South Asia. The objective of this study was to determine survival outcomes in patients who underwent living donor liver transplantation (LDLT) in a busy liver transplant center in Pakistan. METHODS This study was a review of patients who underwent LDLT between 2012 and 2016. A total of 321 patients were included in this study. Early (within 90 days) and late (>90 days) morbidity and mortality was assessed. Estimated 1- and 4-year survival was determined. RESULTS Median age was 48 (18-73) years. Male to female ratio was 4.5:1. Out of total 346 complications, 184 (57.3%) patients developed 276 (79.7%) complications in early post-transplant period, whereas there were 70 (21.3%) late complications. Most common early complication was pleural effusion in 46 (16.6%) patients. Biliary complications were the most common late complication and were seen in 31/70 (44.2%) patients. Overall 21.4% patients had a biliary complication. The 3-month mortality was 14%. The estimated 1- and 4-year OS for a MELD cutoff of 30 was 84.5 versus 72 and 80 versus 57% (P = 0.01). There was no donor mortality. CONCLUSION Acceptable intermediate-term post-transplant outcomes were achieved with LDLT. There is a need to improve outcomes in high-MELD patients.
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Affiliation(s)
- Faisal S Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan
| | - Abu Bakar H Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan.
| | - Ammal I Qureshi
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan
| | - Nusrat Y Khan
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan
| | - Zahaan Eswani
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan
| | - Haseeb H Zia
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4, Pitras Bukhari Road, Islamabad, Pakistan
| | - Eitzaz U Khan
- Department of Anesthesiology, Shifa International Hospital, Islamabad, Pakistan
| | - Nasir A Khan
- Department of Anesthesiology, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Najmul H Shah
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Rashid Nazer
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
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Abu-Gazala S, Olthoff KM. Status of Adult Living Donor Liver Transplantation in the United States: Results from the Adult-To-Adult Living Donor Liver Transplantation Cohort Study. Gastroenterol Clin North Am 2018; 47:297-311. [PMID: 29735025 DOI: 10.1016/j.gtc.2018.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
This article reviews the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL). The findings show that the number of adult-to-adult living donor liver transplants is consistently increasing. Living donor liver transplantation has an important benefit for patients with acute liver failure, does not compromise donor safety, and has lower rates of acute cellular rejection in biologically related donor and recipient. The conclusions from the A2ALL consortium have been critical in transplant advancement, supporting increased use to help decrease waitlist death and improve long-term survival of transplant recipients.
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Affiliation(s)
- Samir Abu-Gazala
- Department of Surgery, Transplantation Unit, Hadassah Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel.
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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14
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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15
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Azzam AZ, Tanaka K. Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004. Indian J Gastroenterol 2017; 36:296-304. [PMID: 28744748 DOI: 10.1007/s12664-017-0771-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 07/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications. METHODS During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively. RESULTS The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%. CONCLUSION Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.
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Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Koichi Tanaka
- Kobe International Frontier, Medical Center Medical Corporation, Kobe, Japan
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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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17
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Tezcaner T, Dinç N, Y Karakayalı F, Kırnap M, Coşkun M, Moray G, Haberal M. Effect of Right Posterior Bile Duct Anatomy on Biliary Complications in Patients Undergoing Right Lobe Living Donor Liver Transplant. EXP CLIN TRANSPLANT 2017; 17:759-767. [PMID: 28128721 DOI: 10.6002/ect.2016.0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications. MATERIALS AND METHODS We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses. RESULTS The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications. CONCLUSIONS Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.
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Affiliation(s)
- Tugan Tezcaner
- From the Department of General Surgery, Başkent University, Ankara, Turkey
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18
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Analysis of Factors Associated With Biliary Complications in Children After Liver Transplantation. Transplantation 2016; 100:1944-54. [DOI: 10.1097/tp.0000000000001298] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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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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20
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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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21
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Abstract
Living donor liver transplant (LDLT) accounts for a small volume of the transplants in the USA. Due to the current liver allocation system based on the model for end-stage liver disease (MELD), LDLT has a unique role in providing life-saving transplantation for patients with low MELD scores and significant complications from portal hypertension, as well as select patients with hepatocellular carcinoma (HCC). Donor safety is paramount and has been a topic of much discussion in the transplant community as well as the general media. The donor risk appears to be low overall, with a favorable long-term quality of life. The latest trend has been a gradual shift from right-lobe grafts to left-lobe grafts to reduce donor risk, provided that the left lobe can provide adequate liver volume for the recipient.
