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Hamed H, Elshobary M, Salah T, Sultan AM, Abou El-Magd ES, Elsabbagh AM, Shehta A, Abdulrazek M, Elsarraf W, Elmorshedi MA, Abdelkhalek M, Shiha U, El Razek HMA, Wahab MA. Navigating complex arterial reconstruction in living donor liver transplantation: the role of the splenic artery as a viable conduit. BMC Surg 2025; 25:9. [PMID: 39757184 PMCID: PMC11702025 DOI: 10.1186/s12893-024-02709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 12/09/2024] [Indexed: 01/07/2025] Open
Abstract
BACKGROUND In living donor liver transplantation (LDLT), maintaining hepatic arterial flow is critical for graft survival. Alternative methods are required when the recipient's hepatic artery is unsuitable due to extensive dissection or inadequate flow. This study evaluates the efficacy and safety of splenic artery transposition (SAT) for hepatic arterial reconstruction in LDLT. METHODS This retrospective cohort study included 10 LDLT patients with hepatic arterial reconstruction by SAT to assess operative parameters, postoperative complications, mortality, and patency rate. RESULTS The splenic artery was used because of arterial dissection (70%) or inadequate arterial blood flow. Operative time ranged from 640 to 1020 min, and no splenic infarction was observed. Post-operative complications were as follows; biliary leakage (10%), pancreatitis (10%), intraabdominal hemorrhage (10%), and arterial thrombosis (10%). Mortality in this cohort was 30%, one of them was due to thrombosis of the conduit and the other two died from sepsis-related complications. With a median follow-up of 43 months, this technique was associated with a 70% survival rate. CONCLUSION The splenic artery is a viable conduit for hepatic arterial reconstruction in LDLT, demonstrating an acceptable safety profile and complication rates. This approach is recommended in cases where the recipient's hepatic artery is significantly compromised.
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Affiliation(s)
- Hosam Hamed
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Mohamed Elshobary
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Tarek Salah
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Ahmad M Sultan
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - El-Sayed Abou El-Magd
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Ahmed M Elsabbagh
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Ahmed Shehta
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Mohamed Abdulrazek
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt.
| | - Waleed Elsarraf
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Anesthesia Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Mohamed A Elmorshedi
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Anesthesia Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Mostafa Abdelkhalek
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Anesthesia Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Usama Shiha
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Radiology Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Hassan Magdy Abd El Razek
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Radiology Department, Mansoura University, Mansoura, Dakahleyya, Egypt
| | - Mohamed Abdel Wahab
- Liver Transplant Unit, Gastrointestinal Surgical Center (GISC), Surgery Department, Mansoura University, Mansoura, Dakahleyya, Egypt
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Toriigahara Y, Matsuura T, Yanagi Y, Yoshimaru K, Uchida Y, Kajihara K, Shirai T, Kawano Y, Kawakubo N, Nagata K, Tajiri T. The advantages of duct-to-duct biliary reconstruction in pediatric living donor liver transplantation. Pediatr Surg Int 2023; 39:286. [PMID: 37919436 DOI: 10.1007/s00383-023-05568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND/PURPOSE Whether Roux-en-Y hepatic jejunectomy (HJ) or duct-to-duct biliary reconstruction (DD) is more useful in pediatric living donor liver transplantation has not yet been fully investigated. Therefore, to assess the feasibility and safety of DD, we compared the surgical outcomes of DD to HJ. METHODS We divided 45 patients, excluding those with biliary atresia, into the DD group (n = 20) and the HJ group (n = 25), according to the type of biliary reconstruction they received. RESULTS The 5-year survival rates (DD vs. HJ = 79.7% vs. 83.6%, p = 0.70) and the incidence of biliary complications, including bile leakage and stricture (DD vs. HJ = 1 [5.0%] vs. 1 [4.0%], p = 0.87) were not significantly different between the groups. However, intestinal complications, including bowel perforation or ileus, were significantly common in the HJ group (9/25 [36.0%]) than in the DD group (1/20 [5.0%]; p = 0.01). The three patients in the HJ group with intestinal perforation all suffered perforation at the anastomosed site in the Roux-en-Y procedure. The subgroup analysis showed the non-inferiority of DD to HJ for biliary or intestinal complications in patients weighting < 10 kg. CONCLUSION With a proper selection of cases, DD should be a safe method for biliary reconstruction in pediatric recipients with little risk of biliary complications equivalent to HJ and a reduced risk of intestinal complications.
