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Kugiyama N, Hashigo S, Nagaoka K, Watanabe T, Ushijima S, Uramoto Y, Yoshinari M, Morinaga J, Gushima R, Tateyama M, Tanaka M, Naoe H, Sugawara Y, Hibi T, Tanaka Y. Clinical usefulness of inside stents in anastomotic biliary strictures after liver transplantation. DEN OPEN 2024; 4:e305. [PMID: 37900614 PMCID: PMC10606956 DOI: 10.1002/deo2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/31/2023]
Abstract
Background Endoscopic biliary stenting is a standard treatment for biliary strictures after liver transplantation. Plastic stents are often replaced before stent dysfunction to prevent the development of cholangitis and jaundice. Therefore, the precise duration of stent patency is unclear. Methods We compared retrospectively the stent patency period and stent dysfunction rate between inside stents (IS) and conventional plastic stents (PS) in 48 patients with post-transplant strictures, distinguishing endoscopic biliary stenting with and without stent dysfunction at stent replacement. Results In observations focused on the first treatment, the median patency periods were 369 days for IS (n = 18) and 154 days for PS (n = 30; p = 0.01), significantly longer for IS. The 1-year cholangitis incidence rate was lower for IS (20% vs. 43%, p = 0.04). Additionally, no stent dislocation was observed for IS, but this occurred for 33.3% of PS (p = 0.004). Comparing all endoscopic biliary stenting, including second and subsequent procedures, IS again had a longer patency period than PS (356 days, n = 89, vs. 196 days, n = 127, p = 0.009). Conclusions IS had a significantly longer patency period than PS, suggesting that IS replacement could be reduced to once per year for patients who prefer less frequent stent replacement.
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Affiliation(s)
- Naotaka Kugiyama
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Shunpei Hashigo
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Katsuya Nagaoka
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Takehisa Watanabe
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Shinya Ushijima
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Yukiko Uramoto
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Motohiro Yoshinari
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Jun Morinaga
- Department of Clinical InvestigationKumamoto University HospitalKumamotoJapan
| | - Ryosuke Gushima
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Masakuni Tateyama
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | | | - Hideaki Naoe
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Yasuhiko Sugawara
- Department of Pediatric Surgery and TransplantationKumamoto University HospitalKumamotoJapan
| | - Taizo Hibi
- Department of Pediatric Surgery and TransplantationKumamoto University HospitalKumamotoJapan
| | - Yasuhito Tanaka
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
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Nagata R, Akamatsu N, Shibata E, Takao H, Ichida A, Mihara Y, Kawaguchi Y, Ishizawa T, Kaneko J, Arita J, Tamura S, Abe O, Hasegawa K. Metallic Stents for Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplantation and their Therapeutic Effects. Transplant Proc 2024; 56:125-134. [PMID: 38177046 DOI: 10.1016/j.transproceed.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/26/2023] [Accepted: 11/30/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Living-donor liver transplantation (LDLT) is established as a standard therapy for end-stage liver disease; however, vessel reconstruction is more demanding due to the short length and small size of the available structures compared with deceased-donor whole liver transplantation. Interventional radiology (IR) has become the first-line treatment for vascular complications after LDLT. Hepatic venous outflow obstruction (HVOO) is a life-threatening complication after LDLT. The aim of this study of 592 adult-to-adult LDLT cases was to investigate the safety and efficacy of stent implantation for HVOO after LDLT. METHODS Records of patients who developed HVOO requiring any treatment were collected with special reference to the metallic stent implantation. There were 232 left-side grafts and 360 right-side grafts. Sixteen cases developed HVOO after LDLT with an incidence rate of 2.7%, 5 with a left liver graft (2%), and 11 with a right-side graft (3%). The IR was attempted for 14 cases; among those, 8 cases were treated by stent implantation. RESULTS The technical success rate of the initial stent implantation was 100%. The pressure gradient at the stenotic site significantly improved from 12.2 (range, 10.9-20.4 cm H2O) to 3.9 cm H2O (range, 1.4-8.2 cm H2O; P = .03). The volume of the congested graft liver decreased significantly from 1448 (range, 788-2170 mL) to 1265 mL (range, 748-1665 mL; P = .01), and the serum albumin level improved significantly from 3.3 (range, 1.7-3.7 g/dL) to 3.7 g/dL (range, 2.9-4.1 g/dL; P = .02). No procedure-related complication was noted, and the long-term stent patency was 100%. CONCLUSION Metallic stent implantation for stenotic venous anastomosis after LDLT is a safe and effective treatment.
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Affiliation(s)
- Rihito Nagata
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Eisuke Shibata
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Hidemasa Takao
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Akihiko Ichida
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Yuichiro Mihara
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Takeaki Ishizawa
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Junichi Kaneko
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Junichi Arita
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Sumihito Tamura
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan.
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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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Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures. Transplantation 2022; 106:1990-1999. [PMID: 35771085 DOI: 10.1097/tp.0000000000004201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Survey on the current status of the indication and implementation protocols for bile replacement in patients with external biliary drainage with special reference to infection control. Surg Today 2022; 52:1446-1452. [PMID: 35182252 DOI: 10.1007/s00595-022-02475-x] [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: 08/19/2021] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE This survey of bile replacement (BR) was conducted on patients with external biliary drainage to assess the current status of indication and implementation protocol of BR with special reference to infection control. METHODS A 12-item questionnaire regarding the performance of perioperative BR was sent to 124 institutions in Japan. RESULTS BR was performed in 29 institutions, and the indication protocol was introduced in 19. BR was performed preoperatively in 11 institutions, pre- and postoperatively in 12, and postoperatively in 6. The methods used for BR administration included oral intake (n = 10), nasogastric tube (n = 1), enteral nutrition tube (n = 3), oral intake and enteral nutrition tube (n = 6), oral intake or nasogastric tube (n = 2), nasogastric tube and enteral nutrition tube (n = 2), and oral intake or nasogastric tube and enteral nutrition tube (n = 5). In 10 of 29 institutions, isolation of multidrug-resistant organisms and a high bacterial load were considered contraindications for the use of BR. Seven institutions experienced environmental contamination. CONCLUSIONS Given the different implementation of BR among institutions, the appropriate indication and protocols for BR should be established for infection control.
