Anastomotic Bile Leak Research Articles

COMPARATIVE STUDY OF BILLIARY COMPLICATIONS AFTER LIVING DONOR LIVER TRANSPLANTATION

Introduction: A considerable proportion of adult living donor liver transplantation (LDLT) recipients are biliary complication (BC). But there are few reports regarding BC based on long-term studies. The present study examined between 2011 and 2017 year’s First Central Hospital’s 40 cases’ BC incidence, risk factors, management and compared with Asan Medical Center 2000 and 2002 years 259 adult patients (225 right liver and 34 left liver grafts) cases. Materials and Methods: The mean follow-up period was 72±1 months. Biliary reconstruction included single duct-to-duct anastomosis (DD, n=31), double DD (n=2), single hepatojejunostomy (HJ, n=4), double HJ (n=1), and combined DD and HJ (n=1) in our center, which compared with other center. There were 4 episodes of anastomotic bile leaks and 5 episodes of anastomotic stenosis in our center. Most leaks occurred within the first month, whereas stenosis occurred over 2 yr. Results: Most stenosis were successfully treated using radiological intervention. Cumulative 1-, 3-, and 5-yr BC rates were 14,8%, 18.2%, and 20.2%, respectively. Our 1 cases had biliary leak on post operation 2 months. BC occurred much more frequently in right liver grafts compared to left liver grafts (P=0.024). Stenosis-free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small-sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P=0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P=0.471). Conclusion: Close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter. Keywords: BC - biliary complication; DD - duct-to-duct anastomosis; HJ - hepaticojejunostomy; LDLT - living donor liver transplantation; PTBD - percutaneous transhepatic biliary drainage.

348 Endoscopic Management of a Recalcitrant Anastomotic Bile Leak After Pancreaticoduodenectomy

INTRODUCTION: A 64-year-old female with past history of pylorus-preserving pancreaticoduodenectomy for pancreatic adenocarcinoma presented for endoscopic management of anastomotic bile leak and suspected stricture at the hepaticojejunostomy which persisted despite surgical and percutaneous intervention. CASE DESCRIPTION/METHODS: At the time of her surgery she was noted to have bile leakage from the new hepaticojejunostomy anastomosis, which was managed with intraoperative revision of the anastomosis and placement of a T-tube. On follow up after her surgery, she continued to have bilious drainage from her drains and was referred to interventional radiology for percutaneous transhepatic cholangiography. Cholangiogram demonstrated a significant leak from the anastomosis into a new subhepatic fluid collection. A percutaneous drainage catheter was placed. On subsequent catheter change, it was also noted that the biliary catheter was actually placed into a fluid collection adjacent to the small bowel and not across the hepaticojejunostomy. Internalization of the biliary catheter was unsuccessful as no flow of contrast from the bile duct to the jejunal limb could be identified. Her course was also complicated by episodes of cholangitis. To manage the persistent anastomotic leak, ERCP was performed. An adult colonoscope was advanced to the hepaticojejunostomy, which appeared widely patent. Contrast injection through the existing external percutaneous drain in the right hepatic duct confirmed complete distal occlusion of the duct without any contrast passage into the jejunum. Careful exam of anastomosis revealed sutures located superior to the hepaticojejunostomy. A 0.018 inch hydrophilic wire was advanced anterograde alongside the external drain under fluoroscopic guidance. This was unable to be passed into the small bowel but advancement of the wire resulted in a bulge in the mucosa seen endoscopically in the area of sutures, confirming the diagnosis of inadvertent surgical closure of right system. To gain access to the right biliary system, a choleodochojejunostomy was created using a needle knife in the area of the bulge created by the antegrade passage of wire through percutaneous tract. This allowed a 10 mm by 4 cm fully covered metal biliary stent to be deployed into the right hepatic duct across the newly created hepaticojejunostomy. DISCUSSION: In this case, we describe the endoscopic diagnosis and treatment of an iatrogenic biliary stricture leading to persistent anastomotic leak after pancreaticoduodectomy. Watch the video: http://bit.ly/2Z1kewv

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

Hepatic artery thrombosis is a concerning complication of orthotopic liver transplantation, and it most often occurs early in the posttransplant period. However, on rare occasions it can occur at a time remote from transplant. We present a case of ischemic cholangiopathy complicated by stricture and anastomotic bile leak from chronic hepatic artery thrombosis that occurred 11 years after the transplant. The initial biliary stenting helped with the resolution of the leak but she was found to have stones, sludge and copious pus at the time of stent exchange. Hepatic arteriography demonstrated complete occlusion of the transplant hepatic artery with periportal collaterals reconstituting intrahepatic hepatic arterial branches. The patient was subsequently referred for repeat liver transplantation.