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Affiliation(s)
- Yukihiro Toriigahara
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yasuyuki Uchida
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keisuke Kajihara
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takeshi Shirai
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yuki Kawano
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Naonori Kawakubo
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Kubo M, Tomimaru Y, Gotoh K, Kobayashi S, Marukawa D, Sasaki K, Iwagami Y, Yamada D, Akita H, Noda T, Takahashi H, Asaoka T, Tanemura M, Marubashi S, Nagano H, Dono K, Doki Y, Eguchi H. Long-Term Feasibility of Rescue Reconstruction for Isolated Bile Ducts With Using Cystic Duct in Living Donor Liver Transplantation. Transplant Proc 2023; 55:1611-1617. [PMID: 37385837 DOI: 10.1016/j.transproceed.2023.03.086] [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: 12/16/2022] [Revised: 03/01/2023] [Accepted: 03/12/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND The isolated bile duct is sometimes observed in the right liver graft of living donor liver transplantation (LDLT). Even though, as a rescue option, it is known to use the recipient's cystic duct (CyD) for duct-to-duct anastomosis, the long-term feasibility of rescue duct-to-CyD (D-CyD) anastomosis remains unclear. METHODS We prospectively collected data in the right liver-LDLT cohort and compared rescue D-CyD anastomosis (n = 4) with standard duct-to-hepatic duct (D-HD, n = 45) anastomosis (D-CyD group, n = 4). RESULTS The observation period was over 5 years (range, 68-171 mo) after LDLT. The D-CyD group included the following anastomosis procedures: anastomosis between the intrahepatic bile duct of the graft and the CyD of the recipient and anastomosis between the posterior HD and the CyD. Surgical outcomes between the 2 groups are similar, excluding the time for the biliary reconstruction (D-CyD, 116 ± 13 min vs D-HD, 57 ± 3 min). During the period, one recipient in the D-CyD group exhibited postoperative biliary stricture and biliary stone, and 6 recipients underwent those complications in the D-HD group (D-CyD, 25.0% vs D-HD, 13.3%) All recipients in the D-CyD group are presently alive and have not experienced liver dysfunction. CONCLUSIONS Our findings suggest that rescue D-CyD anastomosis for an isolated bile duct in a right liver LDLT is acceptable as a life-saving option in terms of long-term feasibility.
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Affiliation(s)
- Masahiko Kubo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Daiki Marukawa
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kazuki Sasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shigeru Marubashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Keizo Dono
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy. HPB (Oxford) 2021; 23:144-153. [PMID: 32646806 DOI: 10.1016/j.hpb.2020.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD. METHODS This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database. RESULTS 241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique. CONCLUSION Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.
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Alim A, Dayangac M, Erdogan Y, Malamutmann E, Yuzer Y, Tokat Y, Oezcelik A. Splenic Artery Transposition for Arterial Reconstruction in Living Donor Liver Transplantation. Transplant Proc 2020; 53:36-41. [PMID: 32505498 DOI: 10.1016/j.transproceed.2020.02.155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/28/2020] [Accepted: 02/09/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE In living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction. METHODS Between July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively. RESULTS There were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%. CONCLUSION If the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.
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Affiliation(s)
- Altan Alim
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey
| | - Murat Dayangac
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey
| | - Yalcin Erdogan
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey
| | - Eugen Malamutmann
- Department of General, Visceral and Transplantation Surgery, University Hospital of Essen, Essen, Germany
| | - Yildiray Yuzer
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey
| | - Yaman Tokat
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey
| | - Arzu Oezcelik
- Department of General and Transplantation Surgery, University Hospital of the Istanbul Bilim University, Istanbul, Turkey; Department of General, Visceral and Transplantation Surgery, University Hospital of Essen, Essen, Germany.