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Kwon CI, Choi SH, Kim KS, Moon JP, Park S, Jeon J, Kim G, Jang JY, Sung MJ, Ko KH, Son JS. Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model. Ann Surg Treat Res 2022; 102:90-99. [PMID: 35198512 PMCID: PMC8831087 DOI: 10.4174/astr.2022.102.2.90] [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: 11/02/2021] [Revised: 12/29/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis. Methods Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion. Results In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05). Conclusion Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kyu Seok Kim
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jong Pil Moon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Sehwan Park
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jinkyung Jeon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Young Jang
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jun Sik Son
- Korea Textile Development Institute, Daegu, Korea
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Chikkala BR, Rahul R, Agarwal S, Vijayashanker A, Pandey Y, Balradja I, Dey R, Gupta S. Outcomes of Right and Left Hepatic Arterial Anastomosis in Right Lobe Living Donor Liver Transplant. EXP CLIN TRANSPLANT 2021; 20:157-163. [PMID: 34791995 DOI: 10.6002/ect.2020.0309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Living donor liver transplant is a complex surgery with well-known complications. Here, we report the use of the right and left hepatic arteries of the recipient for anastomosis and the effects of each procedure on overall outcomes and any associated short-term or long-term biliary complications. MATERIALS AND METHODS This was a prospective observational study with long-term follow-up of 200 patients (100 in the right hepatic artery group and 100 in the left hepatic artery group). RESULTS The average donor age was 28.9 years in the left hepatic artery group and 30.9 years in the right hepatic artery group. Most of the donors (60%) were female. Overall, there was 10.5% mortality in the early postoperative period. Among survivors, there were more late strictures in the right hepatic artery group (29.7% vs 22.7%). Bile leak (P = .42), mortality (P = .71), and incidence of late-onset biliary strictures (P = .83) were less common in the left hepatic artery group. CONCLUSIONS Left artery anastomosis was found to be technically safe and feasible and did not adversely affect patient outcome compared with right artery anastomosis. Left hepatic artery anastomosis may also reduce the incidence of the biliary complications compared with the right hepatic artery anastomosis.
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Del Fabbro D, Cimino MM, Procopio F, Torzilli G. Stent-free duct-to-duct biliary reconstruction after hepatectomy for liver tumors involving biliary confluence at the hepatic hilum: a monocentric experience. Updates Surg 2021; 73:2017-2022. [PMID: 33768448 DOI: 10.1007/s13304-021-00987-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Abstract
Roux-en-Y hepaticojejunostomy (HJ) is the standard of care for biliary reconstruction. Its weaknesses are the loss of the sphincter functionality, which could lead to repeated cholangitis, and the reduced endoscopic accessibility to the biliary tree. In the context of liver transplantation it has been shown that duct-to-duct biliary anastomosis may be suitable as an alternative to HJ, significantly reducing the risk of cholangitis. Here we present our experience on stent-free duct-to-duct reconstruction, performed in six patients receiving hepatectomy with resection of the biliary confluence. Operative mortality was nil. Anastomotic leak occurred in four patients and resolved spontaneously in all cases. One patient developed anastomotic stricture 17 months after surgery and only one patient developed tumor recurrence at the anastomotic site; in both cases the endoscopic stenting succeeded in restoring the ducts patency. With a median follow-up of 24 months (range 19-28 months), no cholangitis or other biliary-related complications were observed. Our experience, although limited, shows satisfactory oncological and functional outcomes, confirming all previously published results.
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Affiliation(s)
- Daniele Del Fabbro
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Matteo Maria Cimino
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy.
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Increased Surgical Complications but Improved Overall Survival with Adult Living Donor Compared to Deceased Donor Liver Transplantation: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1320830. [PMID: 32908865 PMCID: PMC7468609 DOI: 10.1155/2020/1320830] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/19/2020] [Accepted: 08/07/2020] [Indexed: 12/23/2022]
Abstract
Background Living donor liver transplantation (LDLT) provides an alternative to deceased donor liver transplantation (DDLT) for patients with end-stage liver disease in the circumstance of scarcity of deceased grafts. However, the outcomes of LDLT remain controversial. Method A systematic review and meta-analysis were performed to compare the outcomes of LDLT with DDLT. Twelve outcomes were assessed. Results Thirty-nine studies involving 38563 patients were included. LDLT was comparable in red blood cell transfusion, perioperative mortality, length of hospital stay, retransplantation rate, hepatitis C virus recurrence rate, and hepatocellular carcinoma recurrence rate with DDLT. Cold ischemia time was shorter and duration of recipient operation was longer in LDLT. Postoperative intra-abdominal bleeding rate occurred less frequently in LDLT recipients (odds ratio (OR) = 0.64, 95%confidence interval (CI) = 0.46 − 0.88, P = 0.006), but this did not decrease the perioperative mortality. LDLT was associated with significantly higher biliary (OR = 2.23, 95%CI = 1.59 − 3.13, P < 0.00001) and vascular (OR = 2.00, 95%CI = 1.31 − 3.07, P = 0.001) complication rates and better overall survival (OS) (1 year: OR = 1.32, 95%CI = 1.01 − 1.72, P = 0.04; 3 years: OR = 1.39, 95%CI = 1.14 − 1.69, P = 0.0010; and 5 years: OR = 1.33, 95%CI = 1.04 − 1.70, P = 0.02). According to subgroup analysis, biliary complication rate and OS improved dramatically as experience increased, while vascular complication rate could not be improved because it was mainly caused by the difference of the donor type itself. Conclusions LDLT remains a valuable option for patients in need of liver transplantation for it provides an excellent alternative to DDLT without compromising recipient outcomes. Further refinement in biliary and vascular reconstruction techniques and the accumulation of liver transplantation centers' experience are the key factors in expanding the application of LDLT.
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11
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Paradigm shift in the management of bile duct strictures complicating living donor liver transplantation. Indian J Gastroenterol 2019; 38:488-497. [PMID: 32065353 DOI: 10.1007/s12664-019-01000-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023]
Abstract
AIM Validation of new metrics to identify functionally significant obstruction (FSO), to better define biliary strictures complicating living donor liver transplantation (LDLT). METHODS All LDLT recipients who presented with cholestasis were studied. Novel metrics for FSO are as follows: (1) magnetic resonance cholangiopancreatography (MRCP) ductal ratio (MDR): The ratio between hepatic duct and recipient duct diameter on the MRCP taken at presentation; (2) endoscopic retrograde cholangiography (ERC) ductal ratio (EDR): The ratio between hepatic duct and recipient duct diameter on the first ERC done for suspected biliary strictures; (3) delayed contrast drainage (DCD): > 50% contrast retained above the anastomotic site, in more than three consecutive fluoroscopic images taken at least 15 min after contrast instillation. Association between these metrics and endotherapy response was analyzed along with patient demographics, intraoperative variables (cold ischemia time, blood transfusions, biliary anastomosis) and perioperative complications (hepatic artery thrombosis [HAT], bile leak). Favorable response to endotherapy was defined as symptomatic relief with ≥ 80% reduction in total bilirubin/alkaline phosphatase. RESULTS A total of 83 LDLT recipients presented with altered liver function tests. Favorable response was seen in 18/39 patients (46.2%). On univariate analysis, HAT, multiple biliary anastomoses, graft-to-recipient weight ratio (GRWR), MDR, EDR and DCD were significant (p value ≤ 0.05). On multivariate analysis, only MDR ≥ 1.15 was an independent predictor of favorable response to endotherapy (OR 48 [95% CI 7.096-324.71]). CONCLUSION A paradigm shift in the approach to management of biliary strictures complicating LDLT is proposed whereby a multidimensional definition of FSO can help in reliable patient selection for endotherapy and improve patient outcome as a whole.
