Incidence Of Biliary Stricture Research Articles

Untangling biliary reconstruction in liver transplants for primary sclerosing cholangitis.

Biliary reconstruction technique during liver transplant (LT) for primary sclerosing cholangitis (PSC) remains controversial. This study aimed to evaluate the incidence of biliary complications in patients with PSChaving a duct-to-duct (DD) anastomosis or Roux-en-Y hepaticojejunostomy (HJ). A retrospective medical record review of patients with PSC undergoing LT at a single center between June 1st, 2000 and December 31st, 2022 was performed. Primary and secondary endpoints were the incidence of biliary strictures (anastomotic [BAS] and non-anastomotic strictures [NAS]) and non-stricture complications, respectively. Univariable and multivariable regression analyses were performed to identify associations with BAS formation. Patient survival was assessed using a Kaplan-Meier curve. From 105 transplants performed for 101 patients, 54 (51.4%) and 51 (48.5%) received DD and HJ anastomoses. Mean recipient age and follow-up was 47±13years and 98±69months. BAS was more common (48.1% vs. 27.5%, OR 2.45, 95% CI 1.09-5.54, p=0.03) and occurred earlier (4.8months, IQR 2.3-13.1 vs. 41.8months, IQR 7.2-88.7, p=0.001) in the DD than the HJ group. NAS (seen in 36.2% of transplants) had a comparable incidence (p=0.53) in HJ (38.9%) and DD (33.3%) groups. No difference was seen between cohorts regarding time to NAS, requirement for extended biliary dilatation programs (clinically significant biliary stricture), bile leak, and graft failure. On multivariable analysis, only the anastomotic technique was associated with BAS (DD adjusted OR 3.00, 95% CI 1.19-7.56, p=0.02). In carefully selected patients with PSC, DD anastomosis yielded similar outcomes to HJ anastomosis after liver transplantation.

Multimodal Management for Refractory Biliary Stricture After Living Donor Liver Transplantation

Biliary stricture is a common complication of living donor liver transplantation (LDLT). Endoscopic retrograde biliary drainage (ERBD) is the primary treatment of biliary stricture, which is sometimes refractory. This study aimed to evaluate the risk factors for biliary stricture after LDLT and present successful management for refractory biliary stricture. Data from 26 patients who underwent LDLT were retrospectively analyzed. The relationship between the incidence of biliary strictures and clinical variables, including pre/intra/postoperative factors, was assessed. Univariate analysis showed that ABO incompatibility (P=.037) was a significant risk factor for biliary strictures. Case 1 was a 57-year-old woman who underwent LDLT using a left-lobe graft for primary biliary cholangitis (PBC) and developed a biliary stricture 1 month after surgery. Percutaneous transhepatic cholangiodrainage (PTCD) and embolization of the portal vein and hepatic artery were performed. Thereafter, ethanol was injected into the biliary duct, and the intervention was successfully completed. Case 2 was a 54-year-old woman who underwent LDLT using a right-lobe graft and duct-to-duct biliary reconstruction for PBC. Internal plastic stent insertion by ERBD was unsuccessful due to the significantly bending bile duct. After PTCD, the gun-site technique for the posterior branch and dual hepatic vascular embolization of the anterior branch was performed. The patient was followed up without an external fistula tube. ABO incompatibility was a risk factor for refractory biliary stricture. Appropriate procedures should be chosen based on stricture types.

Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation

/Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p=0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p=0.018). This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.

The effect of organ preservation solutions on short-term outcomes after liver transplantation: a single-center retrospective study.