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7
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Platt E, McNally J, Cusick E. Pedicled jejunal interposition for long gap esophageal atresia. J Pediatr Surg 2019; 54:1557-1562. [PMID: 30717983 DOI: 10.1016/j.jpedsurg.2018.10.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/25/2018] [Accepted: 10/30/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Long gap esophageal atresia (LGEA) represents 10% of all esophageal atresias but can be complex to manage. Jejunal interposition (JI) has been recommended as the operative management of choice when esophageal ends cannot be opposed. We report our experience using the pedicled jejunal interposition technique with comparison to patients undergoing primary repair of LGEA. METHODS This was a retrospective analysis of all patients managed for LGEA at our unit between 2003 and 2017 with comparison between pedicled jejunal interposition and primary repair. RESULTS 10 patients were treated with pedicled jejunal interposition and 9 patients underwent primary repair (including one Foker procedure performed elsewhere). Patient demographics and short term outcomes were similar between the two groups, but less anastomotic stricturing and gastroesophageal reflux were observed in the JI group. CONCLUSION This is the largest published series of pedicled jejunal interposition from the UK. Our results support continued use of this procedure with good long term graft function. It is our recommendation that pedicled interposition grafts are used in all patients requiring extensive dissection or tension to achieve opposition for primary repair. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level III.
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8
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Bauschke A, Altendorf-Hofmann A, Malessa C, Rohland O, Settmacher U. [Influence of bile duct anatomy on biliary complications in hepatic right lobe living donors]. Chirurg 2019; 89:222-228. [PMID: 28940029 DOI: 10.1007/s00104-017-0514-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Perioperative morbidity in the living donation of partial livers is mainly due to infections and biliary complications. Bile duct anatomy variants, in particular of the right system, are suspected to be causative. We investigated the influence of bile duct variants on the incidence of biliary donor complications in donations of the right liver lobe. We analyzed 103 donors. Twelve patients had a bile leak that required treatment. All of these were treated endoscopically without any residual defect. We did not see a central extrahepatic bile duct lesion Nagano type C. The anatomic variant Huang A3 is a challenge with respect to the surgical technique. Three of 17 patients with biliary anatomy Huang A3 developed leaks. The bile duct anatomy can be carefully evaluated by magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography. The anatomic variant Huang A3 warrants particular attention for the closure of the bile duct orifice.
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Affiliation(s)
- A Bauschke
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland.
| | - A Altendorf-Hofmann
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - C Malessa
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - O Rohland
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - U Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
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9
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Living Donor Liver Transplantation: Overview, Imaging Technique, and Diagnostic Considerations. AJR Am J Roentgenol 2019; 213:54-64. [PMID: 30973783 DOI: 10.2214/ajr.18.21034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this article is to discuss the process of becoming a liver donor, describe the surgical methods used for transplantation, and critically review preoperative and intraoperative imaging techniques. CONCLUSION. Radiologists play a vital role in ensuring the safety of living liver donors; however, consensus guidelines do not exist for imaging protocol or reporting. Standardization would provide more consistent image quality across centers, improve communication with the transplant team, and facilitate data mining for quality assurance and research.
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10
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Leal-Leyte P, McKenna GJ, Ruiz RM, Anthony TL, Saracino G, Testa G, Klintmalm GB, T W Kim P. Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation. Liver Transpl 2018; 24:1011-1018. [PMID: 29637692 DOI: 10.1002/lt.25075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 12/12/2022]
Abstract
Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.
