Higher Incidence Of Biliary Complications Research Articles

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis.

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations.Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes.Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55).LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

Multiple Graft Bile Ducts Do Not Affect the Postoperative Outcomes of Right Lobe Living Donor Liver Transplantation

Multiple graft duct openings are associated with a high incidence of biliary complications (BCs), and biliary reconstruction for multiple graft bile ducts (BDs) remains a surgical challenge during living donor liver transplantation (LDLT). In particular, biliary reconstruction using "high biliary radicals (HBR)" of recipients for multiple graft BDs has a high probability of BCs. Herein, we analyzed outcomes by retrospectively reviewing 283 patients who underwent right lobe LDLT from January 2013 to September 2019. In total, 112 LDLT procedures using grafts with multiple BDs have been performed under our policies. In recent cases with 2 orifices located on the same hilar plate, we did dunking with a mucosal eversion technique instead of ductoplasty. When 2 orifices are located far apart on different hilar plates, we attempted to perform separate duct-to-duct anastomosis (DDA) using HBR of the recipient instead of hepaticojejunostomy. Among patients with multiple graft BDs, 20 underwent ductoplasty, 50 were treated using dunking with mucosal eversion technique, and 40 underwent separate DDA using HBR (HBR group). The incidence rates of biliary leakage and stricture were 8.9% and 10.7% in the multiple BD group, respectively, congruent with the outcomes of the single BD group. In subgroup analysis, we compared clinical outcomes between the HBR and single BD groups; the incidence of BCs in the HBR group was 15.0%, comparable to that of the single BD group. In conclusion, multiple graft BDs do not negatively impact the BC rate compared with single-graft BD when applying our technique to prevent BCs.

Adult Primary Sclerosing Cholangitis (PSC) subjects have worse biliary disease at diagnosis compared to pediatric PSC subjects

IntroductionAdult Primary Sclerosing Cholangitis (PSC) subjects have worse outcomes compared to pediatric PSC subjects. The reasons for this observation are not completely understood. MethodsIn this single-center, retrospective (2005–17) study we compared clinical information, laboratory data, and previously published MRCP-based scores between 25 pediatric (0–18 years at diagnosis) and 45 adult (19 years and above) subjects with large duct PSC at the time of diagnosis. For each subject, radiologists determined MRCP-based parameters and scores after reviewing the MRCP images. ResultsThe median age at diagnosis for pediatric subjects was 14 years, while that of adult subjects was 39 years. At the time of diagnosis, adult subjects had a higher incidence of biliary complications like cholangitis and high-grade biliary stricture (27% vs. 6%, p = 0.003) and higher serum bilirubin (0.8 vs. 0.4 mg/dl, p = 0.01). MRCP analysis showed that adult subjects had a higher incidence of hilar lymph node enlargement (24.4% vs. 4%, p = 0.03) at diagnosis. Adult subjects had worse sum-IHD score (p = 0.003) and average-IHD score (p = 0.03). Age at diagnosis correlated with higher average-IHD (p = 0.002) and sum-IHD (p = 0.002) scores. Adult subjects had worse Anali score without contrast (p = 0.01) at diagnosis. MRCP-based extrahepatic duct parameters and scores were similar between groups. DiscussionAdult PSC subjects may have higher severity of disease at diagnosis compared to pediatric subjects. Future prospective cohort studies are required to confirm this hypothesis.

What happens after percutaneous cholecystostomy tube for acute calculous cholecystitis?

