Endoscopic Treatment of Biliary Complications After Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Biliary Reconstruction

Abstract

Background and Aims: The aims of this study were to characterize the features of the biliary complications that occur after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary reconstruction and to evaluate the efficacy of treating biliary complications endoscopically. Patients and Methods: The records of 273 consecutive patients who underwent RL-LDLT with duct-to-duct biliary reconstruction from July 1999 through July 2005 at Kyoto University Hospital were reviewed to determine the overall incidence of postoperative biliary complications and the outcome of endoscopic repair of those complications. The biliary strictures and leakages were treated by endoscopic placement of multiple inside-stents above the sphincter of Oddi and nasobiliary drainage, respectively. Results: Biliary complications occurred in 93 of 273 patients (34.1%). These complications included 80 biliary strictures (75 anastomotic and 5 nonanastomotic) and 16 biliary leakages. There was no significant difference in the incidence of biliary stricture between the five types of anastomosis (Table). Endoscopic stenting could treat 51 (68.0%) of the anastomotic strictures and 8 (50.0%) of the biliary leakages. Biliary stones, sludge, or cast developed in 8 (2.9%), all of which were combined with biliary stricture and were endoscopically removed after endoscopic papillary balloon dilation. A bilioenteric fistula combined with the biliary stricture developed in 3 patients (1.1%), all of who were converted to surgical revision. In 2 patients (0.7%), the 4 F polyethylene tube for decompressing the biliary system of the grafted liver broke when it was removed, both of which could be retrieved endoscopically. Conclusion: Wide variety of the biliary complications related to RL-LDLT with duct-to-duct biliary reconstruction can be treated endoscopically. We recommend that endoscopic treatment should be attempted before subjecting patients to invasive surgery. Tabled 1Incidence of biliary stricture based on type of biliary anastomosis Type of anastomosis No. of patients Incidence of biliary stricture (%) ∗ None of the values in parentheses were statistically significant. No. nonanastomotic No. anastomotic (Single duct to duct) One biliary orifice 164 49 (29.9) 3 46 Two biliary orifices 44 10 (22.7) 0 10 (Double duct to duct) Both hepatic ducts 46 14 (30.4) 2 12 Hepatic duct and cystic duct 11 4 (36.4) 0 4 Mixed A single duct-to-duct biliary reconstruction was performed, together with a Roux-en-Y hepaticojejunostomy 8 3 (37.5) 0 3 Total 273 80 (29.3) 5 75 ∗ None of the values in parentheses were statistically significant. ∗∗ A single duct-to-duct biliary reconstruction was performed, together with a Roux-en-Y hepaticojejunostomy Open table in a new tab