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Affiliation(s)
- Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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22
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Chang JH, Lee I, Choi MG, Han SW. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22:1593-1606. [PMID: 26819525 PMCID: PMC4721991 DOI: 10.3748/wjg.v22.i4.1593] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
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23
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Ranjan P, Bansal RK, Mehta N, Lalwani S, Kumaran V, Sachdeva MK, Kumar M, Nundy S. Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India. Indian J Gastroenterol 2016; 35:48-54. [PMID: 26873087 DOI: 10.1007/s12664-016-0625-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/21/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures. METHODS We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated. RESULTS Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3%) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4-60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40%), asymptomatic elevation of liver enzymes in four (40%) and jaundice in two patients (20%). The median time from transplantation to the detection of the stricture was 12 months (2-42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2-5) endoscopic sessions and 3.4 (1-6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2-12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7-11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis. CONCLUSIONS Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.
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Affiliation(s)
- Piyush Ranjan
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - S Lalwani
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - V Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - M K Sachdeva
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - M Kumar
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - S Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
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Feier FH, da Fonseca EA, Seda-Neto J, Chapchap P. Biliary complications after pediatric liver transplantation: Risk factors, diagnosis and management. World J Hepatol 2015; 7:2162-2170. [PMID: 26328028 PMCID: PMC4550871 DOI: 10.4254/wjh.v7.i18.2162] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/30/2015] [Accepted: 08/11/2015] [Indexed: 02/06/2023] Open
Abstract
The expanded indications of partial grafts in pediatric liver transplantation have reduced waiting list mortality. However, a higher morbidity is observed, including an increased rate of biliary complications (BCs). Factors such as the type of graft, the preservation methods applied, the donor characteristics, the type of biliary reconstruction, and the number of bile ducts in the liver graft influences the occurrence of these complications. Bile leaks and strictures comprise the majority of post-transplant BCs. Biliary strictures require a high grade of suspicion, and because most children have a bileo-enteric anastomosis, its diagnosis and management rely on percutaneous hepatic cholangiography and percutaneous biliary interventions (PBI). The success rates with PBI range from 70% to 90%. Surgery is reserved for patients who have failed PBI. BCs in children after liver transplantation have a prolonged treatment and are associated with a longer length of stay and higher hospital costs. However, with early diagnosis and aggressive treatment, patient and graft survival are not significantly compromised.
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25
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Simoes P, Kesar V, Ahmad J. Spectrum of biliary complications following live donor liver transplantation. World J Hepatol 2015; 7:1856-1865. [PMID: 26207167 PMCID: PMC4506943 DOI: 10.4254/wjh.v7.i14.1856] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/22/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
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26
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Dar FS, Bhatti ABH, Dogar AW, Zia H, Amin S, Rana A, Nazer R, Khan NA, Khan EUD, Rajput MZ, Salih M, Shah NH. The travails of setting up a living donor liver transplant program: Experience from Pakistan and lessons learned. Liver Transpl 2015; 21:982-90. [PMID: 25891412 DOI: 10.1002/lt.24151] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/07/2015] [Indexed: 02/05/2023]
Abstract
Living donor liver transplantation (LDLT) is the only treatment option for patients with end-stage liver disease (ESLD) where cadaveric donors are not available. In developing countries, the inception of LDLT programs remains a challenge. The first successful liver transplantation program in Pakistan started transplantation in 2012. The objective of this study was to report outcomes of 100 LDLT recipients in a developing country and to highlight the challenges encountered by a new LDLT program in a resource-limited setting. We retrospectively reviewed recipients who underwent LDLT between April 2012 and August 2014. Demographics, etiology, graft characteristics, and operative variables were assessed. Outcome was assessed on the basis of morbidity and mortality. All complications of ≥ 3 on the Clavien-Dindo grading system were included as morbidity. Estimated 1-year survival was calculated using Kaplan-Meier curves, and a Log-rank test was used to determine the significance. Outcomes between the first 50 LDLTs (group 1) and latter 50 LDLTs (group 2) were also compared. Median age was 46.5 (0.5-72) years, whereas the median MELD score was 15.5 (7-37). The male to female ratio was 4:1. ESLD secondary to hepatitis C virus was the most common indication (73% patients). There were 52 (52%) significant (≥ grade 3) complications. The most common morbidities were bile leaks in 9 (9%) and biliary strictures in 14 (14%) patients. Overall mortality in patients who underwent LDLT for ESLD was 10.6%. Estimated 1-year survival was 87%. Patients who underwent transplantation in the latter period had a significantly lower overall complication rate (36% versus 68%; P = 0.01). Comparable outcomes can be achieved in a new LDLT program in a developing country. Outcomes improve as experience increases.
