Higher Rate Of Biliary Complications Research Articles

Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift.

To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD). In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada. All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups. Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37). With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.

Thrombolytic Therapy During ex-vivo Normothermic Machine Perfusion of Human Livers Reduces Peribiliary Vascular Plexus Injury.

Background: A major limitation in expanding the use of donation after circulatory death (DCD) livers in transplantation is the increased risk of graft failure secondary to ischemic cholangiopathy. Warm ischemia causes thrombosis and injury to the peribiliary vascular plexus (PVP), which is supplied by branches of the hepatic artery, causing higher rates of biliary complications in DCD allografts.Aims/Objectives: We aimed to recondition discarded DCD livers with tissue plasminogen activator (tPA) while on normothermic machine perfusion (NMP) to improve PVP blood flow and reduce biliary injury.Methods: Five discarded DCD human livers underwent 12 h of NMP. Plasminogen was circulated in the base perfusate prior to initiation of perfusion and 1 mg/kg of tPA was administered through the hepatic artery at T = 0.5 h. Two livers were split prior to perfusion (S1, S2), with tPA administered in one lobe, while the other served as a control. The remaining three whole livers (W1-W3) were compared to seven DCD control liver perfusions (C1-C7) with similar hepatocellular and biliary viability criteria. D-dimer levels were measured at T = 1 h to verify efficacy of tPA. Lactate, total bile production, bile pH, and difference in biliary injury scores before and after perfusion were compared between tPA and non-tPA groups using unpaired, Mann-Whitney tests.Results: Average weight-adjusted D-dimer levels were higher in tPA livers in the split and whole-liver model, verifying drug function. There were no differences in perfusion hepatic artery resistance, portal vein resistance, and arterial lactate between tPA livers and non-tPA livers in both the split and whole-liver model. However, when comparing biliary injury between hepatocellular and biliary non-viable whole livers, tPA livers had significantly lower PVP injury scores (0.67 vs. 2.0) and mural stroma (MS) injury scores (1.3 vs. 2.7).Conclusion: This study demonstrates that administration of tPA into DCD livers during NMP can reduce PVP and MS injury. Further studies are necessary to assess the effect of tPA administration on long term biliary complications.

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study

Backgroundliver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage. Material and methodsA retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection. ResultsIn 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months. ConclusionsAnatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.

T-tube or no T-tube for biliary tract reconstruction in orthotopic liver transplantation: an updated systematic review and meta-analysis

ABSTRACT Objectives: Biliary tract reconstruction with or without T-tube is commonly used in orthotopic liver transplantation (OLT). However, the efficacy and safety of T-tube usage remain controversial. This meta-analysis was conducted to assess the latest evidence of clinical outcomes. Methods: Embase, Cochrane Library, PubMed, and Web of Science were systematically searched from inception to 20 January 2021 for eligible studies. The analyses were performed using Review Manager and Stata. Results: A total of 24 trials involving 3320 participants were included in the meta-analysis. Compared with the no T-tube group, there was a higher incidence of overall biliary complications (OR:1.54; 95%CI, 1.06–2.24; P = 0.02), bile leaks (OR:2.34; 95%CI,1.57–3.48; P < 0.0001), cholangitis (OR:2.78; 95%CI,1.19–6.51; P = 0.002), and longer cold ischemia time (MD:22.27; 95%CI,0.80–43.74; P = 0.04) in the T-tube group. Furthermore, the no T-tube group had significantly higher odds of biliary strictures than the T-tube group (OR:0.60; 95%CI, 0.47–0.78; P = 0.0001). Conclusion: T-tube is still not routinely recommended, but is a good choice for OLT patients at high risk of biliary strictures. Notably, the higher rate of biliary complications in the T-tube group did not translate into an increase in endoscopic or re-operative interventions.

