Type Of Biliary Anastomosis Research Articles

Endovascular management of a ruptured hepatic artery pseudoaneurysm after liver transplantation presenting as hemobilia

Vascular and biliary complications can still occur among liver transplants despite advances in surgical technique and immunosuppression. Rupture of a hepatic artery pseudoaneurysm is a rare but lethal complication after liver transplantation and often manifests as acute gastrointestinal bleeding. It occurs in < 3% of cases with an associated mortality as high as 50% especially if diagnosed late. A high index of suspicion may decrease consequent morbidities and potential graft loss. Infection and type of biliary anastomosis are commonly identified risk factors in the development of a pseudoaneurysm. Angiography usually identifies the location which is commonly at the site of anastomosis. Frequent management options include surgical revascularization requiring re-operation or endovascular intervention with the use of coils and stents. No consensus yet as to the standard treatment has been established. We present a case of a 40-year-old male having a ruptured hepatic artery pseudoaneurysm with an arteriobiliary fistula after performing a deceased donor liver transplant managed with endovascular placement of a stent. Patient remains asymptomatic with patent hepatic artery after 6 months of follow-up.

Nonanastomotic Biliary Strictures After Liver Transplantation.

Biliary strictures constitute a major source of morbidity and mortality following liver transplantation (LT). However, studies on the impact of nonanastomotic biliary strictures (NABS) on grafts after LT are limited. 649 patients who underwent LT between January 2013 and June 2017 at our center were retrospectively analyzed and 2.6% (n = 17) of the recipients developed NABS following LT. There were no differences between recipients with and without NABS in indication of LT, graft ischemia time, and type of biliary anastomosis. The incidence of post-LT hepatic artery thrombosis (HAT) (odds ratio [OR]: 15.75, P < .001) and the use of livers from donation after cardiac death (DCD) donors (OR: 8.292, P = .004) were identified as independent significant predictors of NABS by multivariate analysis. Graft survival in those with NABS was significantly worse than in patients without NABS (1-, 3-, and 5-years survival: 64.7%, 57.5%, 0%, vs. 89.8%, 84.0%, 76.4%, P < .001). In conclusion, while the incidence of NABS in our study was relatively low compared to previous reports, NABS was still found to be associated with poor graft survival. Special attention should be paid to NABS occurrence in grafts that develop HAT as well as those from DCD donors.

Laparoscopic management of choledochal cyst in children: Lessons learnt from low-middle income countries.

Choledochal cyst (CC) is a disease with a strong Asian preponderance. As laparoscopic surgery has become mainstay in its treatment, the experience in these countries has been phenomenal. However, there are many contentious issues related with the laparoscopic management of CC. In this review article, we will try to answer the contentious questions related to the laparoscopic management of CC. The issues related to aetiology, classification, surgical technique, type of biliary anastomosis, intrahepatic stones and malignancy are discussed. We also discuss the current and future considerations of laparoscopic management with reference to it becoming a gold standard. This article describes the standard surgical approach and will discuss its technical nuances. This article will also discuss the outcome of treatment in different settings of low- and middle-income countries based on lessons learnt by the authors from their experience and research.

Analysis of Risk Factors Affecting the Development of Infection in Artificial Vascular Grafts Used for Reconstruction of Middle Hepatic Vein Tributaries in Living Donor Liver Transplantation.

To analyze the risk factors affecting the development of infection in artificial vascular grafts (AVGs) used for reconstruction of middle hepatic vein (MHV) tributaries in living donor liver transplantation (LDLT). Between January 2009 and January 2018, 1253 right lobe LDLTs were performed at our Transplant Institute, and MHV tributaries of the 640 right lobe liver grafts were reconstructed with AVG. Reconstructed MHV tributaries were removed due to AVG infection in 25 of these patients (case group; n = 25). To determine risk factors for AVG infection, right lobe LDLT patients without AVG infections were selected as control group (n = 615). Both groups were compared about demographic parameter, transcystic catheter usage, bile leakage, type of biliary anastomosis (duct-to-duct, telescopic duct-to-duct), number of graft biliary duct (=1 versus >1), number of biliary anastomosis (=1 versus >1), AVG thrombosis, AVG types (Dacron versus polytetrafluoroethylene). Univariate analyses were used for comparison of different variables, and variables with P ≤ 0.20 were taken into logistic regression model. Univariate analysis shows that statistically significant differences were found between groups regarding bile leakage (P < 0.001), graft thrombosis (P = 0.002), transcystic catheter (P = 0.049), and AVG types (P = 0.013). Variables with P ≤ 0.20 were taken into logistic regression model. Multivariate analysis shows that bile leakage (odds ratio, 13.3) and AVG thrombosis (odds ratio, 9.8) were determined as independent and strong risk factors for development of AVG infection. This study revealed that bile leakage and graft thrombosis are independent and strong risk factors for infections of AVGs used for anterior sector drainage reconstruction.

Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice.

This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.

Epidemiology and risk factors for infection after living donor liver transplantation.

The epidemiology of infections after living donor liver transplantation (LDLT) is limited. We aimed to study the epidemiology and risk factors of infections after LDLT. The medical records of 223 adult patients who underwent LDLT from January 1, 2000 to August 31, 2015 were reviewed for all infections occurring up to 1 year. We estimated the cumulative incidence of infection using the Kaplan-Meier product limit method. Risk factors were analyzed with time-dependent Cox regression modeling. The majority of patients were Caucasian (94.6%) and male (64.6%), and the median age at transplantation was 55 years. The most common indication for transplantation was primary sclerosing cholangitis (37.7%). A total of 122 patients developed an infection during the follow-up period (1-year cumulative event rate of 56%), with the majority (66%) of these occurring within 30 days after transplantation. Enterococcus sp. was the most frequent pathogen identified. Multivariate analysis showed that increased Model for End-Stage Liver Disease (MELD) score (per 10-point change: hazard ratio [HR], 1.59), history of recurrent infections prior to transplant (HR, 2.01), Roux-en-Y anastomosis (HR, 2.37), increased log-number of packed red blood cell transfusions (HR, 1.39), and biliary complications (HR, 4.26) were independently associated with a higher risk of infection. Infections occur commonly after LDLT, with most infections occurring early and being related to the hepatobiliary system. Higher MELD scores, the type of biliary anastomosis, presence of biliary complications, and prior pretransplant infections are independently associated with a higher risk for infections. Liver Transplantation 23 465-477 2017 AASLD.

Invasive fungal infections following liver transplantation – risk factors, incidence and outcome

The incidence of invasive fungal infections (IFIs), particularly candidiasis and aspergillosis, following solid organ transplantation vary from 1.4% to 42%. IFIs most commonly occur after orthotropic liver transplantation (OLT), lung/heart and pancreas transplantation. Mortality related to IFIs depends on the type of transplant and vary from 3% to 100% of cases. The results largely depend on early initiation of specific treatment for IFIs. Therefore, the diagnosis has to be prompt and based on known risk factors - time of surgical procedure, type of biliary anastomosis, blood loss, rate of rejection and re-transplantation. We evaluated the incidence of fungal infections in patients after liver transplantation in our center. The retrospective analysis of 175 consecutive OLT patients was undertaken to estimate incidence, risk factors and clinical courses of IFIs in the last 6 years at our center. Infections involving Aspergillus (6 cases), Candida (24 cases) and Cryptococcus (1 case) were observed in 17.7% of our recipients. Except for 1 case (Cryptococcus encephalitis), all of the episodes developed during the first month post-transplantation. All cases of lung aspergillosis developed in patients with autoimmune cholestasis prior to transplantation. In 1 case after transplantation, in a patient with bile duct necrosis requiring reoperation, pneumonia developed. In 3 cases, pulses of steroids were used to treat acute rejection. Apart from that, none of the potential risk factors of IFIs described by other authors were noted. Five out of 6 cases of aspergillosis survived on combined antifungal therapy. The recipient diagnosed with cryptococcal encephalitis died. All cases with urinary tract (n=18; 8.6%) or respiratory (n=6; 3.4%) candidiasis survived. Early diagnosis and prompt treatment is fundamental for patient survival.

Detection of biliary stenoses in patients after liver transplantation: Is there a different diagnostic accuracy of MRCP depending on the type of biliary anastomosis?

Purpose Two different forms of biliary anastomosis can be created in patients undergoing liver transplantation: (a) bilio-digestive anastomoses or (b) choledocho-choledochostomy. Aim of this study was to assess the accuracy of MR cholangiopancreatography (MRCP) for the depiction of biliary stenoses in liver transplant patients depending on the type of biliary anastomosis. Method and materials 24 liver transplant patients with clinical suspicion of biliary stenosis were studied (each 12 with bilio-digestive anastomosis/choledocho-choledochostomy). MRCP was performed on a 1.5T scanner (Magnetom Avanto, Siemens) including 2D single shot RARE, 2D T2w HASTE, TrueFISP and 3D high-resolution navigator corrected sequences. Presence of (a) anastomotic stenoses (AST) and (b) NAS (non-anastomotic strictures) were assessed. Percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP) were performed within 48 h after MRCP and served as the standard of reference. Results In patients with bilio-digestive anastomoses sensitivities of MRCP for the detection of AST and NAS amounted to 50% and 67%, respectively with specificity values of 83% and 50%. In patients with choledocho-chledochostomy sensitivities (AST: 100%, NAS: 100%) and specificities (AST: 100%, NAS: 88%) were significantly higher. Conclusion Biliary strictures after liver transplantation can be accurately detected by MRCP in patients after choledocho-chledochostomy. However, the diagnostic value of MRCP is lower if liver transplantation was performed in combination with a bilio-digestive anastomosis. This may be due to the less exact depiction of the anastomosis in the bowel wall. Thus, it is crucial to know the type of biliary anastomosis before choosing a diagnostic procedure.

