CHOLEDOCHOCHOLEDOCHOSTOMY IN LIVER TRANSPLANTATION FOR PRIMARY SCLEROSING CHOLANGITIS

Abstract

741 Purpose: Identify patients with primary sclerosing cholangitis (PSC) who can undergo choledochocholedochostomy at the time of liver transplantation (OLT) in an attempt to 1) prospectively monitor both native and donor bile ducts and 2) utilize a functional recipient biliary system thereby avoiding choledochojejunostomy (CDJ). Methods: Historically it has been stated; although not proven, that all patients diagnosed with PSC should undergo CDJ at the time of OLT. In an effort to identify those patients who may benefit from the incorporation of their native ductal system with the donor duct we have established clinical criteria based on surgical inspection of the degree of ductal disease at the time of OLT. There must be minimal to moderate inflammation around the common bile duct and no saccular dilatation of the native common bile duct. Using the above-mentioned criteria, five of eleven patients with the diagnosis of PSC have been selected for primary duct-to-duct drainage at the time of transplant. Results: Four of the five transplant recipients managed with choledochocholedocostomy are adults (>18 y.o.) and one is a child (≤18 y.o.). The average length of follow-up after the OLT has been 313 ± 209 days (range: 30 - 559 days). Only one of the patients has had to have his biliary drainage converted to a CDJ. This occurred 457 days after transplant for hyperbilirubinemia and ERCP results that demonstrated a moderate to high-grade stricture at the ductal anastomosis with severe irregularities and diverticuli in the distal common bile duct. He had been noted to have mild intrahepatic dilatation within the first month after transplant, but he didn't develop clinical complications until a year post-transplant. Of the four remaining recipients there have been no episodes of ductal dilatation on ultrasound. One recipient did have an episode of hyperbilirubinemia that led to ERCP 2 months after transplant with the only finding of a mild anastomotic narrowing. Conclusions: Clinical criteria can be successfully used to select patients with primary sclerosing cholangitis who can safely undergo choledochocholedocostomy. This approach provides a portal for long-term follow-up of both donor and native common bile ducts via ERCP and avoids the complications of CDJ. It subsequently allows visualization and analysis of the entire ductal system with respect to the development of recurrent sclerosing cholangitis after OLT and the development of strictures (possibly malignant) within the recipient duct.