Pseudo pseudocyst after right lobe live donor liver transplantation.

Abstract

LDLT, live donor liver transplantation; ERCP, endoscopic retrograde cholangiopancreatography. A 48-year-old man who presented with hepatocellular carcinoma complicating chronic hepatitis B liver cirrhosis underwent right lobe live donor liver transplantation (LDLT). The donor was his wife, who weighed 57.5 kg. The liver graft weighed 660 g, which corresponded to 56% of the recipient's estimated standard liver weight.1 Single duct-to-duct biliary anastomosis was performed between the donor and the recipient right hepatic duct while the left hepatic duct was closed with 6-O polypropylene (Prolene®, Ethicon, Edinburgh, UK). Immunosuppressive induction therapy included two doses of intravenous methylprednisolone and basiliximab (Simulect, Novartis, East Hanover, NJ). Immunosuppression was maintained on low-dose tacrolimus (trough level 5 to 10 ng/ml) and mycophenolate mofetil (1.5 g per day). The postoperative course was uneventful, apart from mild derangement of liver function. Liver biopsy showed nonspecific changes and was not diagnostic of rejection or biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) performed on postoperative day 54 showed mild stenosis of the biliary anastomosis without leakage. There was no significant abdominal pain after the procedure, and the patient was discharged home. The patient was readmitted 6 weeks later with epigastric distension and vomiting. There was no evidence of sepsis. The patient was afebrile, and there was no leukocytosis. There was no abdominal sign to suggest peritonitis. The serum total bilirubin level raised to 50 μmol/L, and liver enzymes were normal except that alkaline phosphatase was mildly elevated. Computed tomography showed a 15 cm fluid collection in the lesser sac with no other fluid collection inside the abdomen (Fig. 1). The presumptive diagnosis was pancreatic pseudocyst, possibly a complication of previous ERCP. The liver graft perfusion pattern was normal, but there was mild ductal dilatation. Percutaneous drainage of the collection yielded pure bile. Analysis of the aspirate showed normal amylase level (<30 U/L), and the bacterial culture from the fluid was negative. Subsequent percutaneous cholangiography and drainage revealed biliary leakage from the left hepatic duct stump of the recipient and stricture of the biliary anastomosis (Fig. 2). Computed tomography of the patient showing a large collection (C) in the lesser sac, which mimicked a pancreatic pseudocyst. Abbreviations: S, stomach; G, liver graft; T, nasogastric tube. Percutaneous cholangiogram showing bile leakage from the stump of the recipient left hepatic duct (arrow). Duct-to-duct biliary anastomosis is frequently employed in right lobe LDLT with potential benefits over hepaticojejunostomy.2, 3 Biliary complications, including stricture and leakage after duct-to-duct anastomosis, have been observed in up to 30% of the patients.2 Unlike hepaticojejunostomy, biliary leakage after duct-to-duct biliary anastomosis is less likely to be contaminated by bowel flora. Delayed biliary leakage from the left hepatic duct of the patient was thought to be caused by ischemic changes of the native bile duct, which was also responsible for the stricture of the biliary anastomosis. Adhesion of the stomach to the raw surface of the right lobe liver graft contained the biliary leakage in the lesser sac, mimicking a pancreatic pseudocyst. In addition, previous endoscopic intervention with ERCP also misled the clinicians to believe that it was a pancreatic pseudocyst.