The effect of preservation solutions on outcomes has been subject of many debates but the relative benefits of the various solutions remain unclear. We retrospectively compared short-term outcomes of 885 liver transplantations performed between 1/2000 and 12/2017 and preserved with either Histidine-Tryptophan-Ketoglutarate (HTK, n=190), University of Wisconsin (UW, n=557), or Institute George Lopez 1 preservation solution (IGL-1, n=139). Inverse probability of treatment weighting (IPTW) was performed to account for baseline differences between groups and analyses were adjusted for confounders. In the IPTW analyses, peak AST within 7days was 44% higher (95% CI 15-81%, P<0.001) in HTK than in UW. Mean model of early allograft function (MEAF) score was 0.61 points (95% CI 0.12-1.10, P=0.01) higher in HTK than in UW. Early allograft dysfunction (EAD) was more likely to occur with HTK compared to IGL-1 (IPTW OR=2.87, 95% CI=1.00-8.19, P=0.049) and UW (IPTW OR=1.75, 95% CI=1.06-2.88, P=0.023). The type of preservation solution had no impact on hospital stay, ICU stay, incidence of biliary strictures, or graft and recipient survival. HTK was the least effective on reducing graft injury and increased the probability of graft dysfunction after transplantation. UW and IGL-1 were equally effective in reducing graft injury and dysfunction.

Biliary Strictures Are Associated With Both Early and Late Hepatic Artery Stenosis.

Background.Hepatic artery stenosis (HAS) following liver transplantation results in hypoperfusion and ischemic damage to the biliary tree. This study aimed to investigate how vascular intervention, liver function test derangement, and time point of HAS onset influence biliary complications.Methods.A single-center retrospective study of adult patients that underwent primary liver transplantation. Patients were grouped according to the presence or absence of HAS and then into early (≤90 d) or late (>90 d) subgroups. Biliary complications comprised anastomotic (AS) or non ASs (NASs).Results.Computed tomography angiography confirmed HAS was present in 39 of 1232 patients (3.2%). This occurred at ≤90 and >90 days in 20 (1.6%) and 19 (1.5%), respectively. The incidence of biliary strictures (BSs) in the group with HAS was higher than the group without (13/39; 33% versus 85/1193; 7.1%, P = 0.01). BS occurred in 8/20 (40.0%) and 5/19 (26.3%) of the early and late groups, respectively. The need for biliary intervention increased if any liver function test result was ≥3× upper limit of normal (P = 0.019).Conclusions.BS occurs at a significantly higher rate in the presence of HAS. Onset of HAS at ≤90 or ≥90 days can both be associated with morbidity. Significant liver function test derangement at HAS diagnosis indicates a higher likelihood of biliary intervention for strictures.

Incidence of biliary strictures in Mongolian patients who have received liver transplantation abroad

Incidence of biliary strictures in Mongolian patients who have received liver transplantation abroad

Novel Method for Reconstructing Multiple Graft Bile Ducts During Right Lobe Living Donor Liver Transplant: Dunking With Mucosal Eversion Technique

BackgroundMultiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy. MethodsHere, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique. ResultsOverall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624). ConclusionsOur novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.

The Impact of Portal Vein Thrombosis on Liver Transplant Outcomes: Does Grade or Flow Rate Matter?

Portal vein thrombosis (PVT) makes the technical aspect of liver transplantation challenging and also affects outcomes. Our aim was to study impact of PVT grade and postreperfusion portal flow on posttransplant outcomes. Patients who underwent transplantation with PVT between January 2007 and May 2017 were selected (n = 126). Data on grade of PVT and portal vein flow were collected. Patients were classified into 2 groups; low grade (Yerdel Grade I, n = 73) and high grade (Yerdel Grade II or III, n = 53). Using portal flow rate, patients were divided into high flow (≥1000 mL/min, n = 95) and low flow (<1000 mL/min, n = 31). Additional analyses of flow by graft weight and complications were performed. Postoperatively, incidence of biliary strictures were significantly greater in high-grade PVT compared with low grade (P = 0.02). Incidence of postoperative portal vein thrombosis was higher in low flow after reperfusion compared with high flow (P = 0.02), as was bile leak (P = 0.02). On identifying factors associated with graft loss, moderate to severe ascites preoperatively, high PVT grade and bile leak were associated with worse graft survival. Subanalysis performed combining grade and flow showed that low grade, high flow had the highest graft survival while high grade, low flow had the lowest (P = 0.006). High-grade PVT with low flow also appeared to be an independent risk factor for biliary complications (P = 0.01). In conclusion, biliary complications, especially strictures are more common in high-grade PVT and graft survival is worse in high-grade PVT and low portal flow.

