Biliary Reconstruction In Living Donor Liver Transplantation Research Articles

Eversion technique: A safe anastomosis method of bile duct in living donor liver transplantation without internal or external biliary stent

Biliary stricture (BS) is still a major concern after bile duct anastomosis in living donor liver transplantation (LDLT), even after the technical refinements using a microscope. This study aims to describe our eversion technique without stent insertion of biliary anastomosis and its effects on the incidence of biliary complications. This was a single-center retrospective study of 52 adult LDLT recipients between December 2011 and June 2020. Group 1 consisted of the first 20 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 consisted of 32 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 4/20 patients in group 1 (20.0%) and 2/32 patients in group 2 (6.25%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT. The application of eversion technique could be a key for preventing BAS in duct-to-duct biliary reconstruction in LDLT.

Eversion Technique to Prevent Biliary Stricture After Living Donor Liver Transplantation in the Universal Minimal Hilar Dissection Era.

Biliary anastomosis stricture (BAS) is still among the major concerns after living donor liver transplantation (LDLT), even after the technical refinements including the universal use of the blood flow-preserving hilar dissection technique. The aim of this study is to investigate what are still the factors for BAS after LDLT. An analysis of 279 adult-to-adult LDLT grafts (left lobe, n = 161; right lobe, n = 118) with duct-to-duct biliary reconstruction, since the universal application of minimal hilar dissection technique and gradual introduction of eversion technique, was performed. There were 39 patients with BAS. Univariate analysis showed that a right lobe graft (P = 0.008), multiple bile ducts (P < 0.001), ductoplasty (P < 0.001), not using the eversion technique (P = 0.004) and fewer biliary stents than bile duct orifices (P = 0.002) were among the factors associated with BAS. The 1-year and 5-year BAS survival rates were 17.7% and 21.2% in the noneversion group (n = 134), and 6.2% and 7.9% in the eversion group (n = 145), respectively (P = 0.002). The perioperative factors including graft biliary anatomy were not different between everted (n = 134) and noneverted (n = 145) patients. The application of eversion technique under minimal hilar dissection technique could be a key for preventing BAS in duct-to-duct biliary reconstruction in LDLT.

Minimal Hilar Dissection Prevents Biliary Anastomotic Stricture After Living Donor Liver Transplantation

We introduced a new technique called minimal hilar dissection (Min-HD) technique in living donor liver transplantation (LDLT) to keep vascular networks around the recipient's bile duct. The aim of this study is to investigate whether the Min-HD technique could prevent biliary anastomotic stricture (BAS) after LDLT with duct-to-duct biliary reconstruction. An analysis of 214 adult-to-adult LDLT grafts (left lobe, n=135; right lobe, n=76; posterior segment, n=3) with duct-to-duct biliary reconstruction was performed. There were 46 cases with BAS. The incidence of BAS was 32.1% in the conventional technique group (n=84) and 14.6% in the Min-HD technique group (n=130, P=0.003). Multivariate regression analysis regarding BAS was carried out and detected hepatic artery flow less than 50 mL/min (P=0.002), not using the Min-HD technique (P=0.011), biliary anastomotic leakage (BAL, P=0.027) and ductoplasty (P=0.039) for the significant risk factors for BAS. The incidence BAL was 11.9% in the conventional technique group and 0.7% in the Min-HD technique group (P=0.002). No other factors showed an impact on the occurrence of BAL. The treatments for BAS were performed by endoscopic or percutaneous procedures. The cumulative completion rate of the treatment after developing BAS was 45.1% and 78.6% at 1- and 3-year, respectively. The median period for treating BAS was 10.8 months. The Min-HD technique is a rational surgical method, and it has the potential for preventing BAS and BAL after duct-to duct biliary reconstruction in LDLT.

