17. Portoenteric Fistula Following Living Donor Liver Transplant

Abstract

Background and Aims: Portal venous complications following liver transplantation are uncommon, with potential for developing immediate graft failure. While we do come across portal vein stenosis and portal vein thrombosis, portoenteric fistula following liver transplantation has not been reported so far in literature to best of our knowledge. Case summary: 55-year-old male underwent a living donor liver transplant (LDLT) for recurrent HCC. He had a history of Right hepatectomy, TACE and RFA for tumor recurrences. After a thorough work-up he received a right liver graft with MHV. During the surgery, the donor portal vein length was inadequate and a cryopreserved IVC with Iliac vein bifurcation was used as a conduit between the donor Right anterior Portal vein + Right Posterior portal vein and the recipient Main portal vein. A Roux-en-Y hepatico-jejunostomy with ductoplasty of donor hepatic ducts was done for the biliary reconstruction. Post-operatively the patient developed bile leak. A percutaneous malecot catheter was inserted into a dilated Roux limb under CT guidance to drain urbid bilious fluid from an obstructed Roux limb. Two months following his liver transplant, the patient developed malena and his Hb dropped to 5 gm% following addition of antiplatelet medication (clopidogrel). Within 24 h of this event; the patient developed massive hematochezia, hypotension and loss of consciousness. After transiently stabilizing, he underwent a CT Angiography which revealed a large contrast blush along the portal vein. The anterior sectoral portal vein could not be visualized with lack of blood supply to the anterior sector of the liver graft (Figure 1). An urgent portal vein angiography was done with a percutaneous transhepatic approach. An expandable stent was put across the portal vein (Figure 2). Inspite of being able to control the bleeding, the patient rapidly deteriorated over the next 8 h and died. Conclusions: Portal venous complications are more common with split liver and living related donor transplants (LRDT) than with deceased donor liver transplants (DDLT). Portoenteric fistula is an extremely rare and fatal complication post liver transplantation.Fig. 2Expandable stent was put across the portoenteric fistula.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The authors have none to declare.