Biliary complications after living donor adult liver transplantation

Increased Surgical Complications but Improved Overall Survival with Adult Living Donor Compared to Deceased Donor Liver Transplantation: A Systematic Review and Meta-Analysis

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.

Spectrum of biliary complications following live donor liver transplantation

Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.

Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation

INTRODUCTION

Long-term biliary complications after living donor liver transplantation (LDLT) are not well described in the literature. This study was undertaken to determine the long-term impact of biliary complications after adult right-lobe LDLT.

METHODS

This retrospective review analyzed an 11-yr experience of 344 consecutive right-lobe LDLTs with at least two yr of follow-up.

RESULTS

Biliary leaks occurred in 50 patients (14.5%), and strictures occurred in 67 patients (19.5%). Cumulative biliary complication rates at 1, 2, 5, and 10 yr were 29%, 32%, 36%, and 37%, respectively. Most early biliary leaks were treated with surgical drainage (N = 29, 62%). Most biliary strictures were treated first with endoscopic retrograde cholangiography (42%). There was no association between biliary strictures and the number of ducts (hazard ratio [HR] 1.017 [0.65-1.592], p = 0.94), but freedom from biliary stricture was associated with a more recent era (2006-2010) (HR 0.457 [0.247-0.845], p = 0.01). Long-term graft survival did not differ between those who had or did not have biliary complications (66% vs. 67% at 10 yr).

CONCLUSIONS

Biliary strictures are common after LDLT but may decline with a center's experience. With careful follow-up, they can be successfully treated, with excellent long-term graft survival rates.

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Biliary reconstruction and complications in adult living donor liver transplantation: systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis was to compare outcomes of different techniques used for biliary reconstruction in adult donor liver transplantation.

METHODS

We searched the literature via Pubmed, Embase, Ovid, the Cochrane Hepato-Biliary Group Controlled Trials Regsistry, the Cochrane Central Registry of Controlled Trials, the Cochrane Library database, and Web of Science. Then with the data extracted from the literature, the effects that biliary reconstruction techniques in living-donor liver transplantation (LDLT) had on the occurrence of biliary complications were compared. With the use of random-effects and fixed-effect models, the results were obtained and expressed as odds ratio.

RESULTS

We found 16 eligible studies from various medical centers around the world. Duct-to-duct (DD) reconstruction was performed in the majority of patients (922/1,564). Multiple biliary ducts were encountered in 16.7%-60.4%, and ductoplasty was performed in 7.9%-74% of the patients. Both graft and posterior layer of bile duct anastomosis in DD reconstruction were studied, and no statistically differences in incidence of biliary complications were found between the Roux-en-Y hepaticojejunostomy (RYHJ) and DD groups. Nonsurgical management of biliary complications was the first choice of treatment.

CONCLUSIONS

Our study found that there is no clear evidence in favor of using DD or RYHJ during adult LDLT.

Bile duct reconstruction by a young surgeon in living donor liver transplantation using right liver graft

Biliary strictures and bile leaks account for the majority of biliary complications after living donor liver transplantation (LDLT). The aim of this study was to examine differences in biliary complications after adult LDLTs were performed by an experienced senior surgeon and an inexperienced junior surgeon. Surgeries included bile duct reconstruction after adult LDLT using a right liver graft, and risk factors for biliary stricture were identified. We retrospectively reviewed the medical records of 136 patients who underwent LDLT in order to identify patients who developed biliary complications. The senior surgeon performed 102 surgeries and the junior surgeon performed 34 surgeries. The proportion of patients with biliary stricture was similar between the senior and the junior surgeons (27.5% vs 26.5%; P = 0.911). However, the incidence of biliary leakage was higher in patients of the junior surgeon than in those of the senior surgeon (23.5% vs 2.9%; P = 0.001). The frequency of percutaneous drainage was also higher for the junior surgeon than the senior surgeon because of the junior surgeon's high leakage rate of the drainage. When the junior surgeon performed bile duct anastomosis, biliary leakage occurred in 7 patients between the 11th and 20th cases. However, biliary leakage occurred in only 1 case thereafter. Bile duct reconstruction performed by beginner surgeons in LDLT using right lobe grafts should be cautiously monitored and observed by a senior surgeon until an inexperienced junior surgeon has performed at least 20 cases, because of the high incidence of biliary leakage related to surgeon's inexperience in bile duct reconstructions in LDLT.

