Biliary complications after living donor liver transplantation


  • Shao Fa Wang,

    1. Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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  • Zhi Yong Huang,

    1. Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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  • Xiao Ping Chen

    Corresponding author
    1. Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
    • Institute of Organ Transplantation and Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Da Dao, Wuhan, China 430030
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    • Telephone: +86-27-83663400; FAX: +86-27-83663400


Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge. Liver Transpl 17:1127–1136, 2011. © 2011 AASLD.

In comparison with deceased donor liver transplantation (DDLT), living donor liver transplantation (LDLT) offers several advantages: the large number of organs available for children, lower morbidity and mortality rates and lower overall costs with elective transplantation, good graft viability due to the absence of primary nonfunction, and theoretical immunological advantages (suggested by the lower incidence of steroid-resistant rejection).1-3 Despite these logistical and immunological advantages, biliary complications occur more frequently after LDLT versus DDLT, and they remain the most common and intractable problems after LDLT.4, 5 This might reflect the physiological and technical nuances associated with partial liver grafts. Multiple tiny bile ducts, which often accompany partial liver grafts, and differential blood supplies to these ducts pose special challenges for LDLT programs.6-13 Actually, biliary complications cause significant morbidity and mortality rates in both donors and LDLT recipients.14, 15 Here we describe key points related to the prevention and management of biliary complications after LDLT.


3CA, 3 o'clock artery; 9CA, 9 o'clock artery; A2ALL, Adult-to-Adult Living Donor Liver Transplantation Cohort Study; CHA, common hepatic artery; CTC, computed tomography cholangiography; DD, duct-to-duct anastomosis; DDLT, deceased donor liver transplantation; ERC, endoscopic retrograde cholangiography; GDA, gastroduodenal artery; LDLT, living donor liver transplantation; LHA, left hepatic artery; LHD, left hepatic duct; MRC, magnetic resonance cholangiography; PTC, percutaneous transhepatic cholangiography; RAD, right anterior duct; RHA, right hepatic artery; RHD, right hepatic duct; RPD, right posterior duct; RY, Roux-en-Y hepaticojejunostomy.


Biliary complications after LDLT include strictures (anastomotic and nonanastomotic), leaks (from anastomoses, cut surfaces, T-tube exit sites, and sinus tracts), choledocholithiasis, cholangitis, and other complications. Biliary strictures and bile leaks account for the majority of biliary complications after LDLT, and the outcomes are potentially fatal.14, 15 The reported incidence of these complications differs considerably between centers. The overall incidence of biliary complications in living liver donors ranges from 0.4% to 13.0%, and the rates of biliary leaks and strictures range from 0% to 12.6% and from 0% to 5.8%, respectively14, 16-21 (Table 1). Regardless of the type of segmental graft or biliary reconstruction, the overall incidence of biliary complications in recipients ranges from 5.3% to 40.6%; leaks occur in 0% to 21.9%, and strictures occur in 3.7% to 25.3%22-33 (Table 2).

Table 1. Biliary Complications of Living Liver Donors in the Recent Literature
StudyYearLocationNumber of Donors (Type)Biliary Complications
Leaks (n)Strictures (n)Overall Rate (%)
Iida et al.172010Kyoto, Japan500 (right-sided)53812.2
762 (left-sided)3625.0
El-Meteini et al.142010Cairo, Egypt207 (right-sided)26113.0
Taketomi et al.182009Fukuoka, Japan69 (right-sided)3410.1
137 (left-sided)222.9
Ghobrial et al.192008United States (A2ALL)393 (right-sided)3629.7
Chan et al.202007Hong Kong, China200 (right-sided)021
Hwang et al.162006Asan, Korea591 (right-sided)351.4
571 (left-sided)200.4
Lo212003Asia (multiple centers)561 (right-sided)3467.1
939 (left-sided)4114.5
Total  2521 (right-sided)155287.3
2409 (left-sided)8153.6
4930 (right- and left-sided)236335.5
Table 2. Biliary Complications of LDLT Recipients in Recent Years
StudyYearCountrynFollow-UpGrafts (n)Techniques (n)Biliary Complications (%)
RightLeftDDRYLeaksStricturesOverall Rate
Gondolesi et al.312004United States9624.2 months960435721.922.940.6
Kling et al.222004United States4858 months147048201733.3
Liu et al.322004China4113.3 months4104107.324.324.3
Giacomoni et al.332006Italy23644 days23021.721.734.8
Soejima et al.302006Japan1821.74 years501321067611.525.336.8
Shah et al.262007Canada12823 months1280646414.817.126.0
Soejima et al.282008Japan393902.610.212.8
Mita et al.292008Japan231522602319.5
Marubashi et al.252009Japan832.7 years572661221.27.28.4
Lin et al.242009China7012 months8.9
Kim et al.272010Korea22616 days22022009.19.1
Soin et al.232010India244434 days218262133123.75.3