• PCT can be a temporary treatment for acute calculous cholecystitis. • High incidence of biliary complications after PCT placement calls for timely cholecystectomy. • Interval cholecystectomy is recommended after PCT for calculous cholecystitis. Acute cholecystitis is commonly treated with laparoscopic cholecystectomy, if feasible. However, critically ill patients can be managed with a percutaneous cholecystostomy tube (PCT) for biliary drainage. This is a temporizing measure and does not represent a final treatment. We aimed to compare the outcomes of performing an interval cholecystectomy vs. conservative management after PCT placement. We conducted a retrospective study of all patients with a PCT placed for acute calculous cholecystitis (ACC) at a single center from October 2010 to March 2015. Ninety-five patients (median age 79 years) underwent PCT placement for ACC. Only 26.3% of patients underwent interval cholecystectomy. The mortality rate within 6 weeks of ACC diagnosis was higher in the non-surgical group but this was not statistically significant. The number of re-admissions and complications of biliary disease was higher in the surgical group before undergoing interval cholecystectomy, specifically, choledocholithiasis (44% vs. 21.4%; p = 0.03). Patients who had an ICU admission [OR 0.21; 95% CI 0.07-0.66] or increased age [OR 0.94; 95% CI 0.89-0.98] were less likely to undergo interval cholecystectomy. Nine cholecystectomies were performed laparoscopic, 6 were converted to open and 10 were done in an open fashion. The complication rate in the first 30 days after cholecystectomy was 56%. Most complications occurred when surgery was performed in an open or converted to open technique (11/14=78.6%) vs. laparoscopic (3/14=21.4%). The relatively high incidence of biliary complications in the period between PCT placement and cholecystectomy calls for timely cholecystectomy in patients treated with PCT. When feasible, patients with a history of ACC should undergo interval cholecystectomy.

Abstract No. 525 Yttrium-90 radioembolization of segment IV hepatocellular carcinoma: assessment of biliary complications in a region dense with biliary structures

Biliary complications are a known risk from Yttrium-90 radioembolization of hepatocellular carcinoma (HCC). The proposed mechanism of injury is due to microembolic effect and/or radiation-induced injury to the biliary system1. We investigate whether lesions treated in segment IV demonstrated a higher incidence of biliary complications compared to the literature due to the higher density of biliary structures within this segment. A single-institution retrospective analysis of patients with segment IV HCC treated with Yttrium-90 microspheres from 2013 to 2019. Inclusion criteria included: diagnosis of HCC to segment IV, at least one follow-up computed tomography or magnetic resonance examination within 90 days of treatment, and serum total bilirubin before and within 90 days post treatment. Exclusion criteria included liver transplantation. Thirty patients met criteria with an average length of follow-up imaging at 46 days. Biliary complications included, but were not limited to: biloma, cholecystitis, biliary strictures, and grade 3 or 4 biliary toxicity by National Cancer Institute criteria. Of 30 patients, one patient was found to have multifocal biliary strictures requiring two biliary stents on endoscopic retrograde cholangiopancreatography five months post procedure (n = 1, 3.3%). Two patients demonstrated grade 3/4 bilirubin toxicity (n = 2, 6.7%). The average treatment dosage was 135 Gray (range, 95–341 Gy). Compared to the biliary complication rate described in the literature for HCC with 2.1% for biliary findings on imaging and 6.8% for grade 3/4 bilirubin toxicity2, our study showed comparable rates of 3.3% and 6.7%, respectively. Yttrium-90 radioembolization of segment IV HCC demonstrated no significant difference in biliary complication rates compared to nonsegment specific biliary complication rates reported in the literature.

Biliary Reconstruction Using High Biliary Radical Is Safe Option for Multiple Graft Bile Ducts in Right Lobe Living Donor Liver Transplantation

Multiple small size donor bile ducts (BDs) are related to higher incidence of biliary complications (BCs) and biliary reconstruction for multiple BDs still remains a technical challenge during living donor liver transplantation (LDLT). Especially biliary reconstructions using high biliary radicals (right or left hepatic duct) on the recipient for multiple BDs are associated with very high probability of BCs secondary to devacularization and ischemia. Therefore, hepaticojejunostomy has been preferred in cases with multiple BDs which are not close each other although duct to duct anastomosis (DDA) has more physiological advantages. Herein, we analyzed clinical outcomes through retrospective reviews 227 patients receiving DDA for right lobe grafts LDLT from January 2013 to September 2018. 87 LDLT using grafts with multiple BDs have been performed and among them, 39 patients received DDA using high biliary radicals as recipient's BD using minimal hilar dissection, external biliary stents and mucosal eversion technique. We compared clinical outcomes with those in group using common hepatic duct as recipient's BD for multiple BD (CHD group). The incidence of biliary leakage and stricture were 10.3% and 12.8% and these results were not different to those in CHD group. Moreover, these results were comparable to those in group with single graft BD during the same periods. In conclusion, the choice high biliary radicals as the recipient's BD for multiple graft BDs was not associated with more BCs and could be safe option for biliary reconstruction with multiple BDs under our strategies.