Impact of Hepatic Artery Variations and Reconstructions on the Outcome of Orthotopic Liver Transplantation

BackgroundDonor variational arteries often require complex reconstruction.MethodsWe analysed the incidence of different variations, types of arterial reconstructions and their impact on post-operative results from 409 patients undergoing liver transplantation at Karolinska Institute between 2007 and 2015.ResultsA total of 292 (71.4%) liver grafts had a standard hepatic artery (SHA), and 117 (28.6%) showed hepatic artery variants (HAV). 58% of HAV needed reconstruction. The main variations were variant left hepatic artery (45.3%) from the gastric artery; variant right hepatic artery (38.5%); and a triple combination of variant right and left hepatic artery and the proper hepatic artery from the common hepatic artery (12.8%); other 3.4%. Patients/graft survival and arterial complications were not different between SHA and HAV. Incidence of biliary stricture was numerically higher in left hepatic artery variants (p = 0.058) and in variants where no arterial reconstruction was performed (p = 0.001). Operation and arterial warm ischaemia time were longer in the HAV group. The need for intraoperative re-reconstruction was higher in the HAV group (p = 0.04). Intraoperative bleeding was larger after back-table reconstruction than with intraoperative reconstruction (p = 0.04).ConclusionNo overall differences were found between the HAV and the SHA groups. Occurrence of a variant left hepatic artery and HAV with no reconstruction seems to increase the risk of biliary strictures.

Type of Preservation Solution, UW or HTK, Has an Impact on the Incidence of Biliary Stricture following Liver Transplantation: A Retrospective Study.

Organ preservation plays a crucial role in the outcome following solid organ transplantation. The aim of this study was to perform a retrospective outcome analysis following liver transplantation using histidine tryptophan ketoglutarate (HTK) or the University of Wisconsin (UW) solutions for liver graft preservation. We retrospectively reviewed data on adult patients who were liver-transplanted at Karolinska University Hospital between 2007 and 2015. There was evaluation of donor and recipient characteristics, pre- and post-transplant blood chemistry tests, biliary and vascular complications, graft dysfunction and nonfunction, and patient and graft survivals. A total of 433 patients were included in the analyses, with 230 and 203 patients having received livers preserved with HTK and UW, respectively. Mean follow-up was 45 ± 29 months for the HTK group and 42.4 ± 26 for the UW group. There was no difference between the two groups either in terms of patient and graft survival, or of results of postoperative blood chemistry, or incidence of arterial complications, early allograft dysfunction, or primary graft nonfunction. However, the incidence of biliary stricture was higher in the UW group (22.7%) versus the HTK group (13.5%; p=0.013). Use of UW and HTK preservation solution in liver transplantation has no impact on patient and graft survival. However, use of HTK solution results in a lower incidence of posttransplant biliary stricture.

Graft Related Factors Affecting the Recipient Outcome in Living Donor Liver Transplantation