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Affiliation(s)
- Faisal Saud Dar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | - Abdul-Wahab Dogar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Haseeb Zia
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Sadaf Amin
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | | | | | | | | | - Muhammad Salih
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Najmul Hassan Shah
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Kim PTW, Marquez M, Jung J, Cavallucci D, Renner EL, Cattral M, Greig PD, McGilvray ID, Selzner M, Ghanekar A, Grant DR. Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation. Clin Transplant 2015; 29:465-74. [PMID: 25740227 DOI: 10.1111/ctr.12538] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Long-term biliary complications after living donor liver transplantation (LDLT) are not well described in the literature. This study was undertaken to determine the long-term impact of biliary complications after adult right-lobe LDLT. METHODS This retrospective review analyzed an 11-yr experience of 344 consecutive right-lobe LDLTs with at least two yr of follow-up. RESULTS Biliary leaks occurred in 50 patients (14.5%), and strictures occurred in 67 patients (19.5%). Cumulative biliary complication rates at 1, 2, 5, and 10 yr were 29%, 32%, 36%, and 37%, respectively. Most early biliary leaks were treated with surgical drainage (N = 29, 62%). Most biliary strictures were treated first with endoscopic retrograde cholangiography (42%). There was no association between biliary strictures and the number of ducts (hazard ratio [HR] 1.017 [0.65-1.592], p = 0.94), but freedom from biliary stricture was associated with a more recent era (2006-2010) (HR 0.457 [0.247-0.845], p = 0.01). Long-term graft survival did not differ between those who had or did not have biliary complications (66% vs. 67% at 10 yr). CONCLUSIONS Biliary strictures are common after LDLT but may decline with a center's experience. With careful follow-up, they can be successfully treated, with excellent long-term graft survival rates.
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28
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Chen TW, Fan HL, Feng AC, Ho MH, Kuo SM, Chang WC. Differences in risk factors for early-onset and late-onset biliary complications in liver transplant patients. JOURNAL OF MEDICAL SCIENCES 2015. [DOI: 10.4103/1011-4564.167743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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29
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Shaheen MF, Alabdulkarim MS, Hamshow MM, Abdullah KO, O'Hali WA. Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients. Pediatr Transplant 2014; 18:831-8. [PMID: 25187071 DOI: 10.1111/petr.12349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2014] [Indexed: 12/25/2022]
Abstract
The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.
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Affiliation(s)
- Mohammed F Shaheen
- Department of Hepatobiliary Surgery and Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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30
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Feier FH, Chapchap P, Pugliese R, da Fonseca EA, Carnevale FC, Moreira AM, Zurstrassen C, Santos AC, Miura IK, Baggio V, Porta A, Guimarães T, Cândido H, Benavides M, Godoy A, Leite KMR, Porta G, Kondo M, Seda-Neto J. Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients. Liver Transpl 2014; 20:882-92. [PMID: 24760734 DOI: 10.1002/lt.23896] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/01/2014] [Indexed: 12/17/2022]
Abstract
The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique.