Simultaneous liver-kidney transplantation from donation after cardiac death donors: an updated perspective.

Outcomes of both donation after cardiac death (DCD) liver and kidney transplants are improving. Experience in simultaneous liver-kidney transplant (SLK) using DCD donors, however, remains limited. In an updated cohort (2010-2018), outcomes of 30 DCD SLK and 131 donation after brain death (DBD) SLK from Mayo Clinic Arizona and Mayo Clinic Minnesota were reviewed. The Model for End-Stage Liver Disease score was lower in the DCD SLK group (23 vs 29, P=.01). Kidney delayed graft function (DGF) rates were similar between the 2 groups (P=.11), although the duration of DGF was longer for DCD SLK recipients (20 vs 4days, P=.01). Liver allograft (93.3% vs 93.1%, P=.29), kidney allograft (93.3% vs 93.1%, P=.91), and patient (96.7% vs 95.4%, P=.70) 1-year survival rates were similar. At 1 year, there were no differences in the estimated glomerular filtration rate (57.7±18.2 vs 56.3±17.7, P=.75) or progression of fibrosis (ci) on protocol kidney biopsy (P=.67). A higher incidence of biliary complications was observed in the DCD SLK group, with ischemic cholangiopathy being the most common (10.0% vs 0.0%, P=.03). The majority of biliary complications resolved with endoscopic management. With appropriate selection, DCD SLK recipients can have results equivalent to those of DBD SLK recipients.

Biliary Complications After Liver Transplantation From Uncontrolled Donors After Circulatory Death: Incidence, Management, and Outcome.

The utilization of livers from donation after uncontrolled circulatory death (uDCD) increases the availability of liver grafts, but it is associated with a higher incidence of biliary complications (BCs) and lower graft survival than those organs donated after brain death. From January 2006 to December 2016, we performed 75 orthotopic liver transplantations (OLTs) using uDCD livers. To investigate the relationship of BCs with the use of uDCD OLT, we compared patients who developed BCs (23 patients) with those who did not (non-BC group, 43 patients) after excluding cases of hepatic artery thrombosis (a known cause of BC) and primary nonfunction. The groups had similar uDCD donor maintenance, donor and recipient characteristics, and perioperative morbidity/mortality rates, but we observed a higher rate of hepatocellular carcinoma and hepatitis C virus in the non-BC group. Percutaneous transhepatic biliary dilation, endoscopic retrograde cholangiopancreatography dilation, Roux-en-Y hepaticojejunostomy (HJ), a T-tube, and retransplantation were used for BC management. In the BC group, 1-, 3-, and 5-year patient survival rates were 91.3%, 69.6%, and 65.2%, respectively, versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P=0.89). However, 1-, 3-, and 5-year graft survival rates were 78.3%, 60.9%, and 56.5%, respectively, in the BC group versus 77.8%, 72.9%, and 72.9%, respectively, in the non-BC group (P=0.38). Multivariate analysis did not indicate independent risk factors for BC development. In conclusion, patient and graft survival rates were generally lower in patients who developed BCs but not significantly so. These complications were managed in the majority of patients through radiological dilation, endoscopic dilation, or Roux-en-Y HJ. Retransplantation is necessary in rare cases after the failure of biliary dilation or surgical procedures.

Abstract No. 483 - Drug eluting bead chemoembolization for neuroendocrine tumor metastases: risk factors for biliary toxicity