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Affiliation(s)
- Pilar Leal-Leyte
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Greg J McKenna
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Richard M Ruiz
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Tiffany L Anthony
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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11
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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: 30] [Impact Index Per Article: 4.3] [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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12
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Baker TB, Zimmerman MA, Goodrich NP, Samstein B, Pomfret EA, Pomposelli JJ, Gillespie BW, Berg CL, Emond JC, Merion RM. Biliary reconstructive techniques and associated anatomic variants in adult living donor liver transplantations: The adult-to-adult living donor liver transplantation cohort study experience. Liver Transpl 2017; 23:1519-1530. [PMID: 28926171 PMCID: PMC5818204 DOI: 10.1002/lt.24872] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/11/2017] [Accepted: 09/12/2017] [Indexed: 12/27/2022]
Abstract
Living donor liver transplantation (LDLT) is a technically demanding endeavor, requiring command of the complex anatomy of partial liver grafts. We examined the influence of anatomic variation and reconstruction techniques on surgical outcomes and graft survival in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). Data from 272 adult LDLT recipients (2011-2015) included details on anatomic characteristics and types of intraoperative biliary reconstruction. Associations were tested between reconstruction technique and complications, which included first biliary complication (BC; leak, stricture, or biloma) and first vascular complication (VC; hepatic artery thrombosis [HAT] or portal vein thrombosis [PVT]). Time to patient death, graft failure, and complications were estimated using Kaplan-Meier curves and tested with log-rank tests. Median posttransplant follow-up was 1.2 years. Associations were found between the type of biliary reconstruction and the incidence of VC (P = 0.03) and BC (P = 0.05). Recipients with Roux-en-Y hepaticojejunostomy had the highest probability of VC. Recipients with biliary reconstruction involving the use of high biliary radicals on the recipient duct had the highest likelihood of developing BC (56% by 1 year) compared with duct-to-duct (42% by 1 year). In conclusion, the varied surgical approaches in the A2ALL centers offer a novel opportunity to compare disparate LDLT approaches. The choice to use higher biliary radicals on the recipient duct for reconstruction was associated with more BC, possibly secondary to devascularization and ischemia. The use of Roux-en-Y biliary reconstruction was associated with VCs (HAT and PVT). These results can be used to guide biliary reconstruction decisions in the setting of anatomic variants and inform further improvements in LDLT reconstructions. Ultimately, this information may contribute to a lower incidence of technical complications after LDLT. Liver Transplantation 23 1519-1530 2017 AASLD.
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Affiliation(s)
- Talia B. Baker
- Department of Surgery, University of Chicago Medicine, Chicago IL
| | | | | | - Benjamin Samstein
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - James J. Pomposelli
- Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Carl L. Berg
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Jean C. Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
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13
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Eversion Technique to Prevent Biliary Stricture After Living Donor Liver Transplantation in the Universal Minimal Hilar Dissection Era. Transplantation 2017; 101:e20-e25. [DOI: 10.1097/tp.0000000000001533] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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14
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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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15
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Hashimoto K, Fujiki M, Quintini C, Aucejo FN, Uso TD, Kelly DM, Eghtesad B, Fung JJ, Miller CM. Split liver transplantation in adults. World J Gastroenterol 2016; 22:7500-7506. [PMID: 27672272 PMCID: PMC5011665 DOI: 10.3748/wjg.v22.i33.7500] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/30/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Split liver transplantation (SLT), while widely accepted in pediatrics, remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching, however, have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience, better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly, more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met, SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However, substantial challenges, such as surgical techniques, logistics, and ethics, persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults, focusing on donor and recipient selection based on physiology, surgical techniques, surgical outcomes, and ethical issues.
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Abstract
Living donor liver transplant (LDLT) accounts for a small volume of the transplants in the USA. Due to the current liver allocation system based on the model for end-stage liver disease (MELD), LDLT has a unique role in providing life-saving transplantation for patients with low MELD scores and significant complications from portal hypertension, as well as select patients with hepatocellular carcinoma (HCC). Donor safety is paramount and has been a topic of much discussion in the transplant community as well as the general media. The donor risk appears to be low overall, with a favorable long-term quality of life. The latest trend has been a gradual shift from right-lobe grafts to left-lobe grafts to reduce donor risk, provided that the left lobe can provide adequate liver volume for the recipient.
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Affiliation(s)
- Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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17
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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18
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Abu-Gazala S, Olthoff KM, Goldberg DS, Shaked A, Abt PL. En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation. J Gastrointest Surg 2016; 20:765-71. [PMID: 26676929 DOI: 10.1007/s11605-015-3047-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/25/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Techniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants. METHODS This was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection. RESULTS A total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3%, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs. 23.5%., respectively, p = 0.049). CONCLUSION En bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.
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Affiliation(s)
- Samir Abu-Gazala
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA.
| | - Kim M Olthoff
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - David S Goldberg
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Abraham Shaked
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Peter L Abt
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
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Chang JH, Lee I, Choi MG, Han SW. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22:1593-1606. [PMID: 26819525 PMCID: PMC4721991 DOI: 10.3748/wjg.v22.i4.1593] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
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20
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Vij V, Makki K, Chorasiya VK, Sood G, Singhal A, Dargan P. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:14-23. [PMID: 26390361 DOI: 10.1002/lt.24343] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/19/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.