Management of biliary complications after adult-to-adult living donor liver transplantation. Initial experience in a latin american center

Presenter: Sergio Riveros MD | Pontificia Universidad Católica de Chile Background: Living donor liver transplantation (LDLT) is a complex therapeutic alternative that requires a specialized multidisciplinary team with the capacity to resolve complications. The number of anastomosed ducts has an impact on the rate of postoperative biliary complications, but the literature is still scarce. The objective of this study was to describe early and late postoperative biliary complications with a focus on therapeutic management in the initial experience of a LDLT program. Methods: Non-concurrent cohort study at a Pontificia Universidad Católica de Chile. All patients who underwent adult-to-adult LDLT were included from 2016 to 2020. Patients were divided into two groups according to the number of bile duct anastomoses (single duct, group A; and two or three ducts, group B). Demographic, perioperative, postoperative outcomes regarding early and late biliary complications (>2 months), treatment, major complications (Clavien-Dindo III-IV), mortality, and survival were evaluated and compared between groups. Results: single bile duct was anastomosed in 63.3% (n = 19), two bile ducts in 33.3% (n = 10) and three bile ducts in 3.3% (n = 1). Duct-to-duct (DD) anastomosis was performed in 56.7% (n = 17), hepaticojejunostomy (HJ) in 33.3% (n = 10) and combined in 10% (n = 3). Major complications were reported in 46.7% (n = 14), median length of postoperative stay was 15.5 days (7-46) and median follow-up 17 months (0.4-53.5). Overall graft and patient survival was 87% at 24 months. Group A (n = 19) had major complications in 21% (n = 4), early biliary complications in 15.8% (n = 3) and late biliary strictures in 26.7% (n = 4). None required percutaneous drainage, 5.3% surgical drainage (n = 1) and 10.5% re-anastomosis to a Roux-en-Y HJ (n = 2). They underwent ERCP in 26.7% (n = 4) and percutaneous transhepatic internal-external drainage in 6.7% (n = 1). Four patients (21.1%) had early mortality and one patient (6.7%) late mortality, all unrelated to biliary complications. Group B (n = 11) had major complications in 90.9% (n = 10), early biliary complications in 81.8% (n = 9) and late biliary strictures in 54.5% (n = 6). They required percutaneous drainage in 27.3% (n = 3), surgical drainage in 9.1% (n = 1), endoscopic transgastric drainage in 9.1% (n = 1), duct-to-duct reinforcement (n = 1) and re-anastomosis to Roux-en-Y HJ (n = 4). They underwent ERCP in 27.3% (n = 3) and percutaneous transhepatic internal-external drainage in 18.2% (n = 2). All patients are alive with 100% graft and patient survival. Conclusion: Living donor liver transplantation is a challenging treatment that requires a specialized high-volume center with the ability to rescue postoperative complications. The number of reconstructed ducts affects the rate of early biliary complications, without an impact on graft and patient survival. In our experience, patients with 2-3 graft bile ducts had a high rate of biliary complications, but with adequate management, all patients are alive with functioning grafts. Expertise in advanced endoscopy, interventional radiology, and complex reoperations are crucial to achieve excellent outcomes.

OCTOGENARIAN LIVER DONORS ARE ASSOCIATED WITH HIGH RISK FOR BILIARY COMPLICATIONS

Introduction: Limited donor availability has required the transplant community to push the age limit for donors used for liver transplantation (LT). Some reports have shown that older donors increase the risk for biliary complications (BC). Materials and Methods: From 2006 to 2018, 40 recipients received a graft from donors above 80 years of age. There were 26 males and 14 females with a median age of 60,5 y (range 43-74) and median BMI of 25,5 (range 17-45). All were 1st transplants with whole liver grafts. In 19 out of 40 (47,5%) patients, cancer was the cause for LT, with HCC in 15 of these 19 cases. Median MELD score was 14 (range 6-39) and median waiting time was 27 days (range 0-144). Median donor age was 83 years (range 80-89) with median BMI of 24,6 (range 14-40). Twenty-nine (72,5%) of the donors were female. Standard immunosuppression consisted of steroids, Mycophenolate and Tacrolimus, the latter was switched to Sirolimus after 6 weeks in most patients transplanted due to cancer. Twenty-four patients (60%) received induction with 40 mg Basiliximab. Results: End of study was defined as Oct 10th, 2019. Median follow-up time was 48 months (range 2-97). Median CIT was 398 min (range 257-841) and median units of SAG given peroperatively were 2 (range 0-13). Median ICU stay was 1 day (range 1-30). Eight patients (20%) were diagnosed with biopsy proven acute rejection and treated with steroids. One-, 3- and 5-y patient (PS) and graft survival (GS) (Kaplan Meier) were 95/93%, 86/77% and 76/67%, respectively. At the end of the study, 11 patients were dead. Six patients died with a functioning graft, while two of the remaining 5 patients had undergone a re-LT for graft failure. In total, 4 out of 40 patients (10%) were retransplanted. Seven patients (17,5%) experienced vascular complications, 5 of these were either hepatic artery stenosis or thrombosis and 4 of 7 occurred within 90 days of LT. Nineteen patients (47,5%) were diagnosed with BC, in 13 (68%) these BC occurred within 90 d after LT. All patients with BC required either endoscopic intervention (12 patients) or re-operation (7 patients). Eleven of these patients were diagnosed with biliary anastomosis strictures, 7 with leakages and one patient had both. Neither CIT, donor BMI, recipient BMI, recipient age or MELD score were associated with increased risk for BC (univariate logistic regression). GS did not differ between the group diagnosed with BC compared to group with no BC, and only 2 of the 19 patients with BC were retransplanted as a direct cause of BC. Discussion: Short and mid-term PS and GS using octogenarian donors in LT were good. There was a high rate of BC, but almost all these were manageable through either endoscopic intervention or early reoperation. Conclusion: Octogenarian liver donors offer good outcomes and should be utilized in a setting of organ scarcity. However, active surveillance and awareness of biliary complications is warranted.