Studies published since 2008 have shown a promisingly dramatic drop in the overall incidence of biliary complications in recipients (5.3%-12.8% since 2008 versus 24.3%-40.6% before 2008; see Table 2). Nearly all investigators have attributed this improvement to their newly developed techniques for preparing bile ducts for biliary anastomosis; these techniques preserve the maximum blood supply to the bile ducts in donors and recipients.23, 25, 27, 28


A precise knowledge of the hilar bile duct anatomy is critical for ensuring the safety of donors and for reducing morbidity rates in recipients. The Huang classification is widely used for assessing variations in bile ducts.6 Figure 1 shows 5 patterns of the hepatic duct confluence. According to several groups (including Huang et al.6 and Ohkubo et al.7), a right hepatic duct (RHD) is present in approximately 65% of all cases.8 In other cases (approximately 35%), 2 or more ducts due to a variant biliary anatomy will be found when a right lobe graft is being retrieved.

Figure 1.

Five patterns of the hepatic duct confluence according to Huang et al.6 Type A is a typical confluence of an RHD and an LHD (62.6%), and we have further divided this type into types A1 (a long RHD) and A2 (a short RHD). Type B is a triple confluence of an RAD, an RPD, and an LHD (19%). Type C is a variant in which an RPD drains into an LHD (11%). Type D is a variant in which an RPD drains into the common hepatic duct (5.8%). Type E is a variant in which an RPD drains into the cystic duct (1.6%).

Even when a single right duct is identified, the right duct frequently subdivides into anterior and posterior parts fairly quickly, and this results in a very short neck or a short right duct (Fig. 1, type A2).34 A technical dilemma emerges in this situation: the balance between donor safety and graft quality must be considered. The stump of the graft bile duct should be kept away from the confluence to avoid a stricture of the bile duct remaining in the donor liver. This contributes to the higher incidence of multiple ducts in the right liver graft (up to 50%-80%) that has been reported in previous studies.26, 31, 35, 36 However, surgical persistence in harvesting a single right duct is also fraught with danger because it frequently shifts the line of the transection, which is then too close to the bifurcation and can jeopardize the left duct of the donor. Repeat intraoperative C-arm cholangiography and probing via an incision of the common hepatic duct can help the surgeon to identify the exact point and its perpendicular direction, through which the graft bile duct should be correctly transected.26, 37, 38 When multiple graft ducts are present, they may be narrow and thin-walled. This makes them less likely to hold sutures and more susceptible to twisting and other technical errors.

An aberrant biliary anatomy and the presence of 2 or more ducts have been proved to be significant risk factors for the development of biliary complications.31, 39-41 In one study, the risk of developing biliary complications was 5.9 times higher when the biliary anatomy was any type other than the normal type.40 This can help us to better educate patients about the risks of biliary complications, which may result in multiple endoscopic and percutaneous procedures but have little influence on long-term survival.42 The selection of donors with a biliary anatomy appropriate for LDLT is an evolving process and differs between centers according to the experience of each surgeon and the characteristics of each patient. Generally, donation is precluded by an aberrant biliary anatomy that may yield 3 or more small bile ducts for anastomosis or that has a significant segmental left duct in communication with the right ductal system, and an alternative donor should be located.26, 40, 43, 44 In a few centers, 2 separate ducts in a graft also hinder living liver donation.45