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12
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Choi SH, Kim KW, Kwon HJ, Kim SY, Kwon JH, Song GW, Lee SG. Clinical usefulness of gadoxetic acid–enhanced MRI for evaluating biliary anatomy in living donor liver transplantation. Eur Radiol 2019; 29:6508-6518. [DOI: 10.1007/s00330-019-06292-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/24/2019] [Accepted: 05/29/2019] [Indexed: 12/25/2022]
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13
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Hong SY, Hu XG, Lee HY, Won JH, Kim JW, Shen XY, Wang HJ, Kim BW. Longterm Analysis of Biliary Complications After Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantations. Liver Transpl 2018; 24:1050-1061. [PMID: 29633539 DOI: 10.1002/lt.25074] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
Biliary complication (BC) is still regarded as the Achilles' heel of a living donor liver transplantation (LDLT). This study aims to evaluate the longterm outcomes of the duct-to-duct (DD) biliary reconstruction using 7-0 suture and to identify the risk factors of BCs after LDLTs. Data of 140 LDLTs between 2006 and 2015 were analyzed. All biliary reconstructions were performed as DD anastomoses using 7-0 suture: 102 for the right lobe, 20 for the left lobe, and 18 for right posterior sector grafts. BC was defined as a bile leakage (BL) or a biliary stricture (BS), and the median follow-up time after LDLT was 65 months. A total of 19 recipients (13.5%) developed BCs (8 BLs and 16 BSs) after LDLT. The survival rates between recipients with and without BCs were 83% and 86.7%, respectively (P = 0.88). In univariate analyses, the risk factors for BC were small diameter of the graft's bile duct, long warm ischemic time, small graft-to-recipient weight ratio, and no use of external biliary stent (EBS). The graft's bile duct diameter ≤ 3 mm and no use of EBS were determined as independent risk factors (hazard ratios of 9.74 and 7.68, respectively) in multivariate analyses. The 116 recipients with EBS had no BL, 11 had BSs (9%), while 24 without EBS had 8 BLs (33%) and 5 BSs (21%). After a propensity score match between the recipients with and without EBS, the EBS group (24) developed only 1 BS (4%). In conclusion, DD anastomosis using 7-0 suture combined with EBS could provide favorable longterm outcomes after LDLT, which should thus be considered the surgical technique of choice for LDLTs.
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Affiliation(s)
- Sung Yeon Hong
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Xu-Guang Hu
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University School of Medicine, Suwon, Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Xue-Yin Shen
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hee-Jung Wang
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Bong-Wan Kim
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
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14
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Woo YS, Lee KH, Lee KT, Lee JK, Kim JM, Kwon CHD, Joh JW, Kang D, Cho J. Postoperative changes of liver enzymes can distinguish between biliary stricture and graft rejection after living donor liver transplantation: A longitudinal study. Medicine (Baltimore) 2017; 96:e6892. [PMID: 28984750 PMCID: PMC5737986 DOI: 10.1097/md.0000000000006892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is no known useful clinical parameter that can specifically predict a biliary stricture and differentiate it from other related complications after living donor liver transplantations (LDLT). The aims of this study were to determine whether the changes of liver enzymes can predict postoperative biliary stricture apart from other complications. We reviewed the medical records of 203 patients who underwent LDLT with duct to duct anastomosis from 2008 to 2010. The longitudinal changes of liver enzyme over time and the occurrence of complication were evaluated. A total of 124 patients had no complication up to 2 years after LDLT, and 74 patients had complications including biliary stricture and graft rejection. Complications developed more frequently in patients who's alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) did not return to the baseline plateau at 30 days after LDLT (ALP; P = .045, GGT; P = .047). Aspartate transaminase (AST) and alanine transaminase (ALT) increased continuously until the diagnosis of complication in both stricture and rejection groups with more rapid increase in enzymes in the rejection versus stricture group (P < .05). In addition, AST and ALT were 2-fold higher in the rejection than the stricture group at the diagnosis of each complication (AST; P < .05, ALT; P < .05). The increasing slope and final levels of AST and ALT are potentially helpful parameters to differentiate rejection and stricture, the 2 most common posttransplantation complications.
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Affiliation(s)
- Young Sik Woo
- Department of Interanl Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine
| | - Kwang Hyuck Lee
- Department of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | | | | | | | | | | | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Departments of Epidemiology and Social, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, USA
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15
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Abstract
Living donor liver transplantation (LDLT) has been increasingly embraced around the world as an important strategy to address the shortage of deceased donor livers. The aim of this guideline, approved by the International Liver Transplantation Society (ILTS), is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT. Recommendations were developed from an analysis of the National Library of Medicine living donor transplantation indexed literature using the Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care of living donor liver transplant recipients. Compared to cadaveric liver transplantation, live donor LT (LDLT) is challenged by ethical, medical and surgical considerations, many of which are still unresolved. The aim of this guideline is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT.
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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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Low Platelet Counts and Prolonged Prothrombin Time Early After Operation Predict the 90 Days Morbidity and Mortality in Living-donor Liver Transplantation. Ann Surg 2017; 265:166-172. [PMID: 28009742 DOI: 10.1097/sla.0000000000001634] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the association between platelet count/prothrombin time early after transplant and short-term outcomes among living-donor liver transplant (LDLT) recipients. BACKGROUND Postoperative platelet count and prothrombin time-international normalized ratio (PT-INR) were critical biomarkers in LDLT. METHODS The study participants consisted of 445 initial LDLT recipients, and perioperative variables, including platelet count and PT-INR, were assessed for their association with severe complications (Clavien-Dindo classification grade IIIb/IV) and mortality within 90 days after operation. RESULTS Severe complications and operative mortality occurred in 161 (36%) and 23 patients (5%), respectively. Cox regression analysis revealed that a high body mass index [hazard ratio (HR) 1.2; 95% confidence interval (CI), 1.1-1.4; P = 0.004] and low platelet count on postoperative day (POD)3 (HR 0.88; 95% CI, 0.57-0.97; P < 0.001) were independent predictors for grade IIIb/IV complications after LDLT, whereas high PT-INR on POD5 (HR 1.1; 95% CI, 1.1-1.3; P = 0.021) was the only independent factor for operative mortality. In addtion, the progonostic scoring with low platelet count (<50 × 10/L) and prolonged prothrombin time (PT-INR >1.6) within POD5, 1 point for each, was demonstrated to be useful in predicting the development of Clavien-Dindo grade IIIb/IV/V complications after LDLT (30% for score 0, 46% for score 1, and 72% for score 2: 0 vs 1, P = 0.004; 0 vs 2, P < 0.001; 1 vs 2, P = 0.002). CONCLUSIONS PT-INR above 1.6 and platelet count below 50 × 10/L within POD5 were useful predictors of mortality and severe complications after LDLT.