Biliary and vascular anomalies in living liver donors: the role and accuracy of pre-operative radiological mapping

BACKGROUND

The aim of the present study was to determine the utility of computed tomography (CT) and magnetic resonance imaging (MRI) anatomic mapping in the detection of biliary and vascular anomalies prior to a living liver donor (LLD) operation.

METHODS

A retrospective study of all LLD patient charts, operative and radiology reports from 1 January 2002 to 1 January 2012 was conducted. Primary post-operative outcomes assessed included mortality, re-operation, readmission and need for endoscopic or percutaneous intervention. Sensitivity and specificity of MR and CT pre-operative screening was calculated against the gold standard of intra-operative findings.

RESULTS

A total of 34 donors had an average age of 38 years (range: 22-58) with a body mass index (BMI) of 25.6 kg/m(2) (range: 19.8-32.5) and a length of stay (LOS) of 10.1 days (range: 5-41). There were no donor mortalities. Sensitivity and specificity of CT was 70.0% and 91.3%, and of MRI screening 23.1% and 100.0%, respectively. Patients with inaccurate pre-operative CT or MRI did not have an increased risk of complications.

CONCLUSIONS

Even although it was specific, pre-operative MR screening missed up to 77.0% of biliary anomalies. An impeccable surgical technique remains the key in preventing biliary complications of a living donor hepatectomy where pre-operative MRI screening is false.

Pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant

OBJECTIVES

To summarize the pathotyping and clinical manifestations of biliary cast syndrome in patients after an orthotopic liver transplant.

MATERIALS AND METHODS

The clinical manifestations, auxiliary examination, therapeutic regimen, and clinical efficacy of 103 biliary cast syndrome patients who underwent an orthotopic liver transplant were retrospectively analyzed. Patients were divided into 6 groups from type 1 to type 6, according to the injury level of the biliary duct epithelium.

RESULTS

Many biliary cast syndrome patients showed symptoms including jaundice, dark urine, argillaceous stool, itchy skin, and fever. Serum levels of alanine aminotransferase, γ-glutamyl transpeptidase, alkaline phosphatase, and total bilirubin were increased. In addition, total white cell counts in peripheral blood also were increased. T-tube cholangiography showed filling defects of various amounts. Optical fiber choledochoscope examination revealed that the biliary tract was filled with solid substances, and necrosis of the biliary tract epithelium was observed in some biliary cast syndrome patients. From type 1 to type 6 biliary cast syndrome patients, the probability of clinical symptoms and biliary tract stricture gradually increased, the time needed for supporting gradually prolonged after removal of the biliary cast, and T-tube cholangiography showed that the filling defects gradually expanded.

CONCLUSIONS

Clinical manifestations and cholangiography presentations mainly depend on pathotyping.

Is Duct to Duct biliary Anastomosis the Rule in Orthotopic Liver Transplantation?

Biliary complications after Liver Transplantation continue to be the major cause of morbidity in 11-25 % of patients. Biliary complications in patients who underwent orthotopic liver transplantation (OLT) at our institute between March 2007 and June 2010 were analyzed retrospectively. 32 patients underwent Deceased Donor Liver Transplantation (DDLT) and in 12 patients Living Donor Liver Transplantation (LDLT) was done. No patients were lost to follow up. Follow up ranged between 4 and 44 months. During the study period, 44 patients underwent orthotopic liver transplantation. Patients were divided into two groups: Biliary Complications group (BC) n = 5 and Non Biliary Complications group (NBC) n = 39. Biliary complications occurred in 15.9 % of patients. Bile leaks accounted for majority of biliary complications. Fifteen variables were analyzed as possible risk factors for biliary complications. Of these, split grafts, duct to duct biliary anastomosis and total blood loss were statistically significant (P < 0.05) for biliary complications. Endoscopic treatment was successful in managing biliary complications in 75 % of patients. Biliary complications are the most common major complications in orthotopic liver transplantation. Significant risk factors are split liver grafts and duct to duct biliary anastomosis. Increased blood loss is a predictor for post operative biliary complications. These complications should be managed by endoscopic interventions. Surgery is indicated following failure of endoscopic interventions.

Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications

BACKGROUND

In living-donor liver transplantation, biliary tract complications are a serious problem for recipients and donors.

METHODS

We applied intraoperative real-time cholangiography using a C-arm and/or C-tube drainage to reduce biliary tract complications in donor hepatectomy. From 2003 to 2010, intraoperative real-time cholangiography and C-tube drainage was applied to 39 and 19 donor cases, respectively. Fifteen donor cases had both procedures.

RESULTS

We confirmed the division line of the hepatic duct by visualizing a stricture on the monitor of the C-arm by pulling a thread and dissecting the proper site of the bile duct. The number of hepatic ducts of the graft to be anastomosed was 1 in 11 cases and 2 or 3 in 8 of the 19 cases without intraoperative real-time cholangiography, and it was 1 in 32 cases and 2 in 7 of the 39 cases with intraoperative real-time cholangiography. Bile leakage from the resection occurred in seven donors without, and in none of those with, C-tube drainage.

CONCLUSION

In living-donor liver transplantation, intraoperative real-time cholangiography enables effective determination of the precise division line of the hepatic duct. Moreover, C-tube drainage is effective for reducing bile leakage from the resected surface of the liver of donors.

Role of hepatic stellate cells on graft injury after small-for-size liver transplantation

BACKGROUND AND AIM

Small-for-size grafts are prone to mechanical injury and a series of chemical injuries that are related to hemodynamic force. Hepatic stellate cells activate and trans-differentiate into contractile myofibroblast-like cells during liver injury. However, the role of hepatic stellate cells on sinusoidal microcirculation is unknown with small-for-size grafts.

METHODS

Thirty-five percent of small-for-size liver transplantation was performed with rats as donors and recipients. Endothelin-1 levels as well as hepatic stellate cells activation-related protein expression, endothelin-1 receptors, and ultrastructural changes were examined. The cellular localizations of two types of endothelin-1 receptors were detected. Furthermore, liver function and sinusoidal microcirculation were analyzed using two different selective antagonists of endothelin-1 receptor.

RESULTS

Intragraft expression of hepatic stellate cells activation-related protein such as desmin, crystallin-B and smooth muscle α-actin was upregulated as well as serum endothelin-1 levels and intragraft expression of the two endothelin receptors. The antagonist to endothelin-1 A receptor not to the endothelin-1 B receptor could attenuate microcirculatory disturbance and improve liver function.

CONCLUSIONS

Small-for-size liver transplantation displayed increased hepatic stellate cells activation and high level of endothelin-1 binding to upregulation of endothelin-1 A receptor on hepatic stellate cells, which contracted hepatic sinusoid inducing graft injury manifested as reduction of sinusoidal perfusion rate and elevation of sinusoidal blood flow.

Biliary complications after living donor liver transplantation

Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.

MR evaluation of biliary-enteric anastomotic stricture: does contrast-enhanced T1W MRC provide additional information?

BACKGROUND AND OBJECTIVE

To compare T2W-MRCP and T1W contrast-enhanced MRC (CE-MRC) using Gd-BOPTA for evaluation of biliary-enteric anastomotic (BEA) stricture.

PATIENTS AND METHODS

Twenty-one patients who were suspected to have BEA stricture underwent T2W-MRCP and CE-MRC on a 1.5T scanner. Images were evaluated for evidence of anastomotic stricture. Composite gold standard was used including the findings on percutaneous transhepatic cholangiogram or percutaneous transhepatic biliary dilatation, surgery, alkaline phosphatase level and clinical follow-up.

RESULTS

The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of T2W-MRCP for the diagnosis of anastomotic stricture were 94.4%, 80%, 94.4% and 80% respectively. On CE-MRC, biliary excretion was seen in only 60.87% anastomoses and only these were taken for analysis. The sensitivity, specificity, PPV and NPV of CE-MRC for the diagnosis of anastomotic stricture were 40%, 75%, 80% and 33.3%. The combined evaluation of T2W-MRCP and CE-MRC showed sensitivity, specificity, PPV and NPV of 83.3%, 80%, 93.8% and 57.1%.