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Affiliation(s)
- Flávia H Feier
- Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, Brazil; Hepatology and Liver Transplantation, Sírio Libanês Hospital, São Paulo, Brazil
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31
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Julka KD, Lin TS, Chen CL, Wang CC, Komorowski AL. Reconstructing single hepatic artery with two arterial stumps: biliary complications in pediatric living donor liver transplantation. Pediatr Surg Int 2014; 30:39-46. [PMID: 24292409 DOI: 10.1007/s00383-013-3436-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Liver grafts can at times have two hepatic arterial stumps. This can result in a dilemma whether to reconstruct single or both the arteries. Hepatic artery (HA) thrombosis is the most dreaded complication in pediatric living donor liver transplantation (LDLT) as it can result in biliary complications and subsequent graft loss. We herein report the feasibility of reconstructing single hepatic artery in pediatric living donor liver transplantation having two arterial stumps in the liver graft. MATERIALS AND METHODS From 2008 to 2010, 87 pediatric patients undergoing LDLT were divided into three groups. Group 1 (n = 20): two HA stumps with two HA reconstruction, Group 2 (n = 22): two HA stumps with one HA reconstruction and Group 3 (n = 45): one HA stump with one HA reconstruction. The decision regarding the reconstruction of single or multiple HAs was made depending on the pre-operative radiological and intraoperative assessments. RESULTS The incidence of HA thrombosis (p = 0.126) and biliary complications (p = 0.617), was similar in the three groups. CONCLUSION Single HA reconstruction does not increase the risk of biliary strictures in pediatric LDLT recipients having dual hepatic arterial stumps in the liver graft.
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Affiliation(s)
- Karan D Julka
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan,
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Zimmerman MA, Baker T, Goodrich NP, Freise C, Hong JC, Kumer S, Abt P, Cotterell AH, Samstein B, Everhart JE, Merion RM. Development, management, and resolution of biliary complications after living and deceased donor liver transplantation: a report from the adult-to-adult living donor liver transplantation cohort study consortium. Liver Transpl 2013; 19:259-67. [PMID: 23495079 PMCID: PMC3602918 DOI: 10.1002/lt.23595] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 12/11/2012] [Indexed: 12/22/2022]
Abstract
Adult recipients of living donor liver transplantation (LDLT) have a higher incidence of biliary complications than recipients of deceased donor liver transplantation (DDLT). Our objective was to define the intensity of the interventions and the time to resolution after the diagnosis of biliary complications after liver transplantation. We analyzed the management and resolution of posttransplant biliary complications and investigated the comparative effectiveness of interventions in LDLT and DDLT recipients. For the analysis of biliary complications (leaks or strictures), we used a retrospective cohort of patients who underwent liver transplantation at 8 centers between 1998 and 2006 (median follow-up from onset=4.7 years). The numbers, procedure types, and times to resolution were compared for LDLT and DDLT recipients. Posttransplant biliary complications occurred in 47 of the 189 DDLT recipients (25%) and in 141 of the 356 LDLT recipients (40%). Biliary leaks constituted 38% of the post-DDLT biliary complications (n=18) and 65% of the post-LDLT biliary complications (n=91). The median times to first biliary complications were similar for DDLT and LDLT (11 versus 14 days for leaks, P=0.63; 69 versus 107 days for strictures, P=0.34). Overall, 1225 diagnostic and therapeutic procedures, including reoperation and retransplantation, were performed (6.5±5.4 per recipient; 5.5±3.6 for DDLT versus 6.8±5.8 for LDLT, P=0.52). The median number of months to the resolution of a biliary complication (i.e., a tube-, stent-, and drain-free status) did not significantly differ between the DDLT and LDLT groups for leaks (2.3 versus 1.3 months, P=0.29) or strictures (4.9 versus 2.3 months, P=0.61). Although the incidence of biliary complications is higher after LDLT versus DDLT, the treatment requirements and the time to resolution after the development of a biliary complication are similar for LDLT and DDLT recipients.