A clear understanding of the caudate lobe biliary anatomy is also essential because of the frequent occurrence of bile leaks from the caudate lobe and the difficulty in managing the bile leaks.37, 46-48 The caudate lobe consists of Spiegel's lobe (Couinaud segment I) on the left and the paracaval portion on the right. There are usually 1 to 3 bile ducts draining each portion and a maximum of 5 ducts for the whole caudate lobe. Although the majority of the ducts for Spiegel's lobe drain into the left hepatic duct (LHD), a significant number of variations have been described; the ducts may drain into the right posterior duct (RPD) or, less commonly, into the RHD or even the confluence of the hepatic ducts. Although the majority of ducts from the paracaval portion drain into the RPD, 27% of these ducts drain inversely into the LHD.46 The sites of cut-surface bile leaks are more difficult to identify; they may be due to leaks from the LHD, RHD, or RPD through the divided ducts of the caudate lobe. Leaks from biliary branches of the caudate lobe are usually refractory. Therefore, careful attention should be paid to the performance of continuous suturing and ligation of the bile radicles; this will help to reduce the incidence of bile leakage in both donors and recipients.17, 37


The association between hepatic artery thrombosis and biliary complications supports the belief that ischemia of the bile duct is an important factor in the development of anastomotic and nonanastomotic strictures and anastomotic leaks.9, 49 Nowadays, the interruption of the blood supply to the bile duct is thought to be the most important factor contributing to the higher incidence of biliary complications in patients undergoing LDLT.23, 27, 28, 47, 50 The biliary system is entirely supplied by arterial blood, and it drains into the portal vein. The arterial blood supply of the biliary system has been studied by several groups.9-13

The bile duct is divided into 3 segments: the hilar segment (the RHD and the LHD), the supraduodenal segment (the common hepatic duct and the upper common bile duct), and the retropancreatic segment (the lower common bile duct). The supraduodenal duct receives its blood supply via many small arteries, mainly the 3 o'clock artery (3CA) and the 9 o'clock artery (9CA) running along the lateral borders of the duct and the retroportal artery, which runs along the posterior border of the duct (Fig. 2). On average, 60% of these small vessels arise from the gastroduodenal artery and other arteries below it; 38% arise from the right hepatic artery (RHA) and other arteries above it. Consequently, these small arteries give rise to multiple arteriolar branches, which form a free plexus around the duct, that is, the periductal plexus. The hilar duct is closely related to the RHA and the left hepatic artery (LHA), and they ramify into many small, unnamed arteries, which connect a rich arterial network on the surface of the ducts (also named the periductal plexus). Actually, the whole biliary system is surrounded by the periductal plexus, which is derived from branches originating from the RHA and the LHA (and accessory hepatic arteries when they are present), their segmental branches, and the gastroduodenal artery (GDA; Fig. 2). The plexus around the RHD and the LHD is continuous, with a similar plexus surrounding the common bile duct and the common hepatic duct. The hilar plexus also closely connects the arteries supplying the caudate lobe and links the arterial supplies of the right and left livers (Fig. 2).

Figure 2.

Arterial blood supply of the supraduodenal and hilar ducts. Adapted with permission from Australian and New Zealand Journal of Surgery.11 Copyright 1999, Royal Australasian College of Surgeons.

The Glissonian sheath and the hilar plate are intimately associated with the blood supply of the bile duct. The hilar plate consists of bile ducts, the hepatic artery, the portal vein, and other structures surrounded by a sheath (Glisson's capsule), which is thickened in the hilar area of the liver.51 The Glissonian sheath envelops all the hepatic ducts (single or multiple) as they drain from the right or left lobe into the common hepatic duct. Significantly, all the main arteries and their small branches, which supply the periductal arterial plexus, lie within the Glissonian covering. In Couinaud's opinion,8 the bile duct and the hepatic artery are located within the plate system, but the portal vein is covered with a separate sheath of loose connective tissue; this is the reason that the plate containing the extrahepatic bile duct and the hepatic artery can be easily separated from the portal vein (Fig. 3). An operative technique has confirmed the anatomic interspace (Fig. 3).28

Figure 3.