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Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10:297-311. [PMID: 28600688 DOI: 10.1007/s12328-017-0754-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
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Affiliation(s)
- Takeshi Tsujino
- Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Rao HB, Ahamed H, Panicker S, Sudhindran S, Venu RP. Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome. World J Gastrointest Pathophysiol 2017; 8:77-86. [PMID: 28573070 PMCID: PMC5437505 DOI: 10.4291/wjgp.v8.i2.77] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/23/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT).
METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.
RESULTS Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome (P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis (P < 0.05).
CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.
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20
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Karakas S, Sarici K, Ozdemir F, Ersan V, Ince V, Baskiran A, Kayaalp C, Kutlu R, Yilmaz S. Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up. Transplant Proc 2017; 49:562-565. [DOI: 10.1016/j.transproceed.2017.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Ye S, Dong JH, Duan WD, Ji WB, Liang YR. The Preliminary Study on Procurement Biliary Convergence from Donors with Complicated Bile Duct Variant in Emergency Right Lobe Living Donor Liver Transplantation. J Clin Exp Hepatol 2017; 7:33-41. [PMID: 28348469 PMCID: PMC5357717 DOI: 10.1016/j.jceh.2016.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 09/28/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the bile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high model for end-stage liver disease score patients. METHODS The common hepatic duct (CHD) and the left hepatic duct (LHD) of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed. RESULTS Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up; significant differences (P < 0.05) were found when two stages were compared. CONCLUSION Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant right hepatic ducts in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.
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Key Words
- CHD, common hepatic duct
- CUSA, cavitron ultrasonic surgical aspirator
- CVP, central venous pressure
- HTK, histidine-tryptophan-ketoglutarate
- LDALT, living donor adult liver transplantation
- LDLT
- LHD, left hepatic duct
- MELD, model for end-stage liver disease
- MHA, middle hepatic artery
- MHV, middle hepatic vein
- MRCP, magnetic resonance cholangiopancreatography
- PHA, proper hepatic artery
- RHA, right hepatic artery
- RHD, right hepatic duct
- RHV, right hepatic vein
- RPV, right portal vein
- bile duct variant
- biliary complications
- surgical innovation
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Affiliation(s)
- Sheng Ye
- Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China,Address for correspondence: Sheng Ye, Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China. Fax: +86 10 56118500.Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University168 Litang Road, Dongxiaokou Town, Changping DistrictBeijing102218China
| | - Jia-Hong Dong
- Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China
| | - Wei-Dong Duan
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
| | - Wen-Bing Ji
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
| | - Yu-Rong Liang
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
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22
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Bae SJ, Han DH, Choi GH, Choi JS. The Role of Bile Duct Probe for Bile Duct Division during Donor Right Hemihepatectomy. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.4.172] [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
Affiliation(s)
- Soong June Bae
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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23
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Semenkov AV, Kim EF, Filin AV, Burmistrov DS, Metelin AV, Kamalov YR, Galyan TN, Goncharova AV. [Advisability of biliary drainage in liver fragments reconstruction]. Khirurgiia (Mosk) 2016:4-12. [PMID: 27723689 DOI: 10.17116/hirurgia201694-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM to estimate the effect of decompressive stented drainage of biliary anastomosis on incidence of biliary complications. MATERIAL AND METHODS 294 patients aged from 5 months to 61 years (mean 13.8±0.81) were enrolled. They underwent liver fragments transplantation in the Department of Liver Transplantation of Petrovsky Russian Research Center of Surgery for the period from March 1997 to January 2016. Decompressive stented drainage tubes were used in 28 (9.5%) patients. Reconstruction without drainage was applied in 266 (90.5%) cases. In the group of biliobiliary reconstruction drainage was used in 18 out of 89 cases (20.2%), in the group of biliodigestive reconstruction - in 10 out of 202 cases (4.9%). Incidence of specific biliary complications was assessed. RESULTS There was significant direct correlation of stented drainage of biliodigestive anastomosis with various biliary complications including bile leakage (r= -0,1253; p=0.06), obturation of anastomosis (r=0.045; p=0.501), stricture of anastomosis (r= -0.0665; p=0.320), other strictures of intrahepatic bile ducts (r= -0.0291; p=0.664), hepatolithiasis (r=0.0857; p=0.199). However significant direct correation was observed between stented drainage and incidence of intrahepatic bile ducts strictures (r=0.2117; p=0.046) and anastomosis obturation (r=0.2330; p=0.028) in case of biliobiliary reconstruction. Significant correation with other biliary complications was absent (p>0.05). CONCLUSION Unconstrained stented drainage during primary biliary reconstruction is associated with increased incidence of biliary complications and should not be indicated routinely. Clear need for drainage should be determined in further investigations.
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Affiliation(s)
- A V Semenkov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - E F Kim
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Filin
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - D S Burmistrov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Metelin
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - Yu R Kamalov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - T N Galyan
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Goncharova
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
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24
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Shin M, Joh JW. Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature. World J Gastroenterol 2016; 22:6173-6191. [PMID: 27468208 PMCID: PMC4945977 DOI: 10.3748/wjg.v22.i27.6173] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/25/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.
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25
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Biliary Anastomotic Stricture After Adult Living Donor Liver Transplantation With Duct-to-Duct Reconstruction. Transplantation 2016; 100:1500-6. [DOI: 10.1097/tp.0000000000001187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Vij V. Reply. Liver Transpl 2016; 22:561. [PMID: 26824627 DOI: 10.1002/lt.24409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/15/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and HPB Surgery, Fortis Hospital, Noida, India
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27
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Oh DW, Lee SK, Song TJ, Park DH, Lee SS, Seo DW, Kim MH. Endoscopic management of bile leakage after liver transplantation. Gut Liver 2016; 9:417-23. [PMID: 25717048 PMCID: PMC4413977 DOI: 10.5009/gnl14117] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. METHODS Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. RESULTS In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. CONCLUSIONS ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.