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Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Kausar Makki
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Vishal Kumar Chorasiya
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Gaurav Sood
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Puneet Dargan
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
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21
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Simoes P, Kesar V, Ahmad J. Spectrum of biliary complications following live donor liver transplantation. World J Hepatol 2015; 7:1856-1865. [PMID: 26207167 PMCID: PMC4506943 DOI: 10.4254/wjh.v7.i14.1856] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/22/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
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Affiliation(s)
- Priya Simoes
- Priya Simoes, Varun Kesar, Jawad Ahmad, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Varun Kesar
- Priya Simoes, Varun Kesar, Jawad Ahmad, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Priya Simoes, Varun Kesar, Jawad Ahmad, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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22
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Kim PTW, Marquez M, Jung J, Cavallucci D, Renner EL, Cattral M, Greig PD, McGilvray ID, Selzner M, Ghanekar A, Grant DR. Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation. Clin Transplant 2015; 29:465-74. [PMID: 25740227 DOI: 10.1111/ctr.12538] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Long-term biliary complications after living donor liver transplantation (LDLT) are not well described in the literature. This study was undertaken to determine the long-term impact of biliary complications after adult right-lobe LDLT. METHODS This retrospective review analyzed an 11-yr experience of 344 consecutive right-lobe LDLTs with at least two yr of follow-up. RESULTS Biliary leaks occurred in 50 patients (14.5%), and strictures occurred in 67 patients (19.5%). Cumulative biliary complication rates at 1, 2, 5, and 10 yr were 29%, 32%, 36%, and 37%, respectively. Most early biliary leaks were treated with surgical drainage (N = 29, 62%). Most biliary strictures were treated first with endoscopic retrograde cholangiography (42%). There was no association between biliary strictures and the number of ducts (hazard ratio [HR] 1.017 [0.65-1.592], p = 0.94), but freedom from biliary stricture was associated with a more recent era (2006-2010) (HR 0.457 [0.247-0.845], p = 0.01). Long-term graft survival did not differ between those who had or did not have biliary complications (66% vs. 67% at 10 yr). CONCLUSIONS Biliary strictures are common after LDLT but may decline with a center's experience. With careful follow-up, they can be successfully treated, with excellent long-term graft survival rates.
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Chen TW, Fan HL, Feng AC, Ho MH, Kuo SM, Chang WC. Differences in risk factors for early-onset and late-onset biliary complications in liver transplant patients. JOURNAL OF MEDICAL SCIENCES 2015. [DOI: 10.4103/1011-4564.167743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shaheen MF, Alabdulkarim MS, Hamshow MM, Abdullah KO, O'Hali WA. Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients. Pediatr Transplant 2014; 18:831-8. [PMID: 25187071 DOI: 10.1111/petr.12349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2014] [Indexed: 12/25/2022]
Abstract
The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.
