SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

We describe our early and long-term experience with routine biliary reconstruction via a microsurgical technique in living donor liver transplantation (LDLT). One hundred seventy-seven grafts (including 3 dual grafts) were primarily transplanted into 174 recipients. The minimum follow-up was 44 months. Biliary reconstructions were based on biliary anatomical variations in graft and recipient ducts. The recipient demographics, graft characteristics, types of biliary reconstruction, biliary complications (BCs), and outcomes were evaluated. There were 130 right lobe grafts and 47 left lobe grafts. There were single ducts in 71.8%, 2 ducts in 26.0%, and 3 ducts in 2.3% of the grafts. The complications were not significantly related to the size and number of ducts, the discrepancy between recipient and donor ducts, the recipient age, the ischemia time, or the type of graft. The overall BC rate was 9.6%. The majority of the complications occurred within the first year, and only 1 patient developed a stricture at 20 months. No new complications were noted after 2 years. When the learning-curve phase of the first 15 cases was excluded, the overall BC rate was 6.79%, and the rate of complications requiring interventions was 2.5%. In conclusion, the routine use of microsurgical biliary reconstruction decreases the number of early and long-term anastomotic BCs in LDLT. Liver Transpl 19:207-214, 2013. © 2012 AASLD.

Abbreviations
BC

biliary complication

HBV

hepatitis B virus

HCC

hepatocellular carcinoma

HCV

hepatitis C virus

IDD

interductal distance

LDLT

living donor liver transplantation

LT

liver transplantation

MBR

microsurgical biliary reconstruction

PFIC

progressive familial intrahepatic cholestasis

PTCD

percutaneous transhepatic cholangiodrainage.

Biliary reconstruction has always been regarded as the Achilles’ heel of liver transplantation (LT).[1] This contention is particularly evident in reduced size LT, including split LT and living donor liver transplantation (LDLT). At the onset of whole organ LT, the reported morbidity and mortality rates associated with the procedure were marked at 30% to 50% and 25% to 30%, respectively.[1, 2] With experience and advances in surgical techniques,[3-5] immunosuppressive agents, and postoperative care,[6] the rate of biliary complications (BCs) after whole organ LT is now reported to be as low as 10%.[7] However, the BC rate after LDLT has remained high. The incidence of BCs in LDLT patients has been reported to be 16% to 67%.[3-5, 8-14] These BCs have been conspicuously ascribed to technical difficulties due to the small size and multiple ducts, particularly in right lobe liver grafts.[8] To overcome these complexities, our institution has routinely employed the use of microsurgical biliary reconstruction (MBR) in LDLT since 2006. In our previous report,[15] we elucidated the feasibility and aptitude of this technique for significantly lowering the BC rate in LDLT. Here we highlight the refinements made in our MBR technique to lower the rate of BCs according to a classification of the types of biliary reconstruction variations in LDLT with the microsurgical technique, and we describe the early and long-term results with this technique.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

From March 22, 2006 to May 31, 2012, routine MBR was performed in 580 grafts for 577 consecutive LDLT procedures (including 3 dual graft transplants) at Kaohsiung Chang Gung Memorial Hospital, (Kaohsiung, Taiwan). To assess both early and long-term results, we included only 177 grafts (including 3 dual graft transplants) primarily transplanted into 174 LDLT patients before December 31, 2008 for the analysis. The minimum follow-up was 44 months, and 73 recipients had a minimum follow-up of 5 years. The study protocol was approved by the Chang Gung Memorial Hospital Institutional Review Board.

All biliary reconstructions were performed with a microsurgical technique by a single microsurgeon. The classification of biliary reconstructions was based on the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit (recipient duct or jejunum) used to reconstruct the biliary tree.

Ultrasound was initially used to ascertain significant fluid collections and biliary dilatations. Patients with ultrasound findings suggestive of vascular complications or BCs were further evaluated with computed tomography angiography or magnetic resonance imaging. After discharge, Doppler ultrasound examinations were performed regularly for recipients with vascular complications, every 3 months for patients with hepatocellular carcinoma (HCC), and every 6 months for non-HCC cases. Magnetic resonance cholangiography was performed for cases suspicious for BCs.

Early BCs were defined as BCs occurring within the first 12 months after LT. Late BCs were defined as complications occurring after 12 months. Bile leakage was defined as the presence of bile material in a closed suction drain that persisted more than 7 days after transplantation or as the presence of a biloma around the area of the anastomosis. An anastomotic biliary stricture was defined as an intrahepatic biliary dilatation > 3 mm in the presence of a notable anastomotic narrowing, on the basis of symptoms, or on the basis of abnormal liver function tests. Jaundice, fever, or abdominal pain could be present with a bile leak or stricture. A biloma was diagnosed with ultrasound, computed tomography, or magnetic resonance imaging. A stricture was diagnosed with ultrasound or magnetic resonance imaging and was confirmed with percutaneous transhepatic biliary imaging or endoscopic retrograde cholangiography.

BCs, including leaks and strictures, were commonly managed with nonoperative measures, including radiological interventions such as endoscopic treatments and percutaneous transhepatic cholangiodrainage (PTCD).