Anatomic interspace described by Couinaud8 and others. The extrahepatic bile duct and the hepatic artery are enveloped in the hilar plate, which is circled by the schematic thread. The arrow shows the anatomic interspace between the hilar plate and the portal vein. Adapted with permission from Transplantation.28 Copyright 2008, Lippincott Williams & Wilkins.

A detailed understanding of the blood supply of the bile duct is pivotal to understanding the newly developed and most recently published techniques for preparing the bile duct for biliary reconstruction.23, 25, 27, 28, 38, 50, 52 In a partial liver graft, the blood vessels to the graft bile duct from the common bile duct side (via the supraduodenal periductal plexus) are transected. Thus, the dissection of the RHA or LHA in the donor operation should be restricted to what is absolutely necessary to protect the branches of the hepatic arteries, and the dissection of the hilar duct should be minimal or should be avoided altogether. The principle of minimal dissection in the hilar plate should also be followed in the preparation of bile ducts in recipients for duct-to-duct anastomosis (DD). A complete Glissonian technique preserves the maximum blood supply to the bile duct in LDLT and, consequently, has led to satisfying outcomes in recent reports.23, 27, 50 Kim et al.27 introduced a combination of intrahepatic Glissonian transection for the recipient's hepatectomy and tailored reconstruction of the biliary tract; this avoids any dissection in the plate system and preserves optimum biliary anastomotic vascularity even for multiple anastomoses. Their results showed no leaks and a 9.1% incidence of biliary strictures.27, 50 A complete hilar Glissonian technique for the donor's hepatectomy was also described by Soin et al.23 This method significantly reduced the incidence (5.3%) and severity of biliary complications in recipients. Further follow-up is required to determine the feasibility of these new techniques.


An accurate preoperative evaluation of the biliary anatomy in LDLT donors and an appropriate surgical design can definitely maximize the safety of donors and minimize complications in recipients. Information about any bile duct variations and especially rare aberrant bile ducts can guide the surgical strategy. Sometimes, variants of the biliary anatomy prohibit the use of a partial liver as a graft.44, 53 In addition, when multiple donor candidates are available, information about their biliary anatomy can help with the selection of the optimal donor.

Several biliary imaging approaches and techniques have been used to map the anatomy of the biliary tract; these include endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), magnetic resonance cholangiography (MRC), and computed tomography cholangiography (CTC). ERC and PTC clearly depict the biliary anatomy but are considered invasive procedures. They are seldom used for donor evaluations today.

Conventional MRC, which typically uses heavily T2-weighted, fast spin-echo sequences on a 1.5-T system, is a noninvasive and safe diagnostic modality for LDLT donors. However, it sometimes fails to depict normal intrahepatic bile ducts because of the poor signal-to-noise ratio and the limited spatial resolution. The addition of hepatocyte-specific agents to contrast-enhanced MRC counters the limitations of conventional MRC. Contrast-enhanced MRC itself has several limitations, including the potential risk of contrast-induced adverse reactions and long examination times. Recent advances in MRC have improved the spatial resolution and the signal-to-noise ratio and have made MRC more promising for mapping of the normal biliary tree in donors. Song et al.54 prospectively evaluated the clinical usefulness of unenhanced MRC for depicting the biliary anatomy in 111 LDLT donors. They found that MRC accurately portrayed the anatomy of the biliary system in 98 subjects (88.3%); for differentiating a normal anatomy from a variant anatomy, it had a sensitivity of 95.5%, a specificity of 95.2%, a positive predictive value of 96.8%, and a negative predictive value of 93.3%. In a new report,55 MRC at 3.0 T correctly depicted the biliary anatomy in 90.4% of the subjects, and it enabled better visualization of second- and third-order branches than MRC at 1.5 T. The administration of intravenous morphine and intramuscular glucagon before MRC can improve the visualization of biliary trees both qualitatively and quantitatively, especially for nondilated intrahepatic bile ducts.56 These techniques may be integrated to provide more accurate evaluations of living liver donor candidates.