To evaluate possible risk factors contributing to biliary toxicity after drug-eluting bead transarterial chemoembolization (DEB-TACE) treatment of neuroendocrine tumor (NET) hepatic metastases. 13 patients (mean age: 65.8, 55% males) who underwent 23 DEB-TACE treatments between 2011-2015 for hepatic NET metastases from gut (n = 4), pancreas (n = 6), lung (n = 2) & unidentified (n = 1) primary sites were reviewed retrospectively. Tumor characteristics (grade, burden, arterial supply), previous therapeutic history (systemic chemotherapy and targeted therapies, peptide radiotherapy, resection of primary tumor), and clinical outcomes were evaluated. Because of recent published warnings, special emphasis was placed on biliary toxicity, including biliary ductal dilatation, biloma and/or abscess formation, and biochemical toxicity. 7 patients developed biloma or abscess but only 1 required hospitalization and percutaneous drainage. 10 patients developed focal intrahepatic ductal dilatation. Biliary complications were associated with lower tumor burden (P = 0.036), and prior biliary/pancreatic surgical interventions (P = 0.021). 3 patients demonstrated grade 3/4 alkaline phosphatase elevation, but none had severe elevations of serum bilirubin. No relationship was found with catheterization or treatment selectivity (segmental/lobar) or tumor grade. Large tumor burden and its covariables of large administered dose of doxorubicin (>75 mg) and necessity for supplemental bland embolization, were found to reduce risk of biliary complications (P = 0.033). Prior systemic treatment with antiangiogenic drugs also decreased the risk of biliary complications (P = 0.037). DEB-TACE showed median time to progression (TTP) of 13.7 months and overall survival (OS) of 56.7 months. DEB-TACE is an effective option for treatment of NET hepatic metastases, but is associated with a high incidence of biliary complications. It appears to be safest for patients with large tumor burdens who have undergone previous treatment by systemic antiangiogenic drugs, perhaps due to minimized nontarget deposition.

Analysis of Factors Associated With Biliary Complications in Children After Liver Transplantation.

Biliary complications (BCs) remain an important cause of morbidity after pediatric liver transplantation. Technical factors have already been implicated in the development of BCs. Previous reports have associated the use of partial grafts, particularly living donor grafts, with a higher incidence of BCs. Our aim is to study the factors associated with the development of BCs in a large cohort of pediatric liver transplant recipients. Retrospective cohort study of 670 children (<18 years of age) who underwent a primary liver transplant between March 2000 and January 2015. Patients who did and did not develop BCs were compared with identify associated factors. Univariate and multivariate analyses were performed. A total of 115 patients (17.2%) developed BCs (83 strictures and 44 leaks). Of the study participants, 594 had living donor liver transplants. Multiple arterial anastomoses was a protective factor for BCs, and a ductoplasty was a risk factor. Living donor grafts and multiple biliary anastomoses were more frequently associated with leaks. Patients with BCs had a higher reoperation rate and longer hospital stays. There was no difference in patient or graft survival. Technical factors play a major role in the development of BCs, particularly leaks. Strictures are more frequently associated with an inadequate arterial supply to the bile duct, and multiple arterial anastomoses may protect children from this complication. The use of partial grafts was not an independent factor for BCs in high-volume centers that are experienced with this technique.

Risk of Biliary Events After Selective Cholecystectomy During Biliopancreatic Diversion with Duodenal Switch.

Approximately 20 % of adults over 40 years of age in the USA develop cholelithiasis (Topart et al. Surg Obes Relat Dis. 9(4):526-30, 2013). Despite a higher incidence of biliary complications reported in postbariatric patients, it remains controversial whether simultaneous routine cholecystectomy should be performed during biliopancreatic diversion and duodenal switch (BPD/DS) or if a selective approach is more appropriate. The aim of this study was to evaluate incidence of biliary complications in patients who underwent BPD/DS without simultaneous cholecystectomy. Retrospective review of all patients who underwent BPD/DS between 2006 and 2012 was performed. A total of 361 consecutive patients were included in the study with mean age of 44.8 years (range 20-72), mean body weight of 317.2 lbs (range 205-547), and average body mass index (BMI) of 50.5 kg/m(2) (range 34-71.4). Ninety-seven patients were males (26.8 %). Out of 239 patients who still had their gallbladder after the BPD/DS, 52 patients (22.7 %) developed subsequent biliary symptoms (13 patients (5.4 %) in the first year, 25 (11 %) in the second year, and 14 (6.1 %) beyond the second year). During the study period, 40 patients eventually underwent elective laparoscopic cholecystectomy, and 11 had urgent cholecystectomy (9 laparoscopic and 2 open). One patient underwent open common bile duct exploration for ascending cholangitis. Average follow-up was 31 months (12-72 months) with follow-up rate of 95.6 % at 12 months and 92.8 % at 18 months. Leaving normal gallbladder in situ after BPD/DS is associated with an acceptable risk of biliary events. Risk of developing common bile duct stones is low; however, it may create treatment challenges.