A Bloody Connection: A Case of Hepatic Artery Pseudo Aneurysm Presenting as Hematemesis

Hemobilia is bleeding from biliary tree. It is a rare un-predictable jeopardizing vascular complication that is usually iatrogenic. Other causes include choledochelithiasis, biliary parasites, choledochal varices and biliary tumors. Upper gastrointestinal (GI) bleeding with melena is the most common presentation, followed by abdominal pain and jaundice (Quincke's triad). This triad is present in only 22% of cases. Our patient is a 66-year-old male with past history significant for Hepatitis C related end stage liver disease complicated by hepatocellular carcinoma. He underwent orthotropic liver transplant and he developed elevated liver transaminases postoperatively. Imaging revealed a 13-cm sub capsular collection due to anastomotic bile leak. This was managed initially by placement of a percutaneous biliary drain followed by endoscopic biliary sphincterotomy and 10F bile duct stenting (Figure-1) adjacent to the 6F stent across the anastomosis deployed at surgery. Liver enzymes continued to rise despite adequate biliary drainage and subsequent liver biopsy showed periductular neutrophilic infiltrate consistent with acute cholangitis. Three weeks later, patient suffered an episode of hematemesis of 500 cc of fresh blood. An emergent endoscopy visualized large blood clot in the stomach and oozing of fresh blood from the ampulla of Vater. Prior surgically deployed stent was removed during EGD using rat tooth forceps. CT angiogram revealed a 2-cm PA of the transplanted hepatic artery abutting the bile duct with stent forming a fistula resulting in hemobilia (figure-2). Immediate angiography (figure-3) was performed and a hepatic arterial stent was deployed occluding the PA with prompt cessation of further bleeding. A follow up magnetic resonance cholangiopancreatography confirmed intact CBD and absence of leakage from biliary tree. Hepatic artery dissection and PA, although rare after liver transplantation, can be fatal with mortality reported to be as high as 69%. A high index of suspicion is always required for diagnosis. It's believed that an injury to hepatic artery during liver biopsy is the insult causing PA formation. Although literature was scant on utility of stenting of hepatic PA during acute hemorrhage, our patient responded well to this minimally invasive approach. This report highlights the importance of considering hepatic artery PA, albeit rare, as a cause of hemobilia in those undergoing liver biopsy after liver transplantation.Figure: Blood clot at the ampulla (arrow) along with biliary stents in situ.Figure: A 2-cm PA (red arrow) of the transplanted hepatic artery abutting the bile duct with stent (blue arrow) forming a fistula.Figure: Appearance of PA (red arrow) before stent placement followed by stenting of common hepatic artery PA under fluoroscopic guidance (blue arrow).

Effect of Right Posterior Bile Duct Anatomy on Biliary Complications in Patients Undergoing Right Lobe Living Donor Liver Transplant.

Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications. We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses. The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications. Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.

Biliary complications following liver transplantation: Single-center experience over three decades and recent risk factors.

AIMTo identify independent risk factors for biliary complications in a center with three decades of experience in liver transplantation.METHODSA total of 1607 consecutive liver transplantations were analyzed in a retrospective study. Detailed subset analysis was performed in 417 patients, which have been transplanted since the introduction of Model of End-Stage Liver Disease (MELD)-based liver allocation. Risk factors for the onset of anastomotic biliary complications were identified with multivariable binary logistic regression analyses. The identified risk factors in regression analyses were compiled into a prognostic model. The applicability was evaluated with receiver operating characteristic curve analyses. Furthermore, Kaplan-Meier analyses with the log rank test were applied where appropriate.RESULTSBiliary complications were observed in 227 cases (14.1%). Four hundred and seventeen (26%) transplantations were performed after the introduction of MELD-based donor organ allocation. Since then, 21% (n = 89) of the patients suffered from biliary complications, which are further categorized into anastomotic bile leaks [46% (n = 41)], anastomotic strictures [25% (n = 22)], cholangitis [8% (n = 7)] and non-anastomotic strictures [3% (n = 3)]. The remaining 18% (n = 16) were not further classified. After adjustment for all univariably significant variables, the recipient MELD-score at transplantation (P = 0.006; OR = 1.035; 95%CI: 1.010-1.060), the development of hepatic artery thrombosis post-operatively (P = 0.019; OR = 3.543; 95%CI: 1.233-10.178), as well as the donor creatinine prior to explantation (P = 0.010; OR = 1.003; 95%CI: 1.001-1.006) were revealed as independent risk factors for biliary complications. The compilation of these identified risk factors into a prognostic model was shown to have good prognostic abilities in the investigated cohort with an area under the receiver operating curve of 0.702.CONCLUSIONThe parallel occurrence of high recipient MELD and impaired donor kidney function should be avoided. Risk is especially increased when post-transplant hepatic artery thrombosis occurs.