Abstract Background: Multiple risk factors have been incriminated in poor outcome and survival after Living Donor Liver Trans-plantation (LDLT). We conducted this study to identify graft-related factors that affects recipient outcome and survival after LDLT. Patients and Methods: This is a combined retrospective and prospective study that was conducted at Mansoura Uni-versity Gastrointestinal Surgical Center GISC. We included 460 transplant recipients in the period between June 2004 and July 2016. Moreover, the prospective arm included 50 patients who underwent living donor liver transplantation as a sample size from starting the study in July 2016. After careful pre-operative preparation for both donor and recipient, cases were scheduled for living donor liver transplantation. All cases were performed by the same transplant surgical team using the standard surgical procedure. After procedure, patients were transferred to the liver transplant ICU for 1 week, then to the liver high care unit. In addition to clinical evaluation, follow-up of the recipients was performed by laboratory and radiological investigations. Evaluation of the liver by abdom-inal CT was routinely performed 2 to 3 times over the first year after LT, and then once or twice per year. Results: It was evident that acute rejection was associated with shorter cold ischemia time (31.84 vs. 42.58 minutes-p=0.016). Moreover, larger biliary stoma size was also asso-ciated with acute rejection (4.24 vs. 3.73mm -p=0.045). Re-garding bile leakage, it was found to be associated with smaller hepatic venous reconstruction diameter (26.11 vs. 27.38mm-p=0.036). Additionally, it was found that incidence of biliary strictures was associated with longer warm ischemia time (51.85 vs. 45.32 minutes-p=0.019), smaller vs venous recon-struction diameter (7.41 vs. 8.52-p=0.024), and smaller biliary reconstruction diameter (3.51 vs. 3.84mm -p=0.033). Cases who developed primary graft dysfunction were having signif-icantly prolonged warm ischemia time (66.92 vs. 46.52 min-utes -p 0.011). Chronic graft rejection was associated with larger Makuuchi vein reconstruction diameter (13.40 vs. 9.62mm -p=0.020). However, other graft related factors did not seem to be different between cases who developed and who did not develop chronic rejection.Portal vein thrombosis was associated with larger Maku-uchi vein reconstruction diameter (20 vs. 9.6mm -p=0.001). Cases who developed hepatic artery thrombosis post-operatively were having larger Makuuchi vein reconstruction diameter (20 vs. 9.71mm -p=0.003), and lower numbers of single arterial reconstruction (p=0.003). In addition, cases who developed disease recurrence after transplantation were having larger arterial reconstruction diameter (2.63 vs. 2.45-p=0.020), and more ratio of multiple biliary ductal anastomoses (p=0.018). HCC recurrence after transplant was associated with larger portal vein reconstruction diameter (12.66 vs. 11.43mm -p=0.004), larger arterial recon-struction diameter (2.78 vs. 2.47mm -p=0.029), and smaller biliary reconstruction diameter (3.24 vs. 3.83-p=0.008). On assessment of graft related factors on survivals, all factors were found to be non-significant apart from number of venous anastomoses that was significantly affecting survival (p= 0.042). Conclusion: Multiple graft related factors were studied as risk factors for outcome, survival, and recurrence after LDLT. The rate of early graft failure is low. This was due to optimum donor selection as regards age, sex, Body Mass Index (BMI) and ABO-compatibility; computer-assisted plan-ning and decision making in calculating optimum GRWR; short cold ischemic time; high level of expertise in our center; and timely detection of vascular, biliary and immunological complications responsible for early graft failure together with early and efficient management. Nevertheless, most of the underlying risk factors affecting either outcome, recurrence, or survival were different from each other according to the complication type as previously shown in the results. This necessitates the need for multiple studies to be conducted at this perspective. However, these studies should be specific targeting only one or a small group of complications to get more specific results.

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial.

Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine-tryptophan-ketoglutarate solution either via both the HA and portal vein (DP group, n=62) or only through the portal vein (standard perfusion [SP] group, n=62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09-0.95; P=0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2groups. The 3-year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P=0.004 and P=0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P=0.04 and P<0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

Is Systemic Heparinization Necessary during Living Donor Hepatectomy?