CONCLUSION

At present, T2W-MRCP is still the diagnostic modality of choice in the evaluation of patients with BEA stricture and the usage of Gd-BOPTA enhanced MRC is inappropriate in this setting.

Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome

Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.

Posttransplant bilioportal fistula with portal vein thrombosis: a case report

An 8-year-old female patient, known to have post-Kasai biliary atresia with mild intrapulmonary shunting, underwent living donor liver transplantation because of recurrent cholangitis. After the treatment of postoperative biliary stricture with percutaneous transhepatic biliary drainage, the patient subsequently developed hematochezia with portal vein thrombosis. The intraoperative findings showed portal vein thrombosis with a bilioportal fistula. We performed closure of the bilioportal fistula and reconstruction of the portal vein with a native internal jugular vein interposition graft. A bilioportal fistula due to percutaneous hepatobiliary procedures is a reportedly a rare complication following liver transplantation. The patient is currently doing well after a successful surgical intervention.

Role of magnetic resonance cholangiography in biliary complications of orthotopic liver transplantation

PURPOSE

The aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) in the detection of biliary complications following orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Seventy-eight transplant patients with clinically suspected biliary complications were evaluated with 1.5-T magnetic resonance imaging (MRI) using a surface coil. All patients were imaged with the following sequences: axial T1-weighted and axial and coronal T2-weighted, 2D spin echo (SE) breath-hold radial cholangiography, and coronal 3D single-shot turbo spin echo (SS-TSE) with respiratory triggering. Patients with negative MRI underwent clinical and sonographic followup. When biliary complications were present, diagnostic confirmation was obtained by endoscopic retrograde cholangiopancreatography (ERCP) (n=13), percutaneous transhepatic cholangiography (PTC) (n=20), ultrasonography (n=10) or computed tomography (CT) (n=2). In 11 cases, surgical confirmation was also obtained.

RESULTS

MRC detected biliary complications in 44/78 patients, in particular, 42 biliary strictures (37 anastomotic and five intrahepatic), 40 of which were confirmed by other imaging modalities. In 25/37 cases of anastomotic stricture, preanastomotic dilatation of the biliary tract was also demonstrated. Other MRC-detected biliary complications were biliary sludge (n=4), biloma (n=5), and biliary stones (n=3). In four cases, PTC revealed biliary complications that had not been detected with MRC (false negative results). In two cases, MRC showed unconfirmed strictures of the intrahepatic ducts and biliodigestive anastomosis (false positive results). The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy of MRC were 93.5%, 94.4%, 96.7%, 89.5% and 93.9%, respectively.

CONCLUSIONS

Our results confirm that MRC is a reliable technique for depicting biliary anastomoses and detecting biliary complications after OLT. The high diagnostic accuracy of MRC indicates that this examination should be routinely employed in all OLT patients with clinically suspected biliary complications.

Biliary complications following deceased and living donor liver transplantation: a review

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%).

Biliary reconstruction in living donor liver transplantation: technical invention and risk factor analysis for anastomotic stricture

BACKGROUNDS

Bile duct complications especially biliary stricture remains a major cause of morbidity influencing the postoperative course in living donor liver transplantation (LDLT). The objectives of this study were to investigate the outcome of biliary reconstruction using "open-up" anastomotic technique and to clarify the risk factors for biliary stricture after LDLT.

PATIENTS AND METHODS

We retrospectively analyzed data of 83 consecutive adult patients who underwent LDLT between 1999 and 2007. Hepaticojejunostomy was conducted in 22 patients and duct-to-duct anastomosis in 61 patients. The "open-up" anastomotic technique was applied uniformly for biliary reconstruction.

RESULTS

The mean follow-up period after LDLT was 2.7+/-2.1 years (range, 0.01-7.52). Of the 83 recipients, six (7.2%) developed biliary strictures (four at anastomotic site and two at multiple intrahepatic sites), and one (1.2%) developed biliary leakage after hepaticojejunostomy. Risk factor analysis identified the diameter of donor bile duct and the use of right lateral sector as significant risk factors for biliary stricture at the anastomosis.