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Affiliation(s)
- Michael A. Zimmerman
- Division of Transplant Surgery, University of Colorado, Denver, Denver, Colorado,Corresponding author: Michael A. Zimmerman, MD, University of Colorado, Denver, Division of Transplant Surgery, 1635 Aurora Court, 7th floor, Mail Stop C318, Aurora, CO 80045, Phone 720-848-0833, Fax 720-848-0841,
| | - Talia Baker
- Department of Surgery, Northwestern University, Chicago, Illinois
| | | | - Chris Freise
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Johnny C. Hong
- Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sean Kumer
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Peter Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adrian H. Cotterell
- Department of Surgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Samstein
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - James E. Everhart
- Division of Digestive Diseases and Nutrition, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert M. Merion
- Arbor Research Collaborative for Health, Ann Arbor, Michigan,Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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Soin AS. Smoothing the path: reducing biliary complications, addressing small-for-size syndrome, and making other adaptations to decrease the risk for living donor liver transplant recipients. Liver Transpl 2012; 18 Suppl 2:S20-4. [PMID: 22927168 DOI: 10.1002/lt.23541] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
1. Over the course of the past 2 decades, living donor liver transplantation (LDLT) has become increasingly successful because many of the technical issues plaguing it have been resolved. 2. Although donor safety remains a concern, most challenges related to the recipient's surgery are now better understood, and they appear surmountable. 3. The following concepts need to be addressed for optimal recipient outcomes to be achieved: a. Reduction of the risk of small-for-size syndrome in LDLT (ie, the management of 4 factors: the recipient status, the portal pressure and inflow, the venous outflow, and the graft-to-recipient weight ratio/graft quality). b. Reduction of the risk of surgical complications (biliary complications, reconstitution of the middle hepatic vein outflow in the right lobe graft, and safe hepatic artery and portal vein reconstruction). c. Other adaptations for improving recipient outcomes (adaptations related to LDLT and adaptations common to deceased donor liver transplantation and LDLT).
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Affiliation(s)
- Arvinder S Soin
- Medanta Institute of Liver Surgery and Transplantation, Medicity, Gurgaon, India.
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Anand AC. Hepatology in India and INASL: A Ringside View. J Clin Exp Hepatol 2012; 2:279-82. [PMID: 25755444 PMCID: PMC3940557 DOI: 10.1016/j.jceh.2012.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 07/11/2012] [Indexed: 12/12/2022] Open
Affiliation(s)
- Anil C. Anand
- Address for correspondence: Anil C. Anand, DGMS (Navy) & Chief Consultant (Medicine & Gastroenterology), Room No 142A, A Wing, Sena Bhavan, New Delhi 110011, India. Tel.: +91 11 23093128.
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Chok KSH, Chan SC, Chan KL, Sharr WW, Tam PKH, Fan ST, Lo CM. Bile duct anastomotic stricture after pediatric living donor liver transplantation. J Pediatr Surg 2012; 47:1399-403. [PMID: 22813803 DOI: 10.1016/j.jpedsurg.2011.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 11/08/2011] [Accepted: 12/12/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND/PURPOSE Hepaticojejunostomy is a well-accepted method, whereas duct-to-duct anastomosis is gaining popularity for bile duct reconstruction in pediatric living donor liver transplantation (LDLT). Biliary complications, especially biliary anastomotic stricture (BAS), are not clearly defined. The aim of the present study is to determine the rate of BAS and its associated risk factors. METHODS The study included 78 pediatric patients (<18 years old) who underwent LDLT during the period from end of September 1993 to end of November 2010. The diagnosis of BAS was based on clinical, biochemical, histologic, and radiologic results. RESULTS All patients received left-side grafts. Thirteen patients (16.7%) developed BAS after LDLT. Among them, 3 patients (23.1%) had duct-to-duct anastomosis during LDLT. The median follow-up period for the BAS group and the non-BAS group was 57.8 and 79.5 months, respectively (P = .683). Ten of the patients with BAS required percutaneous transhepatic biliary drainage with or without dilatation for treating the stricture. Multivariable analysis showed that hepatic artery thrombosis and duct-to-duct anastomosis were 2 risk factors associated with BAS. CONCLUSION In pediatric LDLT, hepaticojejunostomy is the preferred method for bile duct reconstruction, but more large-scale research needs to be done to reconfirm this result.