Patient Characteristics or Type of Biliary Anastomosis with or without T-Tube Placement Does Not Influence Biliary Complication Rate after Liver Transplantation

Purpose: Biliary complications remain a substantial cause of morbidity following liver transplantation and can lead to reduced patient and graft survival. There are conflicting data on whether different patient characteristics or differences in surgical techniques would affect biliary complication rates after liver transplantation. Our purpose was to evaluate the effect of patient characteristics and surgical technique on development of biliary complications after liver transplantation. Methods: Patients that underwent liver transplantation at our institution during a two year period (2004–2005) were identified. Information collected included age, gender, indication for transplantation, type of biliary anastomosis, and whether a T-tube was placed during the surgery. Immediate and late post operative biliary complications were recorded. Univariable Cox proportional hazards models were used to estimate the hazard rates for factors of interest. Results: Two hundred and thirteen liver transplantations were performed in 202 patients. Eleven patients (5.4%) had two liver transplantations. Seventy seven patients (38.1%) underwent duct-to-duct anastomosis without T-tube placement, 97 patients (48.0%) underwent duct-to-duct anastomosis with T-tube placement, 21 patients (10.4%) underwent Roux-en-Y choledochojejunostomy, and 7 patients (3.5%) underwent choledochoduodenostomy. Median follow-up period was 12 months (Q25, Q75: 2, 21). A total of 76 biliary complications occurred in 55 patients (27.2%). The biliary complications were as follows: 36 (47.4%) duct-to-duct anastomotic strictures, 25 (32.9%) duct-to-duct anastomotic leaks, 6 (7.9%) non-anastomotic ischemic strictures, 4 (5.3%) biliary enteric anastomotic strictures, 3 (3.9%) biliary enteric anastomotic leaks, 1 (1.3%) cystic duct leak, and 1 (1.3%) gallbladder fossa leak. Age, gender, indication for transplantation or type of biliary anastomosis with or without T-tube placement did not influence the complication rate. Conclusion: Patient characteristics or type of anastomosis with or without T-tube placement does not influence biliary complication rate after liver transplantation.

Pharmacokinetics of enteric‐coated mycophenolate sodium in stable liver transplant recipients

Mycophenolate mofetil (MMF) is one of the major immunosuppressive agents used in liver transplantation recipients. In an attempt to mitigate one of the most common side effects of MMF (gastrointestinal symptoms), enteric-coated mycophenolate sodium (EC-MPS) was developed. In this study, we report the pharmacokinetic profile of EC-MPS in stable liver transplantation recipients administered a single 720 mg dose. Liver transplantation recipients more than one yr after transplantation were administered a single dose of 720 mg EC-MPS after which blood levels of MPA were measured at frequent intervals using a specific and validated LC-MS/MS assay. The characteristics of the 21 patients studied were: mean age was 55.9 yr, 13 were female, eight had hepatitis C, and 14 were on tacrolimus. The mean apparent half-life of MPA was 5.3 +/- 4.3 h, (1.0-15.7). Mean t(max) was 2.4 +/- 1.1 h (1.0-5.0). The mean area-under-curve was 45.3 +/- 23.1 microg-h/mL (17.3-90.0). Trough level concentrations (C(12 h)) showed large inter-individual variability (0-9.2 microg/mL). There was no difference in any of the pharmacokinetic parameters relative to: gender, HCV, administration of tacrolimus vs. cyclosporine or type of biliary anastomosis. There is a wide variation in pharmacokinetic parameters in stable, long-term liver transplantation recipients receiving a single dose of EC-MPS. These data suggest that therapeutic drug monitoring with EC-MPS may have limited utility in liver transplantation recipients.

Biliary complications after liver transplantation

Biliary complications remain a substantial cause of morbidity following liver transplantation. They have been reported to occur in a rate of 10-15% of full-size transplantations and may be higher in living donor, split or reduced size liver transplantations. The most common biliary complications following liver transplantations are leaks and strictures. In both, the incidence varies with respect to type of graft and donor as well as the type of biliary anastomosis. The management of the biliary complications requires a multidisciplinary approach and has changed over the past decade, favoring endoscopic and radiological techniques. Surgical revision including retransplantation is reserved for patients in whom endoscopic and interventional modalities are unsuccessful.