CONCLUSIONS

Care should be taken when anastomosing a small bile duct of the donor graft or right lateral sector graft in LDLT because of the associated high incidence of biliary stenosis. Our technique, including the "open-up" procedure, ensures quality control for bile duct reconstruction and a better outcome after LDLT.

Recipient morbidity after living and deceased donor liver transplantation: findings from the A2ALL Retrospective Cohort Study

Patients considering living donor liver transplantation (LDLT) need to know the risk and severity of complications compared to deceased donor liver transplantation (DDLT). One aim of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) was to examine recipient complications following these procedures. Medical records of DDLT or LDLT recipients who had a living donor evaluated at the nine A2ALL centers between 1998 and 2003 were reviewed. Among 384 LDLT and 216 DDLT, at least one complication occurred after 82.8% of LDLT and 78.2% of DDLT (p = 0.17). There was a median of two complications after DDLT and three after LDLT. Complications that occurred at a higher rate (p < 0.05) after LDLT included biliary leak (31.8% vs. 10.2%), unplanned reexploration (26.2% vs. 17.1%), hepatic artery thrombosis (6.5% vs. 2.3%) and portal vein thrombosis (2.9% vs. 0.0%). There were more complications leading to retransplantation or death (Clavien grade 4) after LDLT versus DDLT (15.9% vs. 9.3%, p = 0.023). Many complications occurred more commonly during early center experience; the odds of grade 4 complications were more than two-fold higher when centers had performed 40). In summary, complication rates were higher after LDLT versus DDLT, but declined with center experience to levels comparable to DDLT.

Biliary complications after orthotopic liver transplantation: MRCP findings

Orthotopic liver transplantation is a widely accepted treatment for end-stage liver disease and selected cases of hepatocellular carcinoma. Despite surgical progresses, biliary complications after transplantation remain a serious cause of morbidity, mortality, and graft dysfunction or failure in recipients. Early complications occur within a few weeks after transplantation and are mainly represented by bile leakage. Late complications, which become evident from 3 months to years, include strictures, stones, intraductal debris or sludge formation, kinking and ampullary dysfunction. Donor-to-recipient common bile duct disproportion has been reported as a borderline condition. Diagnosis is challenging because of the low specificity of clinical and biologic findings. Sonography does not provide projectional images of the biliary tract or direct evaluation of the anastomoses. Moreover, direct cholangiographic procedures have an unacceptable rate of complications to be used in patients with low clinical suspicion. Magnetic resonance cholangiography is a safe and accurate tool, playing an increasing role in the diagnosis and management of biliary complications. Heavily T2-weighted images provide panoramic, detailed evaluation of the biliary tract, showing biliary complications as a variable combination of bile duct dilatation, strictures, filling defects, fluid collections and peculiar morphologic changes, as described in this paper.

Should we still offer split-liver transplantation for two adult recipients? A retrospective study of our experience

The role of split-liver transplantation (SLT) for two adult recipients is still a matter of debate, and no agreement exists on indications, surgical techniques, and results. The aim of this study was to retrospectively analyze the outcome of our series of SLT. From May 1999 to December 2006, 16 patients underwent SLT at our unit. We used 9 full right grafts (segments 5-8) and 7 full left grafts (segments 1-4). The splitting procedure was always carried out in situ with a fully perfused liver. Postoperative complications were recorded in 8 (50%) patients: 5 (55%) in full right grafts and 3 (43%) in full left grafts. No one was retransplanted. After a median follow-up of 55.82 months (range, 0.4-91.2), 5 (31%) patients died, and the 1-, 3-, and 5-year overall survival rate for patients and grafts was 69%. We considered as a control group for the global outcome 232 whole liver transplantations performed at our unit in the same period of time. Postoperative complications were recorded in 53 (23%) patients, and after a median follow-up of 57.37 months (mean, 55.11; range, 1-102.83), the 1-, 3-, and 5-year overall patient survival was 87%, 82%, and 80%, respectively. In conclusion, SLT for two adult recipients is a technically demanding procedure that requires complex logistics and surgical teams experienced in both liver resection and transplantation. Although the reported rate of survival might be adequate for such a procedure, more efforts have to be made to improve the short-term outcome, which is inadequate in our opinion. The true feasibility of SLT for two adults has to be considered as still under investigation.