PROPENSITY SCORE MATCHED RISK OF BILIARY COMPLICATIONS AFTER LIVER TRANSPLANT AND OUTCOME BY DONOR TYPE

Background: Donation after circulatory death (DCD), donation after brain death (DBD), and living donor (LD) liver transplantation (LT) are three types of donors used in patients with end-stage liver diseases. Each type has unique benefits, risks, and potential complications. In this study, we assess the risk of biliary complications, and their effect on long-term outcome. Methods: We collected data on all consecutive DCD, DBD and LD-LT recipients between 1989 and 2019 from a single center, and used propensity score matching to identify three groups. Patient survival, graft survival, and biliary complications (bile leak, anastomotic (AS) and non-anastomotic strictures (NAS)) were analyzed and compared between groups. Adjusted p-values were calculated using multivariate Cox regression models. Results: We identified 141 DCDs, 3,226 DBD, and 386 LD-LT in our cohort, with significantly different recipient age, gender, etiology of liver disease, Na-Model for End-Stage Liver Disease (MELD), incidence of hepatocellular carcinoma (HCC), and donor age, gender, and cold ischemic time. Propensity score matching allowed correction for all differences except MELD, presence of HCC, and etiology of liver disease. This produced three groups of 138 recipients each. Adjustment for MELD, HCC, and etiology of liver disease was then performed using Cox models. Eighteen LT recipients (4.3%) had arterial complications (thrombosis and stenosis; no difference between groups). Bile leak was identified in 10.1% of DCD-LTs, versus 7.2% of DBD-LTs, and 36.2% of LD-LTs (p-values=0.240 and <0.001, respectively). Anastomotic biliary stricture developed in 28.3% DCD-LTs, versus 18.1% of DBD-LTs, and 43.5% of LD-LTs (p-values=0.038 and 0.006, respectively). Non-anastomotic biliary stricture was present in 15.2% of DCD-LT s, versus 1.4% of DBDs-LT, and 4.3% of LD-LTs (p-values=0.004 and 0.005, respectively). Eighteen patients (4.3%) were retransplanted and there was no significant difference in retransplant rate between groups. LD-LTs free of any biliary complications had the best patient survival whereas DCD-LTs with ≥1 biliary complication (presence of a bile leak and/or AS and/or NAS) had the worst survival (Figure). Among the 21 DCD-LT patients with non-anastomotic strictures, six died, two were retransplanted, three remain stent dependent, and ten were ultimately stent-free. Conclusion: DCD and LD-LT recipients had significantly higher rates of biliary complications. Biliary complications in DCD-LTs had the most significant impact on survival, although two thirds of the recipients with ischemic cholangiopathy could ultimately achieve a favorable outcome.