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Affiliation(s)
- Mohammed F Shaheen
- Department of Hepatobiliary Surgery and Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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25
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Chok KSH, Lo CM. Technical Tips and Tricks for Living Donations. CURRENT TRANSPLANTATION REPORTS 2014; 1:61-67. [DOI: 10.1007/s40472-013-0007-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Ikegami T, Shirabe K, Yoshiya S, Yoshizumi T, Yamashita YI, Harimoto N, Toshima T, Uchiyama H, Soejima Y, Maehara Y. A high MELD score, combined with the presence of hepatitis C, is associated with a poor prognosis in living donor liver transplantation. Surg Today 2013; 44:233-40. [DOI: 10.1007/s00595-013-0523-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 11/05/2012] [Indexed: 02/07/2023]
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27
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Shimada H, Endo I, Shimada K, Matsuyama R, Kobayashi N, Kubota K. The current diagnosis and treatment of benign biliary stricture. Surg Today 2012; 42:1143-53. [DOI: 10.1007/s00595-012-0333-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Accepted: 05/12/2011] [Indexed: 02/07/2023]
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28
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Saha A, Naidu C, Ramesh G, Chatterjee J, Puri P, Nandi B, Nambiar P, Madan R. Liver transplantation in Indian Armed Forces-initial experience. Med J Armed Forces India 2012; 68:110-7. [PMID: 24669047 DOI: 10.1016/s0377-1237(12)60018-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/07/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This study retrospectively analyses the initial experience of liver transplantation (LT) in the Indian Armed Forces. METHODS Fifty-three patients underwent LT at Army Hospital (R&R) Delhi Cantt. between March 2007 and March 2011. Of these 35 patients underwent deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) was carried out in 18 patients. The surgical techniques, complications and mortality were analysed. RESULTS A high consent rate of 35.9% for organ donation was achieved by the Armed Forces Organ Retrieval and Transplantation Authority (AORTA). Biliary complications occurred in five patients (9.4%). However, most of them could be managed by endoscopic interventions. Hepatic artery thrombosis (HAT) occurred in five patients (9.4%). Of these, two DDLT grafts were revascularised following HAT, by creating extra-anatomic arterial conduits with excellent outcome. The overall mortality was 18.8% (n = 10). There was no significant difference in the overall complications or mortality in patients undergoing DDLT or LDLT. CONCLUSION The overall survival and morbidity in this study is comparable to those from other centres. Urgent revascularisation of grafts following HAT should be attempted as it can salvage grafts with satisfactory outcome. There is a reduction in the incidence of biliary complications with refinements in surgical techniques.
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Affiliation(s)
- Anupam Saha
- Commandant, Military Hospital, Agra, Agra Cantt. - 282001
| | - Cs Naidu
- Senior Advisor (Surgery & GI Surgery), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Gs Ramesh
- Consultant (CTVS Anaesthesia), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Joy Chatterjee
- Senior Advisor (Paediatric Anaesthesia), INHS Asvini, Colaba, Mumbai
| | - Pankaj Puri
- Senior Advisor, (Gastroenterology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Bhaskar Nandi
- Senior Advisor, (Gastroenterology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Pradhi Nambiar
- Transplant Coordinator, Army Hospital (R&R), Delhi Cantt., New Delhi - 10
| | - Renu Madan
- Classified Specialist (Pathology), Army Hospital (R&R), Delhi Cantt., New Delhi - 10
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Radtke A, Sotiropoulos GC, Molmenti EP, Sgourakis G, Schroeder T, Beckebaum S, Peitgen HO, Cicinnati VR, Broelsch CE, Broering DC, Malagó M. Transhilar passage in right graft live donor liver transplantation: intrahilar anatomy and its impact on operative strategy. Am J Transplant 2012; 12:718-727. [PMID: 22300378 DOI: 10.1111/j.1600-6143.2011.03827.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The passage through the hilar plate during right graft live donor liver transplantation (LDLT) can have dangerous consequences for both donors and recipients. The purpose of our study was to delineate hilar transection and biliary reconstruction strategies in right graft LDLT, with special consideration of central and peripheral hilar anatomical variants. A total of 71 consecutive donors underwent preoperative three-dimensional (3D) CT reconstructions and virtual 3D hepatectomies. A three-modal hilar passage strategy was applied, and its impact on operative strategy analyzed. In 68.4% of cases, type I and II anatomical configurations allowed for an en block hilar transection with simple anastomotic reconstructions. In 23.6% of cases, donors had "difficult" type II and types III/IV hilar bile duct anatomy that required stepwise hilar transections and complex graft biliary reconstructions. Morbidity rates for our early (A) and recent (B) experience periods were 67% and 39%, respectively. (1) Our two-level classification and 3D imaging technique allowed for donor-individualized transhilar passage. (2) A stepwise transhilar passage was favored in types III and IV inside the right-sided hilar corridor. (3) Reconstruction techniques showed no ameliorating effect on early/late biliary morbidity rates.
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Affiliation(s)
- A Radtke
- Department of General, Thoracic and Transplantation Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Minimal Hilar Dissection Prevents Biliary Anastomotic Stricture After Living Donor Liver Transplantation. Transplantation 2011; 92:1147-51. [DOI: 10.1097/tp.0b013e3182336073] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.