Immunosuppression in Pediatric Liver and Intestinal Transplantation: A Closer Look at the Arsenal

Immunosuppression in Pediatric Liver and Intestinal Transplantation: A Closer Look at the Arsenal

Hepatic artery thrombosis following orthotopic liver transplantation: A 10-year experience from a single centre in the United Kingdom

Hepatic artery thrombosis (HAT) occurs in 3-9% of all liver transplants and acute graft loss is a possible sequelae. We present our experience in the management of HAT over a 10-year period. Prospectively collected data from April 1994 to April 2004 were analyzed. There were 1,257 liver transplants, 669 males, median age 51 (16-73) years. There were 61 (4.9%) cases of HAT. Early HAT occurred in 21 (1.8%). Thirty six had graft dysfunction, 11 required a regraft, and 14 died. Positive CMV serology in the donor, cold ischemia time, duration of operation, transfusions of more than 6 units of blood, and 15 units of plasma, an aortic conduit for arterial reconstruction, Roux-en-Y biliary reconstructions, regrafts and relaparotomy were associated with HAT. At multivariate analysis, type of biliary anastomosis was the only significant factor associated with HAT. Split or reduced liver graft were not risk factors for HAT. Number of hepatic arteries requiring multiple arterial anastomosis was not a risk for HAT. HAT resulted in a reduction in overall survival post liver transplantation. The incidence of HAT was 4.9%; with 1.8% early HAT and HAT impacted on survival. Surgical technique was not an aetiological factor for HAT. In conclusion, while a Roux-en-Y biliary reconstruction was an independent risk factor for HAT, cold ischemia and operative times, the use of blood and plasma and the use of aortic conduits in arterial reconstruction were associated with HAT. Regrafts and reoperation were also identified risk factors.

Biliary strictures after liver transplantation

Biliary complications are common after orthotopic liver transplantation, and biliary strictures occur in 1% to 23% of all liver transplants performed. Biliary strictures are typically divided into anastomotic or nonanastomotic strictures, with different risk factors for each type. Endoscopic retrograde cholangiography is the procedure of choice for the diagnosis and management of most biliary strictures after liver transplantation. In this article, we review the incidence, pathogenesis, and risk factors for biliary strictures occurring after liver transplantation. We discuss the relationship between the type of biliary anastomosis and the subsequent development of biliary strictures. Finally, we discuss the indications for endoscopic intervention and focus on the endoscopic management of biliary strictures after liver transplantation.

Infections in liver transplantation: risk factors and strategies for prevention

Infection affects up to 70% of liver transplant recipients and is the second most common complication after rejection and graft dysfunction. Identified risk factors for infection include: previous transplantation; type of biliary anastomosis; transfusion requirements at surgery; surgical complications; duration of operation; duration of postoperative ventilation; serological status of donor and recipient; steroid use and serotherapy for rejection; and pre-and post-transplant antibiotic usage. The majority of symptomatic infections are bacterial and relate to surgery (intra-abdominal, biliary and wound infections), ventilation and intravenous cannulae. Cytomegalovirus infections occur in 45–100% of recipients but are asymptomatic in the majority. Fungal infections are mostly due to Candida albicans but infections due to Aspergillus spp. occur in approximately 6% and carry a high mortality. There are very few prospective comparative trials of antimicrobial prophylaxis in this patient population. The management of these patients needs to be based on such studies.

Gastric ulceration complicating experimental liver transplantation in the pig

The incidence and natural history of gastric ulceration after experimental liver transplantation in the pig were analyzed in 40 experiments, consisting of 20 orthotopic allografts and 20 autograft controls. Each group of pigs was further subdivided into groups of 10 in which biliary anastomosis by joining the gallbladder to the duodenum or the bile duct directly to the bile duct, was assessed. Gastric ulceration was found in 80% of the allografts with a 60% fatality rate. This ulceration occurred exclusively at the esophagogastric junction 5–14 days after transplantation, and was frequently complicated by fatal hemorrhage or occasionally by perforation. The incidence of ulceration was similar in a group of autograft controls, where biliary drainage was achieved by anastomosing the gallbladder to the duodenum and was, therefore, not specifically related to immunological rejection. Ulceration was virtually eliminated in the autograft controls when a direct bile duct-to-bile duct anastomosis was performed. An association was noted between the incidence of gastric ulceration and the occurrence of biochemical and histological evidence of cholestasis, whether the cholestasis was produced by the type of biliary anastomosis or by rejection. The pig appears to be a new model in which peptic ulceration can be studied.