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Affiliation(s)
- Dong-Wook Oh
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Mizuno S, Inoue H, Tanemura A, Murata Y, Kuriyama N, Azumi Y, Kishiwada M, Usui M, Sakurai H, Tabata M, Yamada R, Yamamoto N, Sugimoto K, Shiraki K, Takei Y, Isaji S. Biliary complications in 108 consecutive recipients with duct-to-duct biliary reconstruction in living-donor liver transplantation. Transplant Proc 2015; 46:850-5. [PMID: 24767364 DOI: 10.1016/j.transproceed.2013.11.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 11/05/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biliary complications remain the leading cause of postoperative complications after living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy. The aim of this study was to analyze the causes of these complications. METHODS One hundred eight patients who underwent LDLT with duct-to-duct biliary reconstruction at Mie University Hospital were enrolled in this study. The mean follow-up time was 58.4 months (range, 3-132). The most recent 18 donors underwent indocyanine green (ICG) fluorescence cholangiography for donor hepatectomy. The development of biliary complications was retrospectively analyzed. Biliary complications were defined as needing endoscopic or radiologic treatment. RESULTS Biliary leakages and strictures occurred in 6 (5.6%) and 15 (13.9%) of the recipients, respectively, and 3 donors (2.7%) experienced biliary leakage. However, since the introduction of ICG fluorescence cholangiography, we have not encountered any biliary complications in either donors or recipients. Biliary leakage was an independent risk factor for the development of biliary stricture (P = .013). Twelve (80%) of the 15 recipients with biliary stricture had successful nonoperative endoscopic or radiologic management, and 3 patients underwent surgical repair with hepaticojejunosotomy. CONCLUSIONS Biliary leakage was an independent factor for biliary stricture. ICG fluorescence cholangiography might be helpful to reduce biliary complications after LDLT in both donors and recipients.
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Affiliation(s)
- S Mizuno
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan.
| | - H Inoue
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - A Tanemura
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - Y Murata
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - N Kuriyama
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - Y Azumi
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - M Kishiwada
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - M Usui
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - H Sakurai
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - M Tabata
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
| | - R Yamada
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - N Yamamoto
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - K Sugimoto
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - K Shiraki
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Y Takei
- Department of Gastroenterology and Hepatology, Mie University School of Medicine, Tsu, Mie, Japan
| | - S Isaji
- Department of Hepatobiliary-Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan
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Park CS, Jung BH, Hwang S, Park YH, Kang SH, Park GC, Song GW, Jung DH, Ahn CS, Kim KH, Moon DB, Ha TY, Lee SG. External biliary drainage in living donor liver transplantation using duct-to-duct anastomosis. Transplant Proc 2015; 46:678-81. [PMID: 24767322 DOI: 10.1016/j.transproceed.2013.11.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/01/2013] [Accepted: 11/27/2013] [Indexed: 12/26/2022]
Abstract
PURPOSE This study compared the incidence of biliary complication (BC) in adult living donor liver transplant recipients who underwent right-lobe duct-to-duct anastomosis (DDA) with or without external biliary drainage (EBD) and intended to optimize EBD tube clamping. METHODS This study consisted of a retrospective assessment of EBD effect and a prospective trial for EBD tube-clamping optimization. The retrospective study included the EBD group (n = 208) and the non-EBD group (n = 145). The prospective study included 60 patients with EBD. RESULTS In the retrospective study, single DDA was performed in 83.7% of the EBD group and 80.7% of the non-EBD group (P = .47). One-year overall incidence of BC was 14.4% in the EBD group and 16.8% in the non-EBD group (P = .48). The incidence of early anastomotic bile leakage was 1.0% in the EBD group and 4.8% in the non-EBD group (P = .036). In the prospective study, there was no difference in tube-clamping success rates between low- and high-output EBD groups. There was also no statistical difference between the success and failure groups in terms of graft duct size, liver function tests, and post-transplant days at tube clamping. CONCLUSIONS The size of our EBD tube was too small for the graft duct size, therefore its main role appeared to be early biliary decompression, which helped prevent bile leakage and also simplified the route of cholangiogram in detecting early BC. Hence, EBD is worthy of performing in selected patients with a high risk of anastomotic bile leak.
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Affiliation(s)
- C-S Park
- Department of Surgery, Gangneung Asan Hospital, Gangneung, Gangwondo, Korea
| | - B-H Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Y-H Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S-H Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - G-C Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - G-W Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D-H Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - C-S Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - K-H Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D-B Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - T-Y Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S-G Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Akamatsu N, Sugawara Y, Nagata R, Kaneko J, Aoki T, Sakamoto Y, Hasegawa K, Kokudo N. Adult right living-donor liver transplantation with special reference to reconstruction of the middle hepatic vein. Am J Transplant 2014; 14:2777-87. [PMID: 25395154 DOI: 10.1111/ajt.12917] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/08/2014] [Accepted: 07/10/2014] [Indexed: 01/25/2023]
Abstract
Two hundred fifty-three consecutive living-donor liver transplant recipients with a right liver graft (RLG) were divided into three groups: an extended right liver graft (ERLG) group (n = 47) in which the middle hepatic vein (MHV) trunk was included in the graft, a modified right liver graft (MRLG) group (n = 114) in which the MHV tributaries were reconstructed with cryopreserved homologous veins and a simple RLG group (n = 92) in which the MHV tributaries were sacrificed. The volume of the anterior sector was significantly impaired in the RLG group compared to the other two groups, whereas the volume of the posterior sector was significantly improved in the RLG group, indicating that the impaired anterior sector regeneration by MHV deprivation was compensated by the posterior sector regeneration. The regeneration rate of the anterior sector was highest in the ERLG group (92%), moderate in the MRLG group (71%) and lowest in the RLG group (52%). The whole graft regeneration rate of the ERLG group was significantly higher than that of the other two groups. Poor regeneration, however, was not correlated with delayed functional recovery or long-term outcome. Short-term, the patency of reconstructed MHV tributaries was over 90%, but occlusion occurred frequently over the long-term, especially in V5.
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Affiliation(s)
- N Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Section 9. Technical Details of Microsurgical Biliary Reconstruction in Living Donor Liver Transplantation. Transplantation 2014; 97 Suppl 8:S34-6. [DOI: 10.1097/01.tp.0000446273.13310.77] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Shin M, Joh JW. Section 10. Endoscopic management of biliary complications in adult living donor liver transplantation. Transplantation 2014; 97 Suppl 8:S36-43. [PMID: 24849832 DOI: 10.1097/01.tp.0000446274.13310.b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Living donor liver transplantation (LDLT) has become an accepted therapeutic option for patients with end-stage liver disease. However, biliary complications remain the major causes of morbidity and mortality for LDLT recipients. Although there are currently no reports of a clear therapeutic algorithm, many approaches have been developed to treat biliary complications, including surgical, endoscopic, and percutaneous transhepatic techniques. Endoscopic treatment is currently the preferred initial treatment for patients that have previously undergone duct-to-duct biliary reconstruction. This article discusses aspects of endoscopic management of biliary complications that occur in adult LDLT.
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Affiliation(s)
- Milljae Shin
- 1 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2 Address correspondence to: Jae-Won Joh, M.D., Ph.D., Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea
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Lin TS, Chen CL, Concejero AM, Yap AQ, Lin YH, Liu CY, Chiang YC, Wang CC, Wang SH, Lin CC, Yong CC, Cheng YF. Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation. Liver Transpl 2013. [PMID: 23197399 DOI: 10.1002/lt.23582] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT.