Refractory anastomotic bile leaks after orthotopic liver transplantation are associated with hepatic artery disease

Anastomotic bile leaks are common after orthotopic liver transplant (OLT), and standard treatment consists of placement of a biliary endoprosthesis. The objectives of this study were to identify risk factors for refractory anastomotic bile leaks and to determine the morbidity associated with refractory bile leaks after OLT. Consecutive adult patients who underwent ERCP for treatment of post-OLT biliary adverse events between 2009 and 2014 at a high-volume transplant center were retrospectively identified. A refractory leak was defined as a bile leak that persisted after placement of a plastic biliary endoprosthesis and required repeat endoscopic or surgical intervention. Forty-three subjects met study inclusion criteria. Median age was 57 years, and 36 (84%) subjects were men. Refractory bile leaks were diagnosed in 40% of subjects (17/43). Time-to-event analysis revealed an association between refractory bile leaks and the combined outcome of death, repeat transplant, or surgical biliary revision (hazard ratio, 3.78; 95% confidence interval, 1.25-11.45; P= .01). Hepatic artery disease was more common with refractory compared with treatment-responsive bile leaks (53% vs 8%, P= .001). Refractory anastomotic bile leaks after liver transplantation are associated with decreased event-free survival. Hepatic artery disease is associated with refractory leaks. Large-scale prospective studies should be performed to define the optimal management of patients at risk for refractory bile leaks.

Tu1557 Refractory Anastomotic Bile Leaks After Orthotopic Liver Transplantation Are Associated With Hepatic Artery Compromise and Carry High Morbidity

Tu1557 Refractory Anastomotic Bile Leaks After Orthotopic Liver Transplantation Are Associated With Hepatic Artery Compromise and Carry High Morbidity

Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy

BackgroundThe aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy. MethodsBetween March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions. ResultsThe majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2–14). ConclusionsThe management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.

External Biliary Drainage in Living Donor Liver Transplantation Using Duct-to-Duct Anastomosis

PurposeThis study compared the incidence of biliary complication (BC) in adult living donor liver transplant recipients who underwent right-lobe duct-to-duct anastomosis (DDA) with or without external biliary drainage (EBD) and intended to optimize EBD tube clamping. MethodsThis study consisted of a retrospective assessment of EBD effect and a prospective trial for EBD tube-clamping optimization. The retrospective study included the EBD group (n = 208) and the non-EBD group (n = 145). The prospective study included 60 patients with EBD. ResultsIn the retrospective study, single DDA was performed in 83.7% of the EBD group and 80.7% of the non-EBD group (P = .47). One-year overall incidence of BC was 14.4% in the EBD group and 16.8% in the non-EBD group (P = .48). The incidence of early anastomotic bile leakage was 1.0% in the EBD group and 4.8% in the non-EBD group (P = .036). In the prospective study, there was no difference in tube-clamping success rates between low- and high-output EBD groups. There was also no statistical difference between the success and failure groups in terms of graft duct size, liver function tests, and post-transplant days at tube clamping. ConclusionsThe size of our EBD tube was too small for the graft duct size, therefore its main role appeared to be early biliary decompression, which helped prevent bile leakage and also simplified the route of cholangiogram in detecting early BC. Hence, EBD is worthy of performing in selected patients with a high risk of anastomotic bile leak.

