Choledochoduodenostomy as Biliary Reconstruction in Liver Transplantation

Abstract

Introduction: Choledochoduodenostomy (CDS) has earlier been used for biliary reconstruction in gastroenterological surgery. There are few publications assessing CDS in orthotopic liver transplantation (OLT). Until present the standard method of bilioenteric reconstruction in OLT has been Roux-en-Y choledochojejunostomy (CDJ). There are several arguments in favor of CDS: The procedure is technically simple, and can be performed faster than CDJ. The anastomosis is easily accessible endoscopicallly, and anastomotic complications can often be resolved without reoperation. Endoscopic access to biliary/entero-entero anastomosis in CDJ is possible, but can be challenging. We present our initial experience with CDS, comparing results with CDJ. Methods: From Apr. 2009 to Sept. 2011, 31 patients received CDS during OLT, where duct-to-duct anastomosis was not indicated due to inflammatory biliary disease or anatomical conditions. CDS was chosen if the anastomosis could be performed without tension. As control group we identified 32 patients operated with standard CDJ immediately prior to the CDS cohort, from Oct. 2007 to Mar. 2009. All data were analyzed retrospectively. Early and late biliary complications were recorded. Results: There were no demographical differences between the CDS/CDJ groups. One critically ill patient in the CDS group was lost to follow up due to early death. The median MELD-score was equal in both groups (15/16). The diagnosis primary sclerosing cholangitis was predominant in both groups (73 %/83 %). All liver grafts were from deceased donors, median cold ischaemic times were 382/438 min respectively. During the early follow-up period (≤30days), anastomotic bile leakage occurred in 4 patients in each group (13%/12%). Anastomotic biliary obstruction occurred in 2 patients in each group (6%/6%). In the CDS group, biliary complications were successfully treated endoscopically with stents in 4 patients, 2 patients were re-operated. In the CDJ group 4 patients were re-operated, whereas 2 were stented endoscopically. One patient in each group was later re-transplanted due to non-biliary complications. In the CDS-group 5 (16%) patients experienced an infection considered to be possible cholangitis within 90 days, as opposed to 0 patients in the CDJ-group. All recovered after antibiotic treatment. Late anastomotic strictures have not been observed after CDS, one patient developed stricture after CDJ. Conclusions: Our data show that the risk of biliary complications with CDS is comparable to Roux-en-Y CDJ. CDS may increase the risk of cholangitis but this can usually be resolved with antibiotic treatment. We conclude that CDS is a safe method of biliary reconstruction in liver transplantation, when duct-to-duct anastomosis is not indicated.