Even with the latest state-of-the-art technique, the achievable spatial resolution of magnetic resonance imaging of the biliary tree is lower than the spatial resolution of multidetector computed tomography. Since its introduction in 1997, CTC (computed tomography performed after the intravenous administration of a biliary contrast medium) has been proven to be efficient in accurately assessing the biliary anatomy of potential living donors because of its excretory biliary contrast and its high spatial resolution.57, 58 Its ability to depict bile ducts in conjunction with vascular structures and to collect all these data simultaneously in a 3-dimensional mode can result in an immediate understanding of anatomic variants. Wang et al.59 found that the biliary tree anatomy depicted by CTC was concordant with surgical findings in 23 of 24 right liver donors (96%). Yeh et al.60 compared biliary tree imaging with computed tomography and magnetic resonance imaging and found that CTC provided significantly better visualization of second-order bile ducts than unenhanced MRC or mangafodipir trisodium–enhanced excretory MRC. Recently, McSweeney et al.61 investigated the utility of CTC in the preoperative evaluation of the biliary anatomy when MRC was inconclusive for 19 donors. CTC was concordant with the reference standard, intraoperative cholangiography, in 18 of 19 cases (95%). In the discordant case, CTC identified a tiny accessory right intrahepatic duct joining the common bile duct that was not visualized on intraoperative cholangiography. CTC consistently provides good-to-excellent visualization scores and visualization of the third-order biliary branches in the majority of donors. However, Biliscopin (meglumine iotroxate), a very effective biliary contrast agent, is unavailable in some countries such as China, and the method is limited by the potential for adverse reactions to the radiocontrast agents.

Many improvements have been achieved in the preoperative imaging of the biliary anatomy. Nevertheless, matching the radiological images to the real topographic anatomy of the liver is neither quick nor easy. Therefore, for the donor hepatectomy, most surgeons perform intraoperative cholangiography.26, 47, 62 Although this technique is very useful, its results often agree with the preoperative imaging studies, and it provides only a 2-dimensional view of the biliary anatomy. What we really need is an intraoperative, 3-dimensional view of the hepatic duct confluence and the ramification of the left or right duct; this would allow the definition of the exact plane through which the duct must be divided. Promisingly, Zheng and his coworkers63, 64 successfully used intraoperative, 3-dimensional, contrast-enhanced ultrasonic cholangiography to delineate the anatomy of the biliary tract. This may be an alternative to intraoperative cholangiography for the evaluation of biliary anatomical variations before graft harvesting for LDLT.


Initially, LDLT was introduced to overcome the shortage of organs for pediatric patients, so the biliary reconstruction procedure was Roux-en-Y hepaticojejunostomy (RY).2, 3 RY is preferred for pediatric LDLT because the recipient's bile ducts are too small or because the underlying liver disease (eg, biliary atresia) often mandates RY. When LDLT was applied to adult cases in its early phase, RY was conventionally adopted because of the experience with pediatric LDLT. However, RY does not seem to be mandatory because the recipient's bile duct in an adult is not as small and most underlying liver diseases in adults do not prohibit DD. Nowadays, in comparison with RY, DD is recognized as a simple and favorable method for adult LDLT, and it is currently a standard technique because of its theoretical advantages.24-26, 32, 65, 66 DD is believed to preserve the physiological sphincter of Oddi and, consequently, prevent reflux cholangitis and contamination by intestinal contents if an anastomotic leak occurs. In addition, it decreases the operative time and allows good access for the endoscopic management of postoperative biliary complications.