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Affiliation(s)
- Tsan-Shiun Lin
- Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Carlisle EM, Testa G. Adult to adult living related liver transplantation: Where do we currently stand? World J Gastroenterol 2012; 18:6729-36. [PMID: 23239910 PMCID: PMC3520161 DOI: 10.3748/wjg.v18.i46.6729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 08/03/2012] [Accepted: 08/14/2012] [Indexed: 02/06/2023] Open
Abstract
Adult to adult living donor liver transplantation (AALDLT) was first preformed in the United States in 1997. The procedure was rapidly integrated into clinical practice, but in 2002, possibly due to the first widely publicized donor death, the number of living liver donors plummeted. The number of donors has since reached a steady plateau far below its initial peak. In this review we evaluate the current climate of AALDLT. Specifically, we focus on several issues key to the success of AALDLT: determining the optimal indications for AALDLT, balancing graft size and donor safety, assuring adequate outflow, minimizing biliary complications, and maintaining ethical practices. We conclude by offering suggestions for the future of AALDLT in United States transplantation centers.
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Memeo R, Belli A, Kluger MD, Tayar C, Laurent A, Cherqui D. Duct-to-duct biliary reconstruction during complex hepatectomy: a useful technique in selected cases. World J Surg 2012; 36:129-35. [PMID: 22037690 DOI: 10.1007/s00268-011-1318-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Roux-en-Y anastomosis is the standard of care for biliary reconstruction. Yet, a direct bilio-biliary anastomosis preserves the normal sphincter mechanism and endoscopic access to the biliary tree for diagnostic and therapeutic purposes. Duct-to-duct biliary reconstruction is widely used in liver transplantation. The objective of this study was to analyze the feasibility and results of duct-to-duct biliary reconstruction in the setting of complex hepatic resection with limited biliary confluence involvement. METHODS We identified patients from our prospectively maintained database that underwent major hepatic resection and bile duct resection with a concomitant direct duct-to-duct biliary anastomosis. Postoperative oncological and functional biliary outcomes were analyzed. RESULTS Ten patients were studied. In 9 cases, a biliary stent was left in place to decompress the anastomosis. Two patients developed a biliary fistula: one resolved spontaneously and the other required percutaneous drainage and an endoscopic biliary stent. This latter patient (the only nonstented patient) also developed a biliary stricture that was treated endoscopically. With a mean follow-up of 22 months, no other biliary-related complications were recorded. No patients had a recurrence at the biliary reconstruction site only. In the setting of multifocal hepatic recurrence presenting with jaundice, two patients were palliated by interventional endoscopy. CONCLUSIONS For hepatectomy requiring a short resection of the bile duct or for high bile duct injury during complex hepatectomy, a tension-free, well-vascularized duct-to-duct reconstruction over a stent is a suitable option that offers good oncological clearance of the bile duct and satisfactory functional results.
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Affiliation(s)
- Riccardo Memeo
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Hôpital Henri Mondor, Créteil, France
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Xu X, Wei X, Ling Q, Wang K, Bao H, Xie H, Zhou L, Zheng S. Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation. Eur J Radiol 2012; 81:e457-60. [PMID: 21641138 DOI: 10.1016/j.ejrad.2011.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 05/05/2011] [Accepted: 05/09/2011] [Indexed: 01/19/2023]
Abstract
BACKGROUNDS AND AIMS Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT. METHODS The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed. RESULTS Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P=0.028) and biliary stricture (10.5% vs. 1.6%, P=0.041) compared with cases with large duct opening >5mm. CONCLUSION MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.
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Affiliation(s)
- Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, 79 QingChun Road, Hangzhou, 310003, China
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Is Microsurgical Technique Useful in Biliary Reconstruction of Living Donor Liver Transplantation? Transplant Proc 2012; 44:466-8. [DOI: 10.1016/j.transproceed.2012.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lee YY, Gwak GY, Lee KH, Lee JK, Lee KT, Kwon CHD, Joh JW, Lee SK. Predictors of the feasibility of primary endoscopic management of biliary strictures after adult living donor liver transplantation. Liver Transpl 2011; 17:1467-73. [PMID: 21898773 DOI: 10.1002/lt.22432] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary strictures are a major cause of morbidity and mortality for liver transplant recipients. The endoscopic management of biliary strictures is not well established after living donor liver transplantation (LDLT) in comparison with deceased donor liver transplantation. The aims of this study were to assess the initial success rate of primary endoscopic treatment of biliary strictures after LDLT and to identify predictors of the feasibility of endoscopic management. One hundred thirty-seven adult patients who underwent LDLT and were confirmed to have biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. The biliary strictures were primarily managed endoscopically with internal drainage or nasobiliary catheterization. The initial success rate for the primary endoscopic management of biliary strictures after LDLT was 46.7% (64 of 137 patients), and the feasibility of endoscopic management was associated with the stricture-to-ERCP interval (the interval between the development of the total bilirubin, aspartate aminotransferase, or alanine aminotransferase level to >2 times the upper limit of normal and the performance of ERCP) as well as cholangiographic findings (eg, the stricture morphology and the tip shape of the distal duct). In conclusion, when biliary strictures are noticed after LDLT, prompt endoscopic interventions may improve the initial success rate of primary endoscopic management. In addition, the feasibility of primary endoscopic management can be predicted by the cholangiographic findings, which may help with the choice of the therapeutic modality.
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Affiliation(s)
- Yun Young Lee
- Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
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Cyclosporine A-based immunotherapy in adult living donor liver transplantation: accurate and improved therapeutic drug monitoring by 4-hr intravenous infusion. Transplantation 2011; 92:100-5. [PMID: 21546866 DOI: 10.1097/tp.0b013e31821dcae3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND A paucity of data exists for evaluating therapeutic drug monitoring in association with clinical outcomes of cyclosporine A (CYA) treatment in living donor liver transplantation (LDLT). METHODS A retrospective cohort analysis was conducted on 50 consecutive adult patients who underwent LDLT between 2001 and 2009 to investigate the feasibility and efficacy of 4-hr continuous intravenous infusion of CYA-based immunotherapy (4-hr CYA-IV, n=27) and compare the pharmacokinetic profile and short-term prognoses with an oral microemulsion formulation of CYA (CYA-ME, n=23). RESULTS All patients in the 4-hr CYA-IV group reached target CYA peak by day 3 compared with only 22% in the CYA-ME group (P<0.001). Adjustability to achieve the target range was easier in the 4-hr CYA-IV group compared with the CYA-ME group (P=0.017). Acute cellular rejection rate was lower in the 4-hr CYA-IV group (0%) compared with the CYA-ME group (17%, P=0.038). A subset analysis of the CYA-ME group revealed that CYA exposure was affected by external bile output (P=0.006). Patients in the CYA-ME group showed increased risk of switch to tacrolimus (35%) compared with the 4-hr CYA-IV group (7%, P=0.030). Toxicities and mortality rates were equivalent. The optimal initial dose of oral CYA at conversion from the 4-hr CYA-IV was considered to be 3-fold greater than that of the intravenous dose. CONCLUSIONS In LDLT, our 4-hr CYA-IV immunosuppression protocol was superior to CYA-ME oral dosing and allowed accurate therapeutic drug monitoring with excellent patient compliance.