Living vs deceased donor liver transplantation in cholestatic liver disease: An analysis of the OPTN database

Living donor liver transplantation (LDLT) and donation after circulatory death (DCD) can expand the donor pool for cholestatic liver disease (CLD) patients. We sought to compare the outcomes of deceased donor liver transplant (DDLT) vs LDLT in CLD patients. Retrospective cohort analysis of adult CLD recipients registered in the OPTN database who received primary LT between 2002 and 2018. Cox proportional hazards regression models with mixed effects were used to determine the impact of graft type on patient and graft survival. Five thousand, nine hundred ninety-nine DDLT (5730 donation after brain death [DBD], 269 DCD) and 912 LDLT recipients were identified. Ten-year patient/graft survival rates were DBD: 73.8%/67.9%, DCD: 74.7%/60.7%, and LDLT: 82.5%/73.9%. Higher rates of biliary complications as a cause of graft failure were seen in DCD (56.8%) than LDLT (30.5%) or DBD (18.7%) recipients. On multivariable analysis, graft type was not associated with patient mortality, while DCD was independently associated with graft failure (P=.046). DBD, DCD, and LDLT were associated with comparable overall patient survival. No difference in the risk of graft failure could be observed between LDLT and DBD. DCD can be an acceptable alternative to DBD with equivalent patient survival, but inferior graft survival likely related to the high rate of biliary complications.

Controlled donation after circulatory death up to 80years for liver transplantation: Pushing the limit again.

Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD group, the influence of age on the results obtained with DCD donors aged >70years and up to 80years. All DCD-LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD-LT immediately after each DCD-LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut-off point at 70years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.

Grafts from selected deceased donors over 80 years old can safely expand the number of liver transplants: A systematic review and meta-analysis.

The aim of this systematic review and meta-analysis was to present the outcome of deceased adult liver transplantation from octogenarian (≥80 years old) donors compared to younger grafts. A systematic search was performed on six databases to identify all available original papers that report the outcome of adult recipients who underwent liver transplantation from a deceased octogenarian donor. Overall, 39,034 liver transplantations from 12 studies were reported with 789 (2.02%) cases receiving grafts from octogenarian donors. Eight studies were included in the meta-analysis. There was no difference regarding the one, three, and five-year graft and patient survival between the recipients of livers <80 years old and octogenarian grafts. There were significantly more episodes of biliary complications in the recipients of octogenarian grafts (34/459; 7.4%) in comparison to the recipients of livers <80 years old (372/37074; 1.0%) (OR 0.53; 95% CI = 0.35-0.81; P 0.004; I2 = 0%). The incidence of primary non-function, vascular complications and re-transplantation did not differ between groups. The short- and medium-term graft and patient survival of octogenarian liver transplantation is not inferior compared to the liver transplantation with younger grafts, however with a higher rate of biliary complications.

Compared efficacy of preservation solutions on the outcome of liver transplantation: Meta-analysis.

AIMTo compare the effects of the four most commonly used preservation solutions on the outcome of liver transplantations.METHODSA systematic literature search was performed using MEDLINE, Scopus, EMBASE and the Cochrane Library databases up to January 31st, 2017. The inclusion criteria were comparative, randomized controlled trials (RCTs) for deceased donor liver (DDL) allografts with adult and pediatric donors using the gold standard University of Wisconsin (UW) solution or histidine-tryptophan-ketoglutarate (HTK), Celsior (CS) and Institut Georges Lopez (IGL-1) solutions. Fifteen RCTs (1830 livers) were included; the primary outcomes were primary non-function (PNF) and one-year post-transplant graft survival (OGS-1).RESULTSAll trials were homogenous with respect to donor and recipient characteristics. There was no statistical difference in the incidence of PNF with the use of UW, HTK, CS and IGL-1 (RR = 0.02, 95%CI: 0.01-0.03, P = 0.356). Comparing OGS-1 also failed to reveal any difference between UW, HTK, CS and IGL-1 (RR = 0.80, 95%CI: 0.80-0.80, P = 0.369). Two trials demonstrated higher PNF levels for UW in comparison with the HTK group, and individual studies described higher rates of biliary complications where HTK and CS were used compared to the UW and IGL-1 solutions. However, the meta-analysis of the data did not prove a statistically significant difference: the UW, CS, HTK and IGL-1 solutions were associated with nearly equivalent outcomes.CONCLUSIONAlternative solutions for UW yield the same degree of safety and effectiveness for the preservation of DDLs, but further well-designed clinical trials are warranted.