Mucormycosis in a liver allograft: salvage re‐transplantation and targeted immunosuppressive management

Zygomycetes infection is associated with a high mortality in transplant populations. We describe a child with liver allograft Rhizopus oryzae infection who was salvaged by liver re-transplantation. A 10-year-old child presented with anastomotic bile leak that was repaired. A combined antibiotics and voriconazole regimen was introduced for Escherichia coli and Candida krusei growth in the peritoneal fluid. Despite broad antibiotic and antifungal coverage, the patient continued to have an ongoing infection. A follow-up computed tomography scan 8weeks later showed 2 liver abscesses infiltrating the stomach and the diaphragm, with splenic infarcts and pericardial effusion. Aspirated samples from the liver abscess and the pericardial fluid revealed R. oryzae. Immunosuppression was discontinued and an antifungal regimen combining amphotericin B, posaconazole, and caspofungin was introduced. After 3weeks of treatment with control of the systemic signs of infection, a positron emission tomography showed the fluorescence stain limited to the liver. With infection confined to the liver, the child underwent liver re-transplantation, splenectomy, and partial gastrectomy. Immunosuppression was reintroduced with recovery of the immune response observed by the CD4 cells adenosine triphophate release (Cylex(™) ImmuKnow(®) assay) and posaconazole was continued for another year. At 3-year follow-up, the child maintained normal graft function. We conclude that discontinuation of immunosuppression combined with a modern antifungal regimen may allow salvage re-transplantation in patients with liver mucormycosis.

Acute liver failure associated with antiretroviral treatment for HIV – is there a role for liver transplantation?

IntroductionCombination antiretroviral medication has dramatically improved the prognosis of HIV infected individuals. Hepatotoxicity is an adverse event that can lead to interruption of therapy, clinical hepatitis and death. HIV was...

Role of multislice spiral CT in diagnosis of biliary complications after liver transplantation

Objective To analyze the role of multislice spiral CT in the diagnosis of biliary com-plications following liver transplantation. Methods Forty-four patients with biliary complications re-ceived tri-phase contrast-enhancement CT examination and cholangiography (CP) within one week af-ter the CT scanning. Using the results of CP as the standard, we investigated the efficacy of multislice spiral CT for each kind of biliary complication. All the analyses for bile duct were based on the images on the late portal venous phase and the reconstruction of images performed with multiplan reformat,Results CP depicted biliary strictures involved in extrahepatic bile duct in 23 cases (including the common bile duct and common hepatic duct), left or right hepatic duct in 24 and intrahepatic bile duct in 27. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the CT examination were 91.3%, 83. 3% , 87. 8%, 87. 5% and 88. 2% for biliary stricture in extrahe-patic bile duct, 83. 3% , 88. 2%, 85. 4%, 90. 9% and 78. 9% for biliary stricture in left or right he-patic duct, 74.1%, 92.7%, 80.5%, 95.2% and 65.0%, for biliary stricture in intrahepatic bile duct, respectively. CT detected intrahepatic biloma in 4 cases and abscess in 2 but CP only detected biloma in 2 cases. The other 4 cases did not detected by CP because of severe biliary strictures which filled with biliary sludge. CP confirmed anastomotic bile leak in 3 cases. In these cases, CT only de-picted the fluid collection in hepatic hilum and abdominal cavity, none of the exact leak site could be detected. CP detected biliary sludge or stones in 33 cases. However, the sensitivity, specificity, accu-racy, positive predictive value and negative predictive value of the CT examination for biliary sludge or stones were 72.7%,100.0%,78.1%,100.0%and 47.6%,respectively.Meanwhile,in 1 patient with diffuse intrahepatic biliary strictures,active biliary bleeding was correctly detected by CT exami-nation and confirmed by hepatic arteriography.Conclusion Tri-phase contrast-enhancement CT exam-ination can be used as a general method for biliary complications after liver transplantation.Besides its benefits in biliary complications,it is of great value for depicting complications involved in hepatic pa-renchyma and acute biliary bleeding in the same examination. Key words: Liver transplantation; Biliary complication; Tomography; X-ray computed; Cholangiography

Orthotopic Liver Transplantation: T-Tube or Not T-Tube? Systematic Review and Meta-Analysis of Results

The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangitis," "fewer episodes of peritonitis," and showed a favorable trend for "overall biliary complications." Although the "with T-tube" group showed superior result for "anastomotic and nonanastomotic strictures," the incidence of interventions was not diminished. Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.