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Biliary complications in 106 consecutive duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation performed in 1 year in a single center: a new surgical technique. Transplant Proc 2011; 43:917-20. [PMID: 21486628 DOI: 10.1016/j.transproceed.2010.11.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu. METHODS Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis. RESULTS All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed. CONCLUSION We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.
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Kyoden Y, Tamura S, Sugawara Y, Matsui Y, Togashi J, Kaneko J, Kokudo N, Makuuchi M. Incidence and management of biliary complications after adult-to-adult living donor liver transplantation. Clin Transplant 2011; 24:535-42. [PMID: 19849703 DOI: 10.1111/j.1399-0012.2009.01124.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are few detailed reports of biliary complications in a large adult living donor liver transplantation (LDLT) series. PATIENT AND METHODS Biliary complications, treatment modalities, and outcomes in these patients were retrospectively analyzed in 310 adult LDLT. RESULTS One patient underwent retransplantation. Duct-to-duct anastomosis was primarily performed in 223 patients (72%). During the observation period (median 43 months), biliary complications were observed in 111 patients (36%); 53 patients (17%) had bile leakage, 70 patients (23%) had bile duct stenosis, and 12 patients (4%) had bile leakage followed by stenosis. A biliary anastomotic stent tube was placed in 266 patients (86%) at the time of transplantation. Univariate analysis of various clinical factors revealed duct-to-duct anastomosis as the single significant risk factor (p=0.009) for biliary complications. The three-yr and five-yr overall patient survival rates were 88% and 85% in those with biliary complications, and 85% and 83%, respectively, in those without biliary complications (p=0.59). CONCLUSION Biliary complications are a major cause of morbidity following LDLT. Duct-to-duct anastomosis carried a higher risk for bile duct stenosis. With appropriate management, however, there was little influence on overall survival.
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Affiliation(s)
- Yusuke Kyoden
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Kim SH, Lee KW, Kim YK, Cho SY, Han SS, Park SJ. Tailored telescopic reconstruction of the bile duct in living donor liver transplantation. Liver Transpl 2010; 16:1069-74. [PMID: 20818745 DOI: 10.1002/lt.22116] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Duct-to-duct reconstruction (DDR) of the bile duct has recently become the preferred choice in living donor liver transplantation (LDLT), but biliary complications still remain the most common cause of morbidity. We introduce our new technique of tailored telescopic reconstruction (TTR) of the bile duct for reducing bile duct complications in LDLT: the hilar plate covering the right and left hepatic ducts is bisected lengthwise through the right or left hepatic duct opening to make a funnel-shaped top, into which the donor hepatic duct is telescoped to match the recipient bile duct in size, and DDR is performed in the inner tissue of good vascular integrity of the recipient bile duct without redundancy. Forty-five consecutive LDLT procedures from January to August 2008 were analyzed through a comparison of 23 conventional duct-to-duct reconstructions (cDDRs) and 22 TTRs in bile duct anastomoses. At a mean follow-up of 19.5 months, the rates of overall biliary complications, leakage, and strictures were 43.5%, 26.1%, and 34.8%, respectively, for cDDR and 9.1%, 0%, and 9.1%, respectively, for TTR (P < 0.05 for each). In conclusion, TTR of the bile duct results in excellent outcomes with respect to minimization of biliary complications; thus, TTR can be recommended as a preferred method for biliary reconstruction in LDLT.
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Affiliation(s)
- Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-Si, Gyeonggi-Do, Republic of Korea
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Duailibi DF, Ribeiro MAF. Biliary complications following deceased and living donor liver transplantation: a review. Transplant Proc 2010; 42:517-20. [PMID: 20304182 DOI: 10.1016/j.transproceed.2010.01.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Biliary complications are the most important source of complications after liver transplantation, and an important cause of morbidity and mortality. With the evolution of surgical transplantation techniques, including living donor and split-liver transplants, the complexity of these problems is increasing. Many studies have shown a higher incidence of biliary tract complications in living donor liver transplantation (LDLT) compared with deceased donor liver transplantation (DDLT). This article reviews biliary complications after liver transplantation and correlations with LDLT and DDLT. OBJECTIVE Provide an overview of biliary complications among LDLT and DDLT. RESULTS The incidence of biliary complications is higher among LDLT (28.7%) when compared with DDLT (15.5%). Bile leaks were the most common complication due to LDLT (17.1%); however, stricture was the most common complication due to DDLT (7.5%).
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Affiliation(s)
- D F Duailibi
- Cidade de São Paulo University-Medical School, São Paulo, Brazil
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Soin AS, Kumaran V, Rastogi AN, Mohanka R, Mehta N, Saigal S, Saraf N, Mohan N, Nundy S. Evolution of a reliable biliary reconstructive technique in 400 consecutive living donor liver transplants. J Am Coll Surg 2010; 211:24-32. [PMID: 20610245 DOI: 10.1016/j.jamcollsurg.2010.02.048] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Revised: 02/12/2010] [Accepted: 02/16/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary complications (BCs) are a major cause of morbidity and mortality after living donor liver transplantation (LDLT). They occur because the graft hepatic ducts are often small, thin walled, multiple, and may become ischemic during transection. STUDY DESIGN Of the 460 LDLTs done at our center before November 2009, the first 402 partial liver grafts had at least 3 months of follow-up. In the first 158, conventional hepatic duct isolation was used in the donor (group C). In the last 244 cases, the complete hilar plate and Glissonian sheath approach (HPGS) was used (group H). We compared the incidence and outcomes of BCs in the 2 groups. RESULTS The rate of BC was significantly lower in group H (5.3%) than in group C (15.8%, p = 0.000). The incidence of early (within 3 months of transplant) BCs was similarly significantly lower in group H (3.3%) than in group C (13.2%, P=0.000). The incidence of late BCs in the 145 patients in group H who had completed at least 12 months of follow-up was 2.8%.The proportion of BCs needing surgical correction was much higher in group C (44%) than in group H (7.7%, p = 0.022). CONCLUSIONS By providing a graft with a well-vascularized hepatic duct or ducts with a sheath of supporting tissue that holds sutures well, the HPGS approach minimizes the incidence and severity of BCs in LDLT.