Adult living donor liver transplantation with right lobe graft: the venous outflow management in the Milan-Niguarda experience

In right lobe living donor liver transplantation (ALDLT), reconstruction of middle hepatic vein (MHV) tributaries is often necessary to avoid severe graft congestion. From March 2001, we performed 36 right lobe ALDLT (segments 5, 6, 7, and 8) without MHV and one pediatric transplant (segments 2 and 3). In the presence of MHV tributaries larger than 5 mm, we intraoperatively evaluated the need for reconstruction. At a mean follow-up of 848 days (range=8-2412), 33/37 transplanted patients are alive with overall patient and graft survivals of 89.2% and 83.8%, respectively. Large MHV tributaries (>5 mm) were present in 10 cases, and inferior right hepatic veins (IRHV) draining segment 6 in 11 cases. In 10 cases, we performed an end-to-side anastomosis between the IRHV and the side of the recipient vena cava. In three cases, the MHV tributaries were end-to-end anastomosed to the stump of the recipient MHV. In all other cases, the vein tributaries were not reconstructed. A computed tomography scan performed from 1 to 3 months after surgery did not show any congested area in the liver parenchyma. In our experience, reconstruction of the MHV tributaries was not always necessary when graft-to-recipient weight ratio is >0.8. Pre- and intraoperative evaluation of the segmental branches of the hepatic vein is crucial to decide about reconstructing these collaterals. Anastomosis of V5 or V8 to the stump of the recipient MHV reduces the number of vascular anastomosis and maintains a physiological angle between these collaterals and the caval vein.

Congenital anomalies and variations of the bile and pancreatic ducts: magnetic resonance cholangiopancreatography findings, epidemiology and clinical significance

PURPOSE

The objective of this paper is to document the magnetic resonance cholangiopancreatography (MRCP) findings and the epidemiology of congenital anomalies and variations of the bile and pancreatic ducts and to discuss their clinical significance.

MATERIALS AND METHODS

Three-hundred and fifty patients of both sexes (150 females, 200 males, age range 0-76 years, average age 38 years) underwent MRCP for clinically suspected lithiasic, neoplastic or inflammatory disease of the bile and pancreatic ducts. Patients were imaged with a 1.5-T superconductive magnet (Magnetom Vision, Siemens, Erlangen, Germany), a four-channel phased-array body coil, breath-hold technique, with multislice T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE), MIP reconstructions, and a single-shot T2-weighted turbo-spin-echo sequence rapid acquisition with relaxation enhancement (RARE) with different slice thicknesses. Studies in oncological patients were completed with fat saturation 3D T1 gradient-echo sequences during the intravenous injection of gadolinium diethylene triamine pentaacetate acid (DTPA) (0.2 ml/kg).

RESULTS

MRCP demonstrated recurrent and therefore normal bile and pancreatic ducts in 57% of patients. In the remaining 42.3%, it documented anatomical variants (41%) and congenital anomalies (1.3%). Variants of the intrahepatic bile duct were seen in 21% of cases: crossover anomaly (6.7%), anterior branch of the right hepatic duct draining the IV and VII segments that flow together with the left bile duct (3.1%) and anterior and posterior branches of the right hepatic duct that flow together with the common hepatic duct (3.3%). Variants of the extrahepatic bile ducts were present in 8.8% of patients: low insertion of the cystic duct into the common hepatic duct (4.5%), emptying of the cystic duct into the right hepatic duct (2.7%) and a second-order large branch draining into the cystic duct (1.6%). MRCP identified a double gall bladder in 3% of patients and anatomical variants of the biliopancreatic system in 8.2%: pancreas divisum (5.2%) and a long sphincter of Oddi (3%). Finally, congenital anomalies were diagnosed in 1.3% of cases: bile duct cysts (0.3%), atresia of the bile ducts (0.3%) and multiple biliary hamartomatosis (0.7%).

CONCLUSIONS

The congenital anomalies and anatomical variants of the bile and pancreatic ducts present a complex spectrum of frequent alterations, which are worthy of attention in both the clinical and surgical settings and are readily identified by MRCP.