Biliary complications after liver transplantation: diagnosis with multi-slice CT

Objective To evaluate multisliee CT in the diagnosis of biliary complications after liver transplantation. Methods Eighty-three consecutive patients who had undergone orthotopic liver transplantation (OLT) presented with clinical or biochemical signs of biliary complications and underwent contrast-enhancement CT examination. Three experienced radiologists, who were blinded to patient's clinical data, assessed CT images for the detection of biliary complications in consensus. Diagnostic confirmation of biliary complications was obtained with direct cholangiography in 69 patients, histologie study in 11 patients and hepatieojejunostomy in 3 patients. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CT for the detection of biliary complications were calculated. In addition, CT features of anastomotie biliary stricture (ABS) were compared with those of non-anastomotie biliary stricture (NABS) using x2 test. Results A total of 62 biliary complications (74. 7% ) was eventually confirmed in the 83 patients, including ABS in 32 patients, NABS in 21 patients, biliary duct stones in 16 patients (of which 12 patients with biliary stricture), anastomotie bile leakage in 5 patients, biloma in 4 patients with biliary stricture, and biliogenic abscess in 2 patients with biliary stricture. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CT for the detection of biliary stricture were 90. 6%、86. 7%、89. 2%、92. 3% and 83.9% , respectively. Other biliary complications, including biliary duct stones ( 16 cases) , anastomotic bile leak (5 cases) , biloma (4 cases), and biliogenic abscess (2 cases), were correctly diagnosed by CT; there was no false-positive or false-negative result. The incidence of irregular dilatation of bile duct was 71.4% ( 15/21 ), which was significantly higher in NABS cases than in ABS of 25.0% (8/32,P <0. 01 ) ; whereas the incidence of extrahepatie biliary dilatation was 33.3% (7/21) and regular dilatation was 14. 3% (3/21), which was significantly lower in NABS cases than in ABS of 84. 4% ( 27/32 ) and 68. 8% ( 22/32 ), respectively ( P < 0. 01 ). Of 21 patients with NABS, 66. 7% (14/21)complicated with hepatic artery stenosis or thrombosis, which was markedly more than that of NABS cases (15. 6%, 5/32,P <0. 01 ). Conclusions Multislice CT is a useful imaging procedure in the detection of biliary complications after liver transplantation, and biliary stricture can be primitively classified into ABS and NABS by CT. Hepatic artery ischemia is an important factor that causes NABS. Key words: Liver transplantation; Postoperative complications ; Biliary tract; Tomography, X-ray computed

W1636 A Novel Hepatico-Jejunostomy Technique Featuring a Purse-String Anastomosis and a Biodegradable Stent: A Preclinical Study in Minipigs

Introduction: In small-caliber bile ducts (BD), performing a well-functioning hepaticojejunal (HJ) anastomosis can be challenging: bile leakage and stricture formation are wellknown anastomotic complications. We have developed a biodegradable stent (BDS) and showed that it can be safely and effectively used in conventional HJ anastomosis, as well as in the treatment of cystic duct leakage and benign biliary strictures (GIE 2007). In addition, we have reported good results in patients with novel-technique pancreato-duodenectomy, where the anastomosis was created using purse-string technique and a BDS. We hypothesized that, instead of interrupted sutures, in small caliber BDs it might be easier and safer to create a purse-string anastomosis, and to use a BDS to ensure its patency. The aim of this study was to investigate the use of this novel technique for HJ, featuring a pursestring anastomosis and a BDS, and to compare the results to a conventional anastomosis without any stent in the minipigs. Materials and Methods: In this study the self-expanding PLA-BaSO4 BDSs (length 25 mm, wall 0.25 mm, diam 4/5 mm) and 23-kg minipigs were used. Cholecystectomy was performed and BD inner diameter measured. HJ was performed randomly either conventionally with interrupted sutures without any stent (n=5) or by the novel purse-string technique (n=4), where a BDS was first introduced into the BD, after which the BD with the stent was slide with the aid of 3 stay-sutures well inside the jejunal purse-string, which was then tightened. The animals were followed by repeated x-rays and liver chemistry. Results: The preoperative BD diameter was similar in the groups (aver 4.2 mm). 10 interrupted sutures in average were used in the conventional anastomosis. The time needed for creating the anastomosis was similar in the two groups (28.2 min in the conventional and 25 min in the purse-string + stent group). In the conventional group, one animal was sacrificed due to uncontrolled anastomotic bile leak on the 2nd postoperative day, and another animal developed a mild liver function failure with increased liver values at 1 month, and almost normal values at 3 months. All other animals (3/5 in conventional group and 4/4 in purse-string + stent group) had no signs of anastomotic leakage or liver function failure. In the abdominal radiograph the biodegradable stent had disappeared from all animals by 3 months. Conclusions: The described novel HJ technique featuring a pursestring anastomosis and a BDS is easy and safe to perform, and seems to ensure a wellfunctioning anastomosis in small-calibre BDs. These encouraging initial results point to further trials in the near future.