Many publications have shown the efficacy of DD in comparison with RY in adult LDLT, regardless of the higher incidence of amendable biliary strictures.65, 66 DD with a small duct (<4 mm in diameter) appears to be a risk factor for biliary strictures, whereas RY with such ducts has not been found to be associated with a higher risk.16, 66 Although the type of reconstruction did not affect the development of biliary strictures after LDLT in one study,26 several investigators have found RY to be protective.4, 65, 66 RY is undoubtedly more beneficial than DD from the viewpoint of arterial collateral formation on the graft duct stump.66 So far, there is no randomized study comparing the 2 methods.

Whether internal or external transanastomotic biliary drainage is beneficial for reducing the rate of biliary complications also remains controversial. The general rule in hepatobiliary surgery has been to protect the direct anastomosis with a stent, and several authors have reported a reduction in the rate of biliary complications in patients undergoing LDLT after the introduction of transanastomotic stents for RY or DD.62, 67 The rationale for a stent is the maintenance of the biliary flow despite swelling of the anastomosis as well as easy access for control cholangiography in case of a suspected leak or stricture. However, the stent itself is a foreign body and will induce inflammation and subsequent stricture formation. Liu et al.32 first reported DD without a biliary stent in right lobe LDLT; the rate of biliary complications was 24.3%, which was similar or superior to the rates in previous studies using biliary stents. Furthermore, in a long-term follow-up study of LDLT recipients with an external stent, Kasahara et al.65 found that the overall incidence of biliary strictures was quite high (26.6%) in DD cases, although the external stent tended to reduce biliary complications in RY cases. More and more transplant surgeons are realizing that stenting may be the best compromise for reducing the chance of leaks and maintaining the patency of the duct anastomosis only when the ductal orifice is small (eg, 2 mm).68 Accordingly, in an increasing number of transplant centers, stents are used only for pediatric patients or RY patients, who usually have small bile ducts.23, 66, 69, 70 A prospective randomized trial is needed to definitively settle the controversy.

Microsurgical techniques, which reduce the incidence of hepatic artery thrombosis, are clearly beneficial for hepatic artery anastomoses71, 72; an extrapolation of their use in biliary reconstruction was recently described, and the incidence of biliary strictures was reduced.24

The reconstruction of multiple graft ducts (generally 2), which are tiny, thin-walled, and prone to ischemia, is a real and troublesome challenge of LDLT. When the 2 ducts are adjacent to each other, unification ductoplasty may be applicable. Although this strategy can facilitate the feasibility of a single anastomosis, this artificial manipulation also increases the risk of bile duct stump ischemia.47, 73 Although several strategies (unification ductoplasty, double DD, double RY, or a combination of these) could be adopted,31, 47, 65, 66 intraoperative inability to complete multiple biliary anastomoses can be encountered.74 Moreover, multiple biliary anastomoses are definitely adverse factors that can lead to biliary leaks and stenosis.47, 73 Novel surgical techniques and devices should be developed to overcome these difficulties. Recently, several modified single-hepaticojejunostomy techniques using the Glissonian sheath or liver tissue, which are similar to the Kasai procedure usually used in pediatric patients with biliary atresia, have been established to drain multiple ducts (up to 12) or tiny ducts (<2 mm) in patients with hilar cholangiocarcinoma.75-77 Our method has been further applied to patients with injuries to small and normal RHDs during cholecystectomy.77, 78 Some obscure cases of Glissonian sheath stitching in biliary reconstruction for LDLT have been described.23, 27 We have concluded that the single-hepaticojejunostomy reconstruction of multiple graft bile ducts may be feasible in patients undergoing LDLT when the Glissonian sheath or liver tissue is used to hold sutures.


Currently, the worldwide incidence of biliary complications remains high, even in large LDLT programs, and this makes the management of biliary complications a major concern during the follow-up of donors and recipients.

The approaches to handling biliary complications of LDLT include therapeutic ERC, percutaneous biliary drainage, and open surgery. Most biliary complications can be successfully managed by nonsurgical approaches; ERC is the mainstay of treatment.14, 19, 30, 37 PTC is reserved for severely strictured or disconnected ducts that cannot be traversed by ERC and for patients who have undergone RY (because endoscopic access to the very long Roux limb is impractical).29 Surgical management, which can include a redo of the biliary anastomosis, a conversion from a DD to a hepaticojejunostomy anastomosis, and retransplantation, is the only option when other modalities have failed.