Systemic heparinization has traditionally been performed during living donor hepatectomy (LDH) at most transplant centers because of the possibility of graft vascular thrombosis. However, no consensus on the use of systemic heparinization during LDH has yet emerged. The aims of the present study were to compare donor and recipient outcomes with reference to systemic heparinization and to determine whether or not systemic heparin needs to be administered to living donors. Via a retrospective review, we analyzed the outcomes of 175 LDHs performed at our institution from January 2011 to December 2014; 79 donors received systemic heparinization (group I), whereas 96 did not, but the liver graft was flushed with a heparinized perfusate (group II). The mean follow-up period was 60.6 ± 24.6 months for group I and 47.1 ± 13.5 months for group II. Patient demographics, intraoperative parameters, postoperative complications, and survival rates were compared between the two groups. The overall complication rates in donors did not differ significantly between the two groups, but postoperative bleeding requiring red blood cell transfusions in donors occurred more frequently in group I versus group II (7.6% versus 1.0%, P = 0.028). The incidences of graft vascular thrombosis were similar in the two groups, and no graft loss caused by vascular thrombosis was evident during the early postoperative period. The incidence of biliary stricture in recipients was not higher in donors who did not receive systemic heparin (5.1% versus 8.3%, P = 0.394). Moreover, the 1-,3-,and 5-year graft survival rates in the group I and group II were 87.1%, 84.5%, 81.9% and 96.9%, 94.7%, 93.6%, respectively and so overall graft survival in group II was higher than that in group I (p=0.018). In conclusion, the omission of systemic heparinization during LDH is both feasible and safe, with no adverse effects on donor or recipient outcomes.

The computed tomographic angiography finding of hepatic artery dissection after living donor liver transplantation; what is the clinical significance?

ObjectiveTo correlate computed tomography (CT) findings of hepatic artery dissection (HAD) to clinical manifestations of arterial insufficiency and biliary stricture after living donor liver transplantation (LDLT). MethodsAmong 737 consecutive patients, we retrospectively reviewed incidence, CT findings, and complications of the HAD. ResultsHADs occurred in 43 patients, exclusively in recipient arteries. Most were resolved with recovery of true lumen without specific treatment. Five patients had insignificant hepatic arterial infarctions, and incidence of biliary stricture did not significantly differ with control group. ConclusionsHADs frequently occurred shortly after LDLT. Most HADs spontaneously improved and did not affect incidence of late biliary stricture.

Su1028 Renal Impairment During the Immediate Postoperative Period Is Associated With Increased Risk of Biliary Stricture (BS)- Retrospective Study

Introduction: Biliary stricture is a common complication following orthoptic Liver transplantation. The reported incidence of biliary stricture is 5-15% following deceased donor liver transplantation (1). There is no published data to suggest renal impairment following OLT either increases or decrease the incidence of strictures. We conducted retrospective review to assess the above. Methods: A retrospective review of all adult patients who had OLT between January 2008 and February 2013 were included. Information was obtained from electronic patient record, radiology, endoscopy and pathology reports. We assessed if renal impairment both during the immediate post operative period and at 3 months and 1 year had any impact on the development of strictures. Statistical analysis was done using PRISM 6. Fisher Exact test and chi-squared test were used as appropriate. Results: 812 patient episodes were reviewed of which 304 patients were repatriated to other centers so, they were excluded.508 patients were included in the analysis. The mean age at which they had OLT was 49.71± 12.56 (Male: female-328: 180). The mean blood loss during surgery was 7.5± 6.5 l. 14.2% (71) had biopsy proven rejection. 39(7.6%) patients developed biliary strictures. The odds ratio for developing BS in DCD is 9.02 (95% CI 4.4-18.4, P <0.0001). Patients who had haemofiltration were at increased risk of developing BS (RR 2.33,95% CI 1.28-4.5). Patients whose glomerular filtration rate (GFR) decreased below 60 in the first 14 days were at increased risk of developing biliary stricture (P=0.01). The above trend was not maintained at 3 months and 1 year. The rest of the comparators are shown in the table. Conclusion: Our study shows that there was a modest but significant increase in risk of developing biliary strictures if they had haemofiltration or if their GFR decreased below 60 in the first 14 days following liver transplant. The risk of developing BS is increased by 9 fold if the graft is DCD.