Safety and efficacy of the percutaneous treatment of bile leaks in hepaticojejunostomy or split-liver transplantation without dilatation of the biliary tree

Biliary leaks complicating hepaticojejunostomy (HJA) or fistulas from cut surface are severe complications after liver transplantation (LT) and split-liver transplantation (SLT). The aim of the study was to describe our experience about the safety and efficacy of radiological percutaneous treatment without dilatation of intrahepatic biliary ducts. From 1990 to 2006, 1595 LTs in 1463 patients were performed in our center. In 1199 LTs (75.2%), a duct-to-duct anastomosis was performed, and in 396 (24.8%), an HJA was performed. One hundred twenty-nine anastomotic or cut-surface bile leakages occurred in 115 patients. Sixty-two biliary leaks occurred in 54 patients with HJA; in 48 cases, an anastomotic fistula was found. Cut-surface fistulas occurred in 14 cases: 5 in right SLTs and 5 in left SLTs. Twenty-two patients were treated with 23 percutaneous approaches for 17 HJA fistulas and 6 cut-surface leaks without intrahepatic bile duct dilatation. Two percutaneous therapeutic approaches were used: percutaneous transhepatic biliary drainage (PTBD) for fistula alone and PTBD with percutaneous drainage of biliary collection in patients with both complications. PTBD was successful in 21 cases (91.3%); the median delay from catheter insertion and leak resolution was 10.3 days (range: 7-41). The median maintenance of drainage was 14.8 days. In 1 patient, fistula recurrence after PTBD needed a surgical approach; after that, an anastomotic fistula was still found, and a new PTBD was successfully performed. In another patient, PTBD was immediately followed by retransplantation for portal vein thrombosis. There were no complications related to the interventional procedure. In conclusion, biliary fistulas after HJA in LT or after SLT can be successfully treated by PTBD. The absence of enlarged intrahepatic biliary ducts should not be a contraindication for percutaneous treatment.

Biliary complications in right lateral sector graft live donor liver transplantation

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.

Nonsurgical policy for treatment of bilioenteric anastomotic stricture after living donor liver transplantation

Biliary complications remain a significant cause of morbidity following living donor liver transplantation. The purpose of this retrospective study was to assess the outcome of nonsurgical management for hepatojejunostomy stricture in our institution. We reviewed 22 patients with hepatojejunostomy stricture among the 231 patients who underwent living donor liver transplantation between June 1990 and December 2005. Hepatojejunostomy stricture was confirmed by percutaneous transhepatic or endoscopic retrograde cholangiography. Anastomotic strictures were treated by balloon dilatation. Percutaneous transhepatic cholangiography was performed on 15 of the 22 patients. Two of 15 patients, with complete obstruction of the anastomosis, were treated successfully by Yamanouchi magnet compression anastomosis. Although another two patients died of infectious disease that was unlikely to have been related to biliary complications, anastomotic patency was maintained in the other 13 patients. Endoscopic retrograde cholangiography was performed on seven of the 22 patients. None of the 22 patients required re-operation or died of biliary complications. The 5-year graft survival rate of 85.6% in the 22 patients with stricture was equivalent to that of the patients without stricture (82.9%, P = 0.98). Advances in intervention techniques have enabled wider application of nonsurgical approaches for this complication, and fair results have been obtained.

Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation

AIM: To evaluate risk factors of biliary anastomotic complications (BACs) and outcomes according to type of biliary reconstruction.

METHODS: A total of 33 consecutive adult living donor liver transplantation (LDLT) were reviewed, 17 of which had undergone Duct-to-Duct anastomosis (D-D). The remaining 16 patients received Roux-en-Y anastomosis (R-Y). The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively.

RESULTS: The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy (71.4% vs 10%, P = 0.050). There was no significant difference in the incidence of biliary leakage in patients with D-D vs those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D (60%) than in R-Y (0%) (P = 0.026). However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D (71.4% vs 0%, P = 0.008). In D-D, use of T-tube stent remarkably reduced the incidence of BACs, compared with straight tube stent (0% vs 50%, P = 0.049).

CONCLUSION: Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.