Modifications in the MBR Technique

The MBR technique is described in a previous report.[15, 16] Briefly, all biliary reconstructions were performed under an operating microscope (Carl Zeiss, Jena, Germany) with a magnification of × 5 to 15. Each anastomosis was performed with 6-0 Prolene sutures (Johnson & Johnson, Somerville, NJ) and a 6-0–gauge cardiovascular point needle. The interrupted-suture technique was used for the posterior wall anastomosis first, and then the continuous-suture and interrupted-tie technique was used for the anterior wall. All suture knots were tied extraluminally.[15]

When the MBR technique was initially applied, the recipient duct was reduced in size (recipient reduction ductoplasty) and fashioned in a way to approximate the opening of the graft duct (if this was required). This reduction ductoplasty was performed by an LT surgeon without the aid of an operating microscope or a surgical loupe. Thereafter, the graft and recipient bile ducts were anastomosed by the microsurgeon under an operating microscope with × 5 to 15 magnification. When the graft had multiple duct openings, the choice of performing graft ductoplasty before the biliary anastomosis or performing 2 or 3 separate anastomoses for biliary reconstruction was left exclusively to the judgment of the microsurgeon. However, this practice resulted in an unacceptably high BC rate (40%) in the first 15 cases.[15] After reviewing the technique, we found that despite the recipient reduction ductoplasty, there remained a significant degree of discrepancy between the recipient and graft ducts. Furthermore, the microsurgeon found it difficult to fix such incongruence after the completion of the anastomosis. We believe that the majority of the initial anastomotic BCs were largely attributable to this factor. Hence, we instituted the following modifications in the technique:

  1. Recipient reduction ductoplasty, if this was required because of a discrepancy in the graft and recipient ducts, was to be performed by the microsurgeon under an operating microscope.
  2. Recipient reduction ductoplasty was to be performed after the completion of the anastomosis on the posterior wall and after the laying down of all sutures on the anterior wall of the duct. Moreover, the sutures on the anterior wall of the duct were to be laid down continuously and coursed through the anterior and posterior walls of the remaining length of the recipient duct. This approach precisely approximated the quantity of sutures to securely close the remaining length of the recipient duct (Fig. 1A,B).
  3. When there were multiple duct openings in the graft, donor ductoplasty was to be performed only if the interductal distance (IDD) between the openings was equal to or less than the diameter of the smaller or smallest duct opening. Separate anastomoses were to be performed if the IDD was more than the diameter of the smaller or smallest duct opening.
  4. For these technical modifications and refinements, we created a biliary reconstruction classification system to serve as a guideline for choosing what type of reconstruction would best suit a particular situation.
image

Figure 1. (A) Recipient reduction ductoplasty. (1,2) The reconstruction starts with the completion of the anastomosis in the posterior wall with interrupted sutures. (3) This is followed by the laying down of continuous sutures in the anterior wall of the duct openings and on both sides of the anterior and posterior walls of the remaining length of the recipient duct. (4,5) The reconstruction is completed by interrupted ties. (B) Operative photograph of an actual reduction ductoplasty seen under a microscope (×8). Note the recipient duct to be reduced (arrow).

Download figure to PowerPoint

Biliary Reconstruction Classification

Biliary reconstructions were classified according to the number of graft duct openings, the manner in which these ducts were reconstructed (with or without ductoplasty), and the type of conduit used for reconstructing the biliary tree. The conduits used for reconstruction could be either the recipient duct (right or left hepatic duct or common hepatic duct) or the jejunal Roux limb. The sizes of the duct openings and IDD when there were 2 or more graft duct openings were measured with a caliper. The size of the opening created in the jejunal Roux limb was always patterned to that of the hepatic ducts in the graft.

Single Duct Orifice
  1. In 1-to-1 reconstruction, a single duct opening in the graft was anastomosed to an opening in the recipient duct or jejunum. Reduction ductoplasty was performed when it was necessary.
Two Duct Orifices
  1. In 2-in-1 reconstruction, 2 duct openings in the graft were connected together by ductoplasty and were reconstructed to an opening in the recipient duct or jejunum. This type of reconstruction was performed when the IDD between the 2 ducts in the graft was equal to or less than the diameter of the smaller duct opening.
  2. In 2-to-2 unmixed reconstruction, 2 duct openings in the graft were reconstructed separately to 2 openings in the recipient duct or jejunum. This type of reconstruction was performed when the IDD was greater than the diameter of the smaller duct opening.
  3. In 2-to-2 mixed reconstruction, 2 duct openings in the graft were reconstructed separately with the recipient duct and jejunum. This type of reconstruction was performed when the IDD between the graft ducts was greater than the diameter of the smaller duct opening, there was only 1 bile duct opening in the recipient duct, and its size could accommodate only 1 graft duct opening. The other duct opening was reconstructed with a jejunal Roux limb.
  4. In 2-to-1 reconstruction, 2 duct openings in the graft were anastomosed separately, but a single large recipient duct was used. The recipient duct was partially sutured in its mid part and was fashioned in such a way to accommodate the 2 graft ducts separately. This type of reconstruction was performed when the IDD between the 2 ducts was greater than the diameter of the smaller duct opening and when there was only 1 opening in the recipient duct with a size big enough to accommodate the 2 graft ducts.
Three Duct Orifices
  1. In 3-in-1 reconstruction, 3 duct openings in the graft were connected together by ductoplasty and anastomosed to a single opening in the recipient duct or jejunum. This reconstruction was performed when the IDD between the ducts was equal to or less than the diameter of the smallest duct openings.
  2. In 3-to-3 unmixed reconstruction, 3 duct openings in the graft were reconstructed separately to 3 openings in the recipient duct or jejunum. This was performed when the IDD between adjacent ducts of the 3 ducts was greater than the diameter of the smallest duct opening.
  3. In 2-in-1 and 1-to-1 unmixed reconstruction, 2 of the 3 graft ducts were ductoplastied and reconstructed to 1 of the openings in the recipient duct or jejunum. The remaining duct was reconstructed to another opening distant from the first anastomosis. This type of reconstruction was performed when 2 of the 3