Su1031 High Liver Stiffness Measurement by Transient Elastography Predicts High Grade Post-Hepatectomy Liver Failure in Patients With Hepatocellular Carcinoma: A Prospective Cohort Study

Introduction: Biliary stricture is a common complication following orthoptic Liver transplantation. The reported incidence of biliary stricture is 5-15% following deceased donor liver transplantation (1). There is no published data to suggest renal impairment following OLT either increases or decrease the incidence of strictures. We conducted retrospective review to assess the above. Methods: A retrospective review of all adult patients who had OLT between January 2008 and February 2013 were included. Information was obtained from electronic patient record, radiology, endoscopy and pathology reports. We assessed if renal impairment both during the immediate post operative period and at 3 months and 1 year had any impact on the development of strictures. Statistical analysis was done using PRISM 6. Fisher Exact test and chi-squared test were used as appropriate. Results: 812 patient episodes were reviewed of which 304 patients were repatriated to other centers so, they were excluded.508 patients were included in the analysis. The mean age at which they had OLT was 49.71± 12.56 (Male: female-328: 180). The mean blood loss during surgery was 7.5± 6.5 l. 14.2% (71) had biopsy proven rejection. 39(7.6%) patients developed biliary strictures. The odds ratio for developing BS in DCD is 9.02 (95% CI 4.4-18.4, P <0.0001). Patients who had haemofiltration were at increased risk of developing BS (RR 2.33,95% CI 1.28-4.5). Patients whose glomerular filtration rate (GFR) decreased below 60 in the first 14 days were at increased risk of developing biliary stricture (P=0.01). The above trend was not maintained at 3 months and 1 year. The rest of the comparators are shown in the table. Conclusion: Our study shows that there was a modest but significant increase in risk of developing biliary strictures if they had haemofiltration or if their GFR decreased below 60 in the first 14 days following liver transplant. The risk of developing BS is increased by 9 fold if the graft is DCD.

USE OF COVERED SELF-EXPANDABLE NITINOL STENT FOR ANASTOMOTIC BILIARY STRUCTURE MANAGEMENT AFTER LIVER TRANSPLANTATION: THE FIRST EXPERIENCE

Aim. The aim of this study focuses on the fi rst experience with self-expandable stents, analysis of its ef fi cacy and safety in the treatment of anastomotic strictures after liver transplantation. Materials and methods. There’re 136 liver transplantations performed from 2004 till 2012. To correct anastomotic strictures we’ve used only the self-expandable coated nitinol stent. We performed stenting in 7 recipient. Result. In 131 liver transplant recipi ents incidence of biliary strictures has been 5.3%. All of 5 patients have been managed by retrograde or antegrade way. Conclusion. Our first experience demonstrate efficacy and safety of the used tecniques up to 24 months. The analysis of more long-term results is required.

Biliary stricture is the only concern in ABO-incompatible adult living donor liver transplantation in the rituximab era

With the introduction of rituximab prophylaxis, the survival of ABO-incompatible (ABOi) adult living donor liver transplant (ALDLT) has been strikingly improved due to the decreased incidence of antibody-mediated rejection. However, biliary stricture (BS) related to ABO incompatibility remains an unresolved concern. Excluding 105 dual graft ALDLTs, 1102 ALDLT cases including 142 ABOi recipients were included in this study. The desensitization protocol for overcoming the ABO blood group barrier comprised pretransplant plasma exchange, and rituximab (300-375 mg/m(2) BSA). The mean follow-up period was 34.2 ± 15.4 months. The cumulative graft and patient survival rates were comparable in the two groups. The 1- and 3-year BS-free survival rates of ABOi ALDLT were 81.5 and 79.0%, respectively, lower than those of ABOc ALDLT (87.6 and 85.7%, respectively, p=0.022). In the risk factor analysis, diameter of graft bile duct opening <5mm, antecedent acute cellular rejection, and ABO incompatibility were independent risk factors for BS. Diffuse intrahepatic biliary stricture (DIHBS) exclusively occurred in 12 patients (8.5%) receiving ABOi ALDLT. The deaths of 3 patients and 4 cases of re-transplantation were related to DIHBS. Graft and patient survival rates were significantly reduced in ABOi ALDLT recipients with DIHBS. However, we failed to identify any significant risk factors for DIHBS. The incidence of BS in ABOi ALDLT is higher than in ABOc, mainly due to the fact of DIHBS which significantly affected survival outcomes. To predict and prevent DIHBS, we need further studies to identify significant risk factors.