ERC is the first choice for DD patients with biliary strictures. Therapeutic ERC procedures include biliary sphincterotomy, the balloon dilation of the stricture, and the placement of a plastic stent. The stent is then exchanged for a larger stent every 3 months to dilate the stricture and to prevent stent occlusion or stone formation.73 Patients often require multiple sessions of endoscopic therapy involving the placement of multiple smaller caliber stents (7-8.5 Fr), which are limited by the donor duct size. The successful endoscopic management of biliary anastomotic strictures is achieved in only 58% to 76% of LDLT cases and in 80% to 90% of DDLT cases.26, 73, 79, 80 The unsuccessful cases are subjected to PTC. Gwon et al.81 recently developed a technique using percutaneous dilation (14 Fr) and anastomotic dual-catheter dilation (up to 22.5 Fr), and they achieved a 3-year primary patency rate of 91% with a mean follow-up period of 34.5 months. The endoscopic success rate for patients with nonanastomotic strictures is even poorer (25%-33%),73, 82 although nonanastomotic strictures account for less than 7% of all strictures.80, 82 Up to 50% of patients with nonanastomotic strictures will die or need retransplantation.73, 83 The lower success rate for LDLT patients versus DDLT patients can be attributed to multiple, small-caliber anastomoses, peripheral locations, and twisted structures, which probably result from anastomotic fibrosis and hypertrophy of the transplanted liver.

For patients with RY strictures, PTC with balloon dilatation is generally recommended as a minimally invasive therapeutic intervention.29 However, it is associated with a significant risk of complications, including bile leakage, hemorrhaging, and infection, and can result in significant patient discomfort and inconvenience. Recently, the use of double-balloon enteroscopy, which requires a dedicated endoscopic system and highly specialized expertise, has been regarded as an alternative form of PTC for RY patients.29

For the treatment of patients for whom ERC and PTC have failed, Muraoka et al.84 have introduced a novel magnetic compression anastomosis to avoid an operation; transmural compression with 2 magnets causes gradual ischemic necrosis and thus creates a new anastomosis between the dilated bile duct and the small intestine or an unobstructed bile duct. This is an alternative to open surgery in select cases.74, 85

Most bile leaks can be managed by nonsurgical approaches.14, 19, 73 A biliary leak from a cut surface is usually treated conservatively by percutaneous intra-abdominal drainage. An endoscopic or percutaneous transhepatic biliary intervention is useful for most anastomotic leaks with DD or RY.65, 86 However, major problems that are associated with mortality (eg, sepsis, hemorrhaging, and pseudoaneurysms) can occur even after these active treatments. In one study, 17% of the patients whose bile leaks were treated with therapeutic PTC died of sepsis.86 In another study, 19% of the patients with bile leaks died perioperatively because of bile leak–related complications.31 These findings indicate the need to aggressively treat bile leaks; operative management should be considered when anastomoses are seriously disrupted, major leaks occur, or the patient's condition is deteriorating after a nonsurgical treatment.65, 86 Even with aggressive therapy (including surgery), bile leaks are still a significant risk factor for biliary strictures.41, 42, 82

Although biliary complications after LDLT continue to be a challenge, therapeutic ERC has been proven to be safe and effective, and it has resulted in less utilization of surgical revision and PTC management techniques. To obtain more favorable outcomes, more effective procedures with refined devices need to be established.

In summary, the anatomical limitations of multiple tiny bile ducts and the differential blood supplies of graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in LDLT versus DDLT. Most biliary complications after LDLT can be successfully treated by nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.


The authors thank Professor Sheung Tat Fan (Queen Mary Hospital, University of Hong Kong, Hong Kong, China) for helpful suggestions and editing and Dr. Bryon Jaques (Newcastle Hospital, Newcastle, United Kingdom) for language revisions.