Evolving Strategies to Prevent Biliary Strictures After Living Donor Liver Transplantation

Introduction The optimal surgical technique has not been elucidated that reduces the occurrence of biliary strictures after living donor liver transplantation (LDLT). Method We performed retrospective analysis of 193 consecutive LDLTs, including 78 right and 115 left lobe grafts. An external biliary stent was used for all of the cases. Results The overall 1-, 3-, and 5-year biliary stricture–free survival rates were 87.5%, 85.3%, and 85.3%, respectively. The 1- and 3-year biliary stricture–free survival rates for duct-to-duct reconstruction were 86.9% and 84.9%, and those for hepaticojejunostomy were 90.1% and 80.8%, respectively. A multivariate analysis revealed that the original number of graft bile ducts greater than the number of external stents, right lobe grafts, bile leaks, and recipient age older than 60 years represented the significant risk factors ( P < .05) to develop a biliary stricture after LDLT. All cases with biliary strictures (n = 61) were initially managed nonsurgically, but 4 patients ultimately required interventions. Conclusions Biliary reconstruction in LDLT using an appropriate number of external stents resulted in fairly acceptable outcomes. However, not only the proper use of stents or graft selection, but also nonsurgical factors, are important factors that determine the incidence of biliary strictures after LDLT.

Tailored telescopic reconstruction of the bile duct in living donor liver transplantation

Duct-to-duct reconstruction (DDR) of the bile duct has recently become the preferred choice in living donor liver transplantation (LDLT), but biliary complications still remain the most common cause of morbidity. We introduce our new technique of tailored telescopic reconstruction (TTR) of the bile duct for reducing bile duct complications in LDLT: the hilar plate covering the right and left hepatic ducts is bisected lengthwise through the right or left hepatic duct opening to make a funnel-shaped top, into which the donor hepatic duct is telescoped to match the recipient bile duct in size, and DDR is performed in the inner tissue of good vascular integrity of the recipient bile duct without redundancy. Forty-five consecutive LDLT procedures from January to August 2008 were analyzed through a comparison of 23 conventional duct-to-duct reconstructions (cDDRs) and 22 TTRs in bile duct anastomoses. At a mean follow-up of 19.5 months, the rates of overall biliary complications, leakage, and strictures were 43.5%, 26.1%, and 34.8%, respectively, for cDDR and 9.1%, 0%, and 9.1%, respectively, for TTR (P < 0.05 for each). In conclusion, TTR of the bile duct results in excellent outcomes with respect to minimization of biliary complications; thus, TTR can be recommended as a preferred method for biliary reconstruction in LDLT.

Prolonged Cold Ischemic Time Is a Risk Factor for Biliary Strictures in Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantation

Duct-to-duct (DD) anastomosis is an accepted procedure for biliary reconstruction in living donor liver transplantation (LDLT). However, biliary complication rates in LDLT recipients have been reported to be as high as 20% to 30% or more. In this study, we examined various potential risk factors for biliary stricture (BS) that occurs in the context of DD reconstruction in a single-active transplant center. Enrolled in this study were adults who underwent their first LDLT with DD reconstruction between August 2002 and May 2007 (n=283). BSs were defined as anastomotic strictures that required interventions or operative procedures to be corrected. We reviewed retrospectively the medical records of recipients, including medical history, surgical procedures, and progress, and analyzed risk factors of BS with the Kaplan-Meier method. BS occurred in 58 of the 283 recipients (20.5%). The mean follow-up period was 24.4 months posttransplant (SD=16.5). The univariate analysis revealed that recipient age (P=0.032), bile duct size (P=0.003), biliary reconstruction surgeon (P=0.023), perfusion solution (P=0.001), cold ischemic time (CIT) (P<0.001), and biliary leakage history (P<0.001) were significant risk factors. In the multivariable analysis, CIT (P=0.001), biliary leakage history (P=0.002), bile duct size (P=0.021), and recipient age (P=0.036) were significant risk factors for BS. And, a CIT cutoff value of 71 min was calculated using the minimum P value approach with correction by the Miller and Siegmund method (P=0.0186). In this study, prolonged CIT is identified as a risk factor for BS in DD biliary reconstruction in LDLT.