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Affiliation(s)
- Shao Fa Wang
- Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation. Clin Transplant 2011; 25:504-510. [PMID: 21070364 DOI: 10.1111/j.1399-0012.2010.01338.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. METHODS Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. RESULTS Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). CONCLUSIONS In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.
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Affiliation(s)
- Hatem Khalaf
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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Kirimlioglu V, Tatli F, Ince V, Aydin C, Ersan V, Ara C, Aladag M, Kutlu R, Kirimlioglu H, Yilmaz S. 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; 43:917-920. [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] [MESH Headings] [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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Affiliation(s)
- V Kirimlioglu
- General Surgery Department, Yeni Yuzyil University School of Medicine, Uskudar, Istanbul, Turkey.
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Feng XN, Ding CF, Xing MY, Cai MX, Zheng SS. Technical aspects of biliary reconstruction in adult living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10:136-42. [PMID: 21459719 DOI: 10.1016/s1499-3872(11)60022-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The last decade has witnessed great progress in living donor liver transplantation worldwide. However, biliary complications are more common in partial liver transplantation than in whole liver transplantation. This is due to an impaired blood supply of the hilar bile duct during organ procurement and recipient surgery, commonly encountered anatomical variations, a relatively small graft duct, and complicated surgical techniques used in biliary reconstruction. DATA SOURCES MEDLINE and PubMed were searched for articles on "living donor liver transplantation", "biliary complication", "anatomical variation", "biliary reconstruction", "stenting" and related topics. RESULT In this review, biliary complications were analyzed with respect to anatomical variation, surgical techniques in biliary reconstruction, and protection of the arterial plexus of the hilar bile duct. CONCLUSION Transecting the donor bile duct at the right place to secure a larger bile duct stump, anastomosing techniques, and stenting methods as well as preserving the blood supply to the bile duct are all important in reducing biliary complications.
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Affiliation(s)
- Xiao-Ning Feng
- Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Evolving Strategies to Prevent Biliary Strictures After Living Donor Liver Transplantation. Transplant Proc 2010; 42:3624-9. [DOI: 10.1016/j.transproceed.2010.07.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 07/19/2010] [Indexed: 12/14/2022]
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Taketomi A, Morita K, Toshima T, Takeishi K, Kayashima H, Ninomiya M, Uchiyama H, Soejima Y, Shirabe K, Maehara Y. Living donor hepatectomies with procedures to prevent biliary complications. J Am Coll Surg 2010; 211:456-64. [PMID: 20822745 DOI: 10.1016/j.jamcollsurg.2010.04.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 04/22/2010] [Accepted: 04/27/2010] [Indexed: 01/04/2023]
Abstract
BACKGROUND Biliary complications in donor hepatectomies are still common, and occur in approximately 5% of the procedures. STUDY DESIGN To evaluate the usefulness of the management and surgical procedures to prevent the biliary complications in donor hepatectomies, a total of 343 donors were retrospectively studied. The clinical and surgical parameters of the donors and the postoperative biliary complications were evaluated. RESULTS Fourteen donors had biliary complication (BC) during the follow-up period (4.1%). Donors were divided into 2 groups; donors without BC (non-BC group; n = 329) and donors with BC (BC group; n = 14). Mean peak level of total bilirubin, mean duration of hospital stay after surgery, and medical cost in the BC group were significantly higher than in the non-BC group (p < 0.01). As improved procedures to prevent the BC were established at 2005, including the use of a real-time cholangiography by the C-arm, a minimized dissection of the hepatic vessels, the meticulous closure of the bile duct, and/or the use of Pringle maneuver during the parenchymal transection, the donors were divided into 2 groups before and after these establishments (the early period, n = 173; the later period, n = 170). Refinements in the management and surgical procedures reduced the occurrence of biliary complications from 6.4% during the early period to 1.8% during the later period (p < 0.01), and no biliary complications in the last 69 consecutive donors were observed. CONCLUSIONS Technical refinements described in this study might be useful to prevent the occurrence of biliary complications in a donor hepatectomy. It is particularly important to preserve the blood supply for the biliary tract of both the graft and the remnant liver.
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Affiliation(s)
- Akinobu Taketomi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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