Single Center Experience of Biliary Reconstruction in Living Donor Liver Transplantation: Duct-to-Duct Anastomosis

Background: Duct-to-duct anastomosis is the most common biliary reconstruction method in living donor liver transplantation. However, biliary complications can frequently occur. The objective of this study was to examine biliary complications and related risk factors of patients with living donor liver transplantation during the last 12 years in our institution. Methods: Surgical outcomes of 252 consecutive patients with duct-to-duct anastomosis for biliary reconstruction in living donor liver transplantation between December 2000 and July 2012 were analyzed retrospectively. Results: Among the 252 patients, there were 65 cases (25.8%) of biliary complications. Before 2010, the incidence of biliary complications was 30.4% (56 of 184 cases). After 2011, the incidence was significantly (P<0.05) decreased to 13.2% (nine out of 68 cases). The complication rate of anastomosis of two separated bile ducts of graft to recipient two separated bile ducts using cystic duct and common bile duct of recipient was 50% (10 out of 20), which was relatively higher compared to that of single to single duct anastomosis (47 out of 191, 24.6%) or multiple duct to single duct anastomosis (eight out of 41, 19.5%). Conclusions: Duct to duct anastomosis between two separated bile ducts of a graft to two separated bile ducts of a recipient, the most common biliary reconstruction method, was associated with higher rate of biliary complications. Complications related to biliary reconstruction of living donor liver transplantation was gradually decreased. Standardization of bile duct anastomosis might lead to sequential reduction of biliary complications in living donor liver transplantations.

Endoscopic management of biliary complications after liver transplantation: An evidence-based review.

Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.

Ratio of hepatic arterial flow to recipient body weight predicts biliary complications after deceased donor liver transplantation

ObjectivesAdequate hepatic arterial (HA) flow to the bile duct is essential in liver transplantation. This study was conducted to determine if the ratio of directly measured HA flow to weight is related to the occurrence of biliary complications after deceased donor liver transplantation. MethodsA retrospective review of 2684 liver transplants carried out over a 25-year period was performed using data sourced from a prospectively maintained database. Rates of biliary complications (biliary leaks, anastomotic and non-anastomotic strictures) were compared between two groups of patients with HA flow by body weight of, respectively, <5 ml/min/kg (n = 884) and ≥5 ml/min/kg (n = 1800). ResultsPatients with a lower ratio of HA flow to weight had higher body weight (92 kg versus 76 kg; P < 0.001) and lower HA flow (350 ml/min versus 550 ml/min; P < 0.001). A lower ratio of HA flow to weight was associated with higher rates of biliary complications at 2 months, 6 months and 12 months (19.8%, 28.2% and 31.9% versus 14.8%, 22.4% and 25.8%, respectively; P < 0.001). ConclusionsA ratio of HA flow to weight of < 5 ml/min/kg is associated with higher rates of biliary complications. This ratio may be a useful parameter for application in the prevention and early detection of biliary complications.

Biliary Complications After Right Lobe Living Donor Liver Transplantation: Two Transplant Centers Experience.

Adult living-donor liver transplantation (ALDLT) has a high rate of biliary complications (BC). We identified risk factors that correlate with biliary complications by combining data from two European centers. 121 ALDLT right lobe recipients at two centers between March 2001 and June 2012 were reviewed. Patient and graft survival at 1, 3, and 5 years were 84.3%, 78.3%, 69.3% and 78.5%, 72.3%, 65% respectively. Biliary reconstructions were performed using either duct-to-duct (DD) or Roux-en-Y hepaticojejunostomy and were sub classified by anatomic type, number of anastomoses performed, and stent use. 65 donors presented 1 biliary duct, 49 and 7 presented 2 and 3 biliary ducts respectively. Prevalence of a biliary leak and/or stricture was 39,6% (73,4 and 26,6% respectively); 8,2% of recipients developed both. Multiple duct and anastomoses, bilioplasty and association of hepatic artery thrombosis had significantly higher incidence of BC. Mortality and graft loss due to BC were 0.03%. Although the incidence of BC is still high, mainly related to more than one biliary ducts or anastomoses in association with bilioplasty, the BC related mortality and graft loss are insignificant.