Introduction of Microsurgical Technique to Biliary Reconstruction in Living Donor Liver Transplantation

Objective High rates of biliary complications continue to be a major concern associated with living donor liver transplantation (LDLT). In this article, we report our experience of applying a microsurgical technique to biliary reconstruction in LDLT. Patients and Methods From January 2001 to December 2005, 32 patients underwent LDLTs (8 children and 24 adults). Biliary reconstruction for 43 hepatic duct orifices in the 32 donor grafts 21 duct-to-duct anastomoses, and 22 cholangiojejunostomies. Nine cholangiojejunostomies in 4 donors used a microsurgical technique under an operative microscope. Results Biliary complications weren’t observed among the cases of cholangiojejunostomy using a microsurgical technique. An anastomotic biliary leakage was found in a recipient with cholangiojejunostomy performed using a surgical loupe and a biliary stricture in another recipient who underwent duct-to-duct anastomoses using a surgical loupe. Conclusion Introduction of a microsurgical technique for biliary reconstruction in LDLT, especially using an operating microscope in the setting of hepatico-jejunostomy for small hepatic duct (≤2 mm in diameter), showed good results. We believe that using the operative microscope for biliary reconstruction could reduce the incidence of biliary complications associated with LDLT.

Introduction of microvascular surgery to biliary reconstruction in living donor liver transplantation

To explore the feasibility of introduction of microvascular surgery into biliary reconstruction in living donor liver transplantation (LDLT) so as to reduce the incidence of postoperative biliary complications. The experience in the microvascular surgery performed on 32 patients undergoing LDLT, 8 children and 24 adults, including duct-to-duct anastomosis in 21 case, hepato-jejunostomy under surgical loupe in 13 cases, and hepato-jejunostomy under operative microscopy in 9 cases, totally 43 cases of biliary reconstruction manipulations. Post-operative biliary complications occurred in 2 patients. One male patient who underwent hepato-jejunostomy under surgical loupe suffered from leakage from a bilioenteric anastomotic stoma 3 days after operation and laparotomy was performed to repair the leakage and carry out drainage. Mild stricture of the anastomotic stoma occurred in the other patient 3 months after operation and conservative treatment was given. Both patients recovered. Introduction of microvascular surgery to biliary reconstruction in LDLT, especially the use of operative microscopy for hepato-jejunostomy on very small hepatic ducts, <or= 2 mm in diameter, achieves good results, with significant reduction of post-operative complications.

Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations

Biliary complications appear to be the leading cause of postoperative complications after living donor liver transplantation (LDLT). The aim of this study is to analyze the complications, treatment modalities, and outcomes of biliary anastomoses in a series of 50 consecutive right-lobe LDLTs. Median patient age was 45 years, and median right-lobe graft volume was 740 g. Graft-recipient weight ratio was 0.69 to 1.80. Median follow-up time was 15 months (range, 2 to 38 months). Eleven of 50 patients died, resulting in an overall allograft and patient survival rate of 78%. In biliary reconstruction, a duct-to-duct (D-D) anastomosis or a standard Roux-en-Y (R-Y) anastomosis was performed. Twenty-nine grafts (58%) had a single duct for anastomosis. Seventeen grafts (34%) had two bile duct orifices, and four grafts (8%) had three bile duct orifices. A D-D anastomosis was performed in 36 cases (72%), whereas R-Y reconstruction was preferred in 14 cases (28%). The overall incidence of biliary anastomotic complications was 30% in this series. Five patients developed biliary leaks, presumably from the cut surface, and all of them healed spontaneously. Two bilomas were drained percutaneously. Anastomotic strictures occurred in 8 patients (16%) and were significantly greater than in the R-Y group (P = .03). Although strictures seemed to develop more frequently in allografts with multiple bile ducts, this did not reach statistical significance (P = .05). All strictures were managed by nonsurgical measures initially. Restenosis occurred in 2 patients, both of whom had an R-Y anastomotic stricture. These anastomoses were revised surgically, giving a reoperation rate of 4% for biliary problems. No graft or patient was lost because of biliary problems. Our data suggest that D-D anastomosis is a safe and feasible method of biliary reconstruction in LDLT by preserving physiological bilioenteric continuity and allowing easy access through endoscopic techniques. (Liver Transpl 2003;9:575-580.)