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Affiliation(s)
- Kenneth S H Chok
- Department of Surgery, The University of Hong Kong, Hong Kong, China.
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Saha A, Naidu C, Ramesh G, Chatterjee J, Puri P, Nandi B, Nambiar P, Madan R. Liver transplantation in Indian Armed Forces-initial experience. Med J Armed Forces India 2012; 68:110-7. [PMID: 24669047 DOI: 10.1016/s0377-1237(12)60018-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/07/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This study retrospectively analyses the initial experience of liver transplantation (LT) in the Indian Armed Forces. METHODS Fifty-three patients underwent LT at Army Hospital (R&R) Delhi Cantt. between March 2007 and March 2011. Of these 35 patients underwent deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) was carried out in 18 patients. The surgical techniques, complications and mortality were analysed. RESULTS A high consent rate of 35.9% for organ donation was achieved by the Armed Forces Organ Retrieval and Transplantation Authority (AORTA). Biliary complications occurred in five patients (9.4%). However, most of them could be managed by endoscopic interventions. Hepatic artery thrombosis (HAT) occurred in five patients (9.4%). Of these, two DDLT grafts were revascularised following HAT, by creating extra-anatomic arterial conduits with excellent outcome. The overall mortality was 18.8% (n = 10). There was no significant difference in the overall complications or mortality in patients undergoing DDLT or LDLT. CONCLUSION The overall survival and morbidity in this study is comparable to those from other centres. Urgent revascularisation of grafts following HAT should be attempted as it can salvage grafts with satisfactory outcome. There is a reduction in the incidence of biliary complications with refinements in surgical techniques.
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Affiliation(s)
- Anupam Saha
- Commandant, Military Hospital, Agra, Agra Cantt. - 282001
| | - Cs Naidu
- Senior Advisor (Surgery & GI Surgery), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Gs Ramesh
- Consultant (CTVS Anaesthesia), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Joy Chatterjee
- Senior Advisor (Paediatric Anaesthesia), INHS Asvini, Colaba, Mumbai
| | - Pankaj Puri
- Senior Advisor, (Gastroenterology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Bhaskar Nandi
- Senior Advisor, (Gastroenterology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Pradhi Nambiar
- Transplant Coordinator, Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Renu Madan
- Classified Specialist (Pathology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
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Abstract
Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.
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Affiliation(s)
- Shao Fa Wang
- Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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Segment IV preserving middle hepatic vein retrieval in right lobe living donor liver transplantation. J Am Coll Surg 2011; 213:e5-16. [PMID: 21641832 DOI: 10.1016/j.jamcollsurg.2011.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Revised: 04/27/2011] [Accepted: 04/27/2011] [Indexed: 02/07/2023]
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Varma V, Mehta N, Kumaran V, Nundy S. Indications and contraindications for liver transplantation. Int J Hepatol 2011; 2011:121862. [PMID: 22007310 PMCID: PMC3189562 DOI: 10.4061/2011/121862] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 08/10/2011] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic liver disease and certain patients with acute liver failure require liver transplantation as a life-saving measure. Liver transplantation has undergone major improvements, with better selection of candidates for transplantation and allocation of scarce deceased donor organs (according to more objective criteria). Living donor liver transplantation came into existence to overcome the shortage of donor organs especially in countries where there was virtually no deceased donor programme. Advances in the technical aspects of the procedure, the intraoperative and postoperative care of both recipients and donors, coupled with the introduction of better immunosuppression protocols, have led to graft and patient survivals of over 90% in most high volume centres. Controversial areas like transplantation in alcoholic liver disease without abstinence, acute alcoholic hepatitis, and retransplantation for recurrent hepatitis C virus infection require continuing discussion.
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Affiliation(s)
- Vibha Varma
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Naimish Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital Room No. 2221, SSR Block, Rajinder Nagar, New Delhi 110060, India,*Samiran Nundy:
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