Section 15. A desensitizing protocol without local graft infusion therapy and splenectomy is a safe and effective method in ABO-incompatible adult LDLT.

The use of rituximab (Rit) to prevent antibody-mediated rejection (AMR) of ABO-incompatible (ABOi) adult living donor liver transplants (ALDLTs) has raised questions about the role of local graft infusion therapy (LGIT) and splenectomy (SPN); however, they are still regarded as essential components of the desensitization (DSZ) protocol. The DSZ protocol consisted of plasma exchange and Rit. None of the patients underwent SPN. The patients were divided into two groups. The patients in Group I (n=20) received LGIT via the hepatic artery or portal vein. The patients in Group II (n=100) did not receive LGIT. One hundred twenty ABOi ALDLTs were performed from November 2008 to June 2012, and there was only one case of operative mortality (0.8%). There was no significant difference in the 3-year patient survival rates between patients receiving ABO-compatible and ABOi ALDLT (88.8% vs. 94.8%; P=0.11). LGIT catheter-related complications occurred in six patients (30.0%). There was no statistically significant difference in the 3-year patient survival rates between the groups (90.0% vs. 95.0%; P=0.26). One patient in Group 1 (0.8%) experienced AMR. Diffuse intrahepatic biliary stricture occurred in two patients (10.0%) in Group I and in five patients (5.0%) in Group II, although the difference was not statistically significant (P=0.11). The incidence of biliary stricture was similar in both groups (P=0.06), but the incidence of infection was significantly higher in Group I (P=0.03). The DSZ protocol without LGIT and splenectomy is a safe and effective method of attaining a successful outcome of ABOi ALDLT.

Duct-to-duct reconstruction in liver transplantation for primary sclerosing cholangitis is associated with fewer biliary complications in comparison with hepaticojejunostomy

There is no consensus on the preferred type of biliary reconstruction for patients undergoing orthotopic liver transplantation (OLT) for primary sclerosing cholangitis (PSC). The aim of this study was to compare long-term outcomes after OLT for PSC using either duct-to-duct anastomosis or Roux-en-Y hepaticojejunostomy for biliary reconstruction. In a consecutive series of 98 adult patients undergoing OLT for PSC, 45 underwent duct-to-duct reconstruction, and 53 underwent Roux-en-Y biliary reconstruction. The median follow-up was 8.2 years (interquartile range = 3.9-14.5 years). The outcomes of the 2 groups were compared. There were no significant differences in patient demographics or general surgical variables between the groups. The overall patient and graft survival rates were similar for the 2 groups. The incidence of biliary strictures and biliary leakage within the first year after transplantation did not differ between the 2 groups. However, significantly more patients in the Roux-en-Y group suffered at least 1 episode of cholangitis within the first year (9% in the duct-to-duct group versus 25% in the Roux-en-Y group, P = 0.04). In addition, Roux-en-Y reconstruction was associated with a significantly higher rate of late-onset (>1 year after transplantation) nonanastomotic biliary strictures (NAS) in comparison with duct-to-duct reconstruction (24% versus 7% at 5 years and 30% versus 7% at 10 years, P = 0.01). In conclusion, duct-to-duct biliary reconstruction in patients with PSC is associated with lower rates of posttransplant cholangitis and late-onset NAS in comparison with Roux-en-Y hepaticojejunostomy. If technically and anatomically feasible, duct-to-duct anastomosis can be performed safely in patients undergoing OLT for PSC.