Percutaneous Therapy for Anastomotic Bile Leak in Liver-Transplant Patients with Nondilated Bile Ducts

Bile leaks remain a significant cause of postoperativemorbidity in 4.9% to 26.6% of liver transplant recipients[1–4] and can be managed surgically or nonsurgically.Most leaks can be treated with interventional radiologictechniques. However, in cases with bile ducts that aredecompressed because of massive leakage (mostly anas-tomotic), percutaneous access into a peripheral bile duct isusually difficult. In the cases presented here, we performedretrograde catheterization of a peripheral bile duct to makethe percutaneous procedure easier to perform and lesstraumatic for the patient.Case ReportsCase 1Forty-nine days after orthotopic liver transplantation, a 59-year-oldman presented withabdominalpainandtenderness.A large perihepatic fluid collection, or biloma, was found onultrasound examination. After bile-stained fluid aspiration,percutaneous drainage of the perihepatic biloma was per-formed under ultrasonographic guidance. Following thisprocedure, output through the drainage catheter was high(>200 ml per 24 h). Two weeks later, drip-infusion pouch-ography obtained via the drainage catheter showed a com-munication between the biloma and the biliary system at thesite of the surgical anastomosis. Endoscopic managementwas our first treatment option, but it failed in crossing theanastomosis. We decided to perform percutaneous transhe-patic biliary drainage. Because the leak had caused decom-pressionofbileducts,wedecidedtouseourbilomaaccesstomake the percutaneous bile duct puncture easier.The procedure was performed after antibiotic prophy-laxis. After initiation of intravenous (IV) sedation and localanesthesia, the drainage catheter was exchanged for a 6-Fintroducer sheath (Arrow International, Inc., Reading, PA,USA) positioned over a guide wire. A 5-F catheter (SOSOMNI; AngioDynamics, Queensbury, NY, USA) was in-serted from the biloma pouch and passed through the dis-rupted anastomosis. Then a microcatheter (fast tracker;Boston Scientific, Natick, MA, USA) was coaxially in-serted into a peripheral bile duct available for percutaneousaccess (Fig. 1), and contrast material was injected throughthe microcatheter to opacify and distend this duct. Underfluoroscopy and using a 21-gauge needle (AccuStickIntroducer System; Boston Scientific), a percutaneouspuncture was made in the same duct.After the percutaneous needle puncture was made in theduct, a coaxial dilator (AccuStick Introducer System;Boston Scientific) was placed over an 0.018-in. Nitinolguide wire, then a 0.035-in. glide wire (Terumo, Tokyo)was advanced through the dilator, and a 6-F introducer(Terumo) was inserted into the duct over the wire. A 5-Fcatheter (Terumo) with a guide wire was used to cross theleak site. Then, over a stiff guide wire (Amplatz Super StiffGuide Wire; Boston Scientific), a 10-F biliary drainagecatheter (Flexima; Boston Scientific) with multiple sideholes positioned on both sides of the anastomosis wasplaced to divert bile away from the defect. The leak haddisappeared after 57 days of percutaneous biliary drainage.

Biliary complications following liver transplantation in the model for end-stage liver disease era: Effect of donor, recipient, and technical factors

Biliary complications remain a significant problem following liver transplantation in the Model for End-Stage Liver Disease (MELD) era. We hypothesized that donor, recipient, and technical variables may differentially affect anastomotic biliary complications in MELD era liver transplants. We reviewed 256 deceased donor liver transplants after the institution of MELD at our center and evaluated these variables' association with anastomotic biliary complications. The bile leak rate was 18%, and the stricture rate was 23%. Univariate analysis revealed that recipient age, MELD, donor age, and warm ischemia were risk factors for leak, whereas a Roux limb or stent was protective. A bile leak was a risk factor for anastomotic stricture, whereas use of histidine tryptophan ketoglutarate (HTK) versus University of Wisconsin (UW) solution was protective. Additionally, use of a transcystic tube/stent was also protective. Multivariate analysis showed that warm ischemia was the only independent risk factor for a leak, whereas development of a leak was the only independent risk factor for a stricture. HTK versus UW use and transcystic tube/stent use were the only independent protective factors against stricture. Use of an internal stent trended in the multivariate analysis toward being protective against leaks and strictures, but this was not quite statistically significant. This represents one of the first MELD era studies of deceased donor liver transplants evaluating factors affecting the incidence of anastomotic bile leaks and strictures. Donor, recipient, and technical factors appear to differentially affect the incidence of anastomotic biliary complications, with warm ischemia, use of HTK, and use of a stent emerging as the most important variables.