Impact of Early Biliary Complications On Long Term Graft and Patient Survival After Right Lobe Living Donor Liver Transplantation (LD).

Background: There is a significantly higher incidence of biliary complications after LD compared to deceased donor liver transplantation. It is not clear if this negatively impacts long term patient and graft survival after LD. Methods: Analysis of a prospectively maintained database of 120 LD with >2 year follow up at a single center. Actuarial patient and graft survival rates were estimated using Kaplan Meier methods. Results: 26 patients had biliary complications (bile leak=24;Stricture=12) and all occurred within 90 days post tx. 20 patients were managed by endoscopic stenting (58 procedures in 20 pts);6 required surgical exploration(none in the last 5 yrs). Time-to-complete resolution of leak and stricture was 37 and 82 days respectively. Number of bile ducts, duct to duct vs.roux-en-y, interrupted vs. continuous anastomosis, graft weight were not statistically associated with biliary complications. By Multivariate Cox Proportional Hazards regression model cardiovascular disease pretransplant (p=0.042) and HCV etiology (p=0.026) were associated with higher incidence of biliary complications. The one-year graft survival was lower (88% vs.97%; p=0.034) in biliary complications group, however there was no statistical difference in the 5-year graft survival (p=0.380).Figure: No Caption available.The patient survival was similar between the groups(p=0.331).Figure: No Caption available.Conclusions: Early Biliary complications result in lower 1-year graft survival but do not negatively impact long term patient survival after living donor liver transplantation.

Development, management, and resolution of biliary complications after living and deceased donor liver transplantation: A report from the adult-to-adult living donor liver transplantation cohort study consortium

Adult recipients of living donor liver transplantation (LDLT) have a higher incidence of biliary complications than recipients of deceased donor liver transplantation (DDLT). Our objective was to define the intensity of the interventions and the time to resolution after the diagnosis of biliary complications after liver transplantation. We analyzed the management and resolution of posttransplant biliary complications and investigated the comparative effectiveness of interventions in LDLT and DDLT recipients. For the analysis of biliary complications (leaks or strictures), we used a retrospective cohort of patients who underwent liver transplantation at 8 centers between 1998 and 2006 (median follow-up from onset=4.7 years). The numbers, procedure types, and times to resolution were compared for LDLT and DDLT recipients. Posttransplant biliary complications occurred in 47 of the 189 DDLT recipients (25%) and in 141 of the 356 LDLT recipients (40%). Biliary leaks constituted 38% of the post-DDLT biliary complications (n=18) and 65% of the post-LDLT biliary complications (n=91). The median times to first biliary complications were similar for DDLT and LDLT (11 versus 14 days for leaks, P=0.63; 69 versus 107 days for strictures, P=0.34). Overall, 1225 diagnostic and therapeutic procedures, including reoperation and retransplantation, were performed (6.5±5.4 per recipient; 5.5±3.6 for DDLT versus 6.8±5.8 for LDLT, P=0.52). The median number of months to the resolution of a biliary complication (i.e., a tube-, stent-, and drain-free status) did not significantly differ between the DDLT and LDLT groups for leaks (2.3 versus 1.3 months, P=0.29) or strictures (4.9 versus 2.3 months, P=0.61). Although the incidence of biliary complications is higher after LDLT versus DDLT, the treatment requirements and the time to resolution after the development of a biliary complication are similar for LDLT and DDLT recipients.

The Biliary Complications in Live Donor Liver Transplant Do Not Affect the Long-Term Results

IntroductionLiving donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. Patients and methodsFrom 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analysed retrospectively. Results39 patients (55.7%) had some type of biliary complication. 29 presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs 29.5% at 5 years, P=.05). With a median follow-up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35. ConclusionsLDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications.