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Affiliation(s)
- Arvinder Singh Soin
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation. Transplantation 2009; 88:1280-5. [PMID: 19996927 DOI: 10.1097/tp.0b013e3181bb48c2] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. METHODS We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. RESULTS Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). CONCLUSIONS Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.
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Lin TS, Concejero AM, Chen CL, Chiang YC, Wang CC, Wang SH, Liu YW, Yang CH, Yong CC, Jawan B, Cheng YF. Routine microsurgical biliary reconstruction decreases early anastomotic complications in living donor liver transplantation. Liver Transpl 2009; 15:1766-75. [PMID: 19938121 DOI: 10.1002/lt.21947] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Biliary reconstruction using a microsurgical technique in living donor liver transplantation was routinely performed on 88 grafts primarily transplanted into 85 patients. All procedures were performed under a microscope by a single microsurgeon. Except for biliary atresia and Alagille syndrome, duct-to-duct reconstruction was performed. Stents were not used. The outcomes with microsurgical biliary reconstruction (MB) were compared with the outcomes of a cohort of 86 grafts in 85 patients that underwent conventional biliary reconstruction (CB). The identification of complications included only up to 12 months of follow-up for each recipient in both groups. The average graft duct sizes were 2.8 mm for MB and 3.4 mm for CB. Most complications occurred in the first 15 cases with MB, and these cases were considered to constitute the learning curve phase. The MB complication rate was 46.7% in the first 15 cases, 20.0% in the next 15 cases, and 5.4% in the last 55 cases. When the learning curve phase was excluded, the overall complication rate over time with MB (8.9%) was significantly lower than that with CB (21.9%). CB increased the risk of biliary complications by 2.5 times (relative risk: 2.5; attributable risk: 128; odds ratio: 2.9). In conclusion, routine MB is a technical innovation that leads to decreased early anastomotic complications in living donor liver transplantation.
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Affiliation(s)
- Tsan-Shiun Lin
- Liver Transplantation Program, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Kishi Y, Imamura H, Sugawara Y, Sano K, Kaneko J, Kokudo N, Makuuchi M. Evaluation of donor vasculobiliary anatomic variations in liver graft procurements. Surgery 2009; 147:30-9. [PMID: 19879610 DOI: 10.1016/j.surg.2009.06.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Accepted: 06/01/2009] [Indexed: 01/27/2023]
Abstract
BACKGROUND The relationship among bile duct (BD), portal vein (PV), and/or hepatic artery (HA) anatomy is controversial, but no investigation has previously compared left and right liver graft transplantation in terms of variant vasculobiliary anatomy. Therefore, in this study, we explored whether variant BD anatomy can be predicted from portal PV or HA anatomy, and we compared left and right liver graft transplantation from the standpoint of vasculobiliary reconstruction. METHODS The associations between BD and PV and/or HA anatomies were evaluated in 361 donors. The number of vasculobiliary stumps in each graft, the number of stumps reconstructed, and the clinical outcomes were then compared between 133 left and 154 right liver grafts. RESULTS Variant BD was more frequently associated with variant than with normal PV anatomy (57.0% vs 28.4%). No correlation was found between variant BD and variant HA anatomy. Multiple PVs (left versus right, 0% vs 5.8%) and BDs (40.6% vs 59.7%) appeared more frequently in right liver grafts, and all stumps were reconstructed. Although multiple HAs appeared more frequently in left liver grafts (47.4% vs 1.3%), multiple stumps were rarely anastomosed. The incidence of HA/PV thrombosis or biliary strictures was comparable between left and right liver grafts. CONCLUSION Variant PV, but not variant HA, anatomies frequently accompany variant BD anatomy. Vasculobiliary variations sometimes lead to technical complexities, but this is more problematic in right liver graft transplantation. Left liver grafts are more feasible for vasculo-biliary reconstruction.
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Affiliation(s)
- Yoji Kishi
- Department of Hepato-Biliary-Pancreatic Surgery and Artificial Organ Transplantation, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Abstract
Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.
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Affiliation(s)
- Deok-Bog Moon
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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García-Valdecasas JC, Fuster J, Fondevila C, Calatayud D. [Adult living-donor liver transplantation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:577-83. [PMID: 19647346 DOI: 10.1016/j.gastrohep.2009.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 02/13/2009] [Indexed: 11/30/2022]
Abstract
Living donor liver transplantation in adults continues to be controversial. Viewed as an alternative to prevent deaths on the waiting list, this type of transplant is the only possibility in Asian countries (Japan, Korea, China, etc) but is not widely applied in the west. This intervention is associated with significant donor morbidity (depending on the scale of the intervention) and mortality which, although sporadic, reduces its acceptance, especially in a context with high cadaveric donation. Outcomes in recipients are similar to those in cadaveric transplant recipients, although the high incidence of biliary complications could compromise long-term results. We describe the experience of Hospital Clínic in a total of 67 transplant recipients. Graft and patient survival at 1 and 5 years was 90.7%, 70.3%, 90.7% and 77.6%, respectively. Although the frequency of biliary complications was high (37.3%), death from sepsis and retransplantation only occurred in two patients.
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Affiliation(s)
- Juan Carlos García-Valdecasas
- Departamento de Cirugía, Universidad de Barcelona, IDIBAPS, CIBEREHD, Unidad de Trasplante Hepático, Hospital Clínic i Provincial de Barcelona, Barcelona, España.
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Abstract
After liver transplantation, the prevalence of complications related to the biliary system is 6-35%. In recent years, the diagnosis and treatment of biliary problems has changed markedly. The two standard methods of biliary reconstruction in liver transplant recipients are the duct-to-duct choledochocholedochostomy and the Roux-en-Y-hepaticojejunostomy. Biliary leakage occurs in approximately 5-7% of transplant cases. Leakage from the site of anastomosis, the T-tube exit site and donor or recipient remnant cystic duct is well described. Symptomatic bile leakage should be treated by stenting of the duct by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTCD). Biliary strictures can occur at the site of the anastomosis (anastomotic stricture; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). AS occur in 5-10% of cases and are due to fibrotic healing. Treatment by ERCP or PTCD with dilatation and progressive stenting is successful in the majority of cases. NAS can occur in the context of a hepatic artery thrombosis, or with an open hepatic artery (ischaemic type biliary lesions or ITBL). The incidence is 5-10%. NAS has been associated with various types of injury, e.g. macrovascular, microvascular, immunological and cytotoxic injury by bile salts. Treatment can be attempted with multiple sessions of dilatation and stenting of stenotic areas by ERCP or PTCD. In cases of localized diseased and good graft function, biliary reconstructive surgery is useful. However, a significant number of patients will need a re-transplant. When biliary strictures or ischaemia of the graft are present, stones, casts and sludge can develop.
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Affiliation(s)
- Robert C Verdonk
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, The Netherlands.
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