Response to endoscopic therapy for biliary anastomotic strictures in deceased versus living donor liver transplantation

Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT). LDLT is thought to be associated with higher rates of biliary complications, but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups. This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT. This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) after liver transplantation. The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT. The response of anastomotic stricture to endoscopic therapy was also analyzed. A total of 362 patients underwent liver transplantation between 2003 and 2011, with 125 requiring ERCP to manage biliary complications. Thirty-three (9.9%) cases of DDLT and 8 (27.6%) of LDLT (P=0.01) were found to have anastomotic stricture. When comparing DDLT and LDLT, there was no difference in the mean time to the development of anastomotic strictures (98+/-17 vs 172+/-65 days, P=0.11), likelihood of response to ERCP [22 (66.7%) vs 6 (75.0%), P=0.69], mean time to the resolution of anastomotic strictures (268+/-77 vs 125+/-37 days, P=0.34), and the number of ERCPs required to achieve resolution (3.9+/-0.4 vs 4.7+/-0.9, P=0.38). Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation. Anastomotic strictures occur more frequently in LDLT compared with DDLT, with equivalent endoscopic treatment response and outcomes for both groups.

Living donor versus deceased donor liver transplantation: a surgeon-matched comparison of recipient morbidity and outcomes

Informed consent for living donor liver transplantation (LDLT) requires that patients are provided with accurate information on the relative benefits and risks of this procedure compared with deceased donor liver transplantation (DDLT). There is strong evidence to suggest that LDLT facilitates timely transplantation to patients; however, information on the relative morbidity and death risks after LDLT as compared with DDLT is limited. A matched cohort comparison was performed matching recipients for age, MELD, date of transplant, gender, primary diagnosis, and recipient surgeon. A total of 145 LDLT were matched with 145 DDLT. LDLT had a higher overall rate of perioperative surgical complications (P = 0.009). Most of this difference was caused by a higher rate of biliary complications. However, the complications that occurred in the DDLT group tended to be more serious (P = 0.037), and these complications were strongly associated with graft loss in multivariate analysis. The 3- and 5-year graft and patient survivals were similar. In conclusion, DDLT and LDLT have different complication profiles, but comparable hospital stays and survival rates. In areas of deceased donor organ shortages, LDLT offers an excellent alternative to DDLT because it facilitates access to a liver transplant without compromising short- or medium-term recipient outcomes.

Complications of high grade liver injuries: management and outcomewith focus on bile leaks

BackgroundAlthough liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively.Patients and methodsThis is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed.ResultsOf 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure.ConclusionsA high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

Ischemic Cholangiopathy After Controlled Donation After Cardiac Death Liver Transplantation

To conduct a meta-analysis to enhance understanding of the risks of biliary complications, particularly ischemic cholangiopathy (IC), after donation after cardiac death (DCD) compared with donation after brain death (DBD) liver transplantation. Biliary complications after liver transplantation have profound health and economic implications which merit further investigation. The MEDLINE (1950–2009), EMBASE, and Cochrane Library databases were searched and supplemented by review of conference proceedings and publication bibliographies. All original single institution studies reporting outcomes for DCD and DBD liver transplant recipients were considered. Odds ratios (OR) and 95% confidence intervals (CI) based on random effects models were calculated. Eleven publications, all retrospective cohort studies, involving 489 DCD and 4455 DBD recipients, were included. Donation after cardiac death recipients had a 2.4 times increased odds of biliary complications (95% CI= 1.8–3.4) and a 10.8 times increased odds of IC (95% CI = 4.8–24.2).Ischemic cholangiopathy was present in 16% of DCD compared with 3% of DBD recipients. Donation after cardiac death recipients also experienced higher odds of 1-year patient mortality (OR = 1.6, 95% CI = 1.04–2.5) and graft failure (OR = 2.1, 95% CI = 1.5–2.8). Donation after cardiac death liver transplantation is marred by inferior outcomes including higher rates of biliary complications and IC as well as increased mortality and graft failure. Despite current federal mandates to increase DCD donation, these serious complications translate into poor outcomes for individuals and increased healthcare costs. These risks should be considered in decisions regarding the utilization of these grafts.

Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers

Adult living-donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow-up <180 d. Biliary reconstructions were performed using either duct-to-duct (DD) or Roux-en-Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.