Las complicaciones biliares en el trasplante hepático de donante vivo no afectan los resultados a largo plazo

IntroductionLiving donor liver transplantation (LDLT) is an effective treatment for patients with terminal chronic liver disease, despite the high incidence of biliary complications. The objective is to evaluate the results and long-term impact of biliary complications after THDV. Patients and methodsFrom 2000 to 2010, 70 right lobe LDLT were performed. Biliary complications (leakage and stenosis) of the 70 LDLT recipients were collected prospectively and analyzed retrospectively. ResultsA total of 39 patients (55.7%) had some type of biliary complication. Twenty nine presented a leak, and of these, 14 subsequently developed a stricture. In addition, 10 patients had a stenosis without prior leakage. The median time to onset of stenosis was almost a year. Patients with previous biliary leakage were more likely to develop stenosis (58% vs. 29.5% at 5 years, P=.05). With a median follow up of 80 months, 70.8% of patients were successfully treated by interventional radiology. After excluding early mortality, there were no differences in survival according to biliary complications. A decrease of biliary complications was observed in the last 35 patients compared with the first 35. ConclusionsLDLT is associated with a high incidence of biliary complications. However, long-term outcome of patients is not affected. After a median follow-up time of nearly seven years, no differences were found in survival according to the presence of biliary complications.

Biliary Complications After Liver Transplantation Using Side-to-Side Choledochocholedochostomy Reconstruction With or Without T-Tube

BackgroundBiliary complications are a frequent cause of morbidity, graft loss, and death after orthotopic liver transplantation (OLT). The choledochocholedochostomy anastomosis without a T-tube is controversial, as it has been related to more biliary complications. AimsThe aims of this study were to determine the incidence and to identify the risk factors of post-OLT biliary complications after reconstruction with or without a T-tube. Materials and MethodsNinety-five consecutive adult patients with deceased donor liver transplantations (overall survival rate, 86.3%; mean follow-up, 22.2 months) were analyzed to determine the incidence and type of biliary complications in 2 groups: choledochocholedochostomy with (45 patients, Group I) or without a T-tube (50 patients, Group II). The incidence of biliary complications in Groups I and II was 40% (18/45) and 30% (15/50), respectively (P > .05). In Group I, 49% of the complications were directly related to the T-tube. Biliary anastomosis stricture was more frequent in Group II (28% vs 8.9% in Group I; P = .018). Endoscopic retrograde cholangiopancreatography (ERCP) was the most common therapeutic procedure for the resolution of biliary complications in both groups (Group I, 66.5%; Group II, 58.2%). Arterial thrombosis, high pretransplantation Model for End-Stage Liver Disease (MELD) score, and donor obesity were identified as risk factors for biliary complications after OLT. ConclusionOLT biliary reconstruction without a T-tube is not related to an increased risk of biliary complications, although stricutre of the anastomosis is more frequent in this group of patients. Donor obesity, arterial thrombosis, and high pretransplantation MELD score are associated with a higher incidence of biliary complications after OLT.

Endoscopic Management of Biliary Complications following Liver Transplantation after Donation from Cardiac Death Donors

Previous studies have shown a higher incidence of biliary complications following donation after cardiac death (DCD) liver transplantation compared with donation after brain death (DBD) liver transplantation. The endoscopic management of ischemic type biliary strictures in patients who have undergone DCD liver transplants needs to be characterized further. A retrospective institutional review of all patients who underwent DCD liver transplant from January 2006 to September 2011 was performed. These patients were compared with all patients who underwent DBD liver transplantation in the same time period. A descriptive analysis of all DCD patients who developed biliary complications and their subsequent endoscopic management was also performed. Of the 36 patients who received DCD liver transplants, 25% developed biliary complications compared with 13% of patients who received DBD liver transplants (P=0.062). All DCD allograft recipients who developed biliary complications became symptomatic within three months of transplantation. Ischemic type biliary strictures in DCD allograft recipients included disseminated biliary strictures in two patients, biliary strictures of the hepatic duct bifurcation in three patients and biliary strictures of the donor common hepatic duct in three patients. There was a trend toward increasing incidence of total biliary complications in recipients of DCD liver allografts compared with those receiving DBD livers, and the rate of diffuse ischemic cholangiopathy was significantly higher. Focal ischemic type biliary strictures can be treated effectively in DCD liver transplant recipients with favourable results. Diffuse ischemic type biliary strictures in DCD liver transplant recipients ultimately requires retransplantation.

Outcomes of Patients with Benign Liver Diseases Undergoing Living Donor versus Deceased Donor Liver Transplantation

Background/AimsThe number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT.MethodsA total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation.ResultsThe waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT.ConclusionsPatients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.

Sorafenib before liver transplantation for hepatocellular carcinoma: risk or give up

Dear Sirs, We read with interest the article by Truesdale et al. [1] regarding their experience in the use of sorafenib before liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). The authors compare ten patients who were administered sorafenib during waiting time for LT with twenty-three patients to whom the drug was not given. No difference in terms of overall and HCC recurrence-free survival was seen between the two groups. Indeed a higher incidence of biliary complications (67% vs. 17%) and acute cellular rejections (67% vs. 22%) was observed in the first group. The authors assume that the higher amount of complications is secondary to the use of sorafenib because of its main effect in inhibiting the vascular endothelial growth factor (VEGFR), reducing the resistance to apoptosis of cholangiocytes and thus both hindering the integrity of biliary vascularization and altering the immune pathway leading to cellular rejection. However, some major issues arise reading this paper: the authors do not specify the inclusion criteria for the use of sorafenib, the extension of the tumour burden before LT, the number of locoregional treatments before the drug was given and in general the efficacy of down-sizing procedures in this group of patients. An interesting matter of debate is the time to stop the administration of sorafenib. Infact the authors assert that the drug was stopped on the day of LT. In our experience [2], it seems not to be safe to continue with the administration of the drug until the day of LT: although there is no international agreement about this point [2–5], we usually interrupt the drug at least 3 weeks before a surgical procedure such as LT, because of the increased risk of bleeding of impaired wound healing and of liver dysfunction in the perioperative period in this setting of patients. Another intriguing issue is that doubtlessly sorafenib cannot still be considered nowadays in the group of the standard down-staging procedures of HCC in terms of safety and cost–effectiveness, but it should be reserved to the patients with advanced HCC traditionally treated with locoregional therapies/hepatic resection in whom sorafenib plays as important role in bringing them within the accepted criteria for LT with HCC. So as to exploit as much as possible the potential of the drug, we believe that sorafenib should not be reserved to patients with advanced HCC to whom any other curative treatment is not possible, but it should be offered also to a different setting of patients such as young patients outside standard criteria to LT. In the future, the challenge will be to break the Damocles sword of medical therapies for HCC, until now no effective therapy exists. The integration of sorafenib in the medical practice and its fully comprehension may permit the best management of these patients as possible.

High incidence of biliary complications in rat liver transplantation: can we avoid it?

To investigate how to reduce the incidence of biliary complications in rat orthotopic liver transplantation. A total of 165 male Wistar rats were randomly divided into three groups: Group A, orthotropic liver transplantation with modified "two-cuff" technique; Group B, bile duct was cut and reconstructed without transplantation; and Group C, only laparotomy was performed. Based on the approaches used for biliary reconstruction, Group A was divided into two sub-groups:A1 (n = 30), duct-duct reconstruction, and A2 (n = 30), duct-duodenum reconstruction. To study the influence of artery reconstruction on bile duct complication, Group B was divided into four sub-groups: B1 (n = 10), duct-duct reconstruction with hepatic artery ligation, B2 (n = 10), duct-duct reconstruction without hepatic artery ligation, B3 (n = 10), duct-duodenum reconstruction with hepatic artery ligation, and B4 (n = 10), duct-duodenum reconstruction without hepatic artery ligation. The samples were harvested 14 d after operation or at the time when significant biliary complication was found. In Group A, the anhepatic phase was 13.7 ± 1.06 min, and cold ischemia time was 50.5 ± 8.6 min. There was no significant difference between A1 and A2 in the operation duration. The time for biliary reconstruction was almost the same among all groups. The success rate for transplantation was 98.3% (59/60). Significant differences were found in the incidence of biliary complications in Groups A (41.7%), B (27.5%) and C (0%). A2 was more likely to have biliary complications than A1 (50% vs 33.3%). B3 had the highest incidence of biliary complications in Group B. Biliary complications are almost inevitable using the classical "two cuff" techniques, and duct-duodenum reconstruction is not an ideal option in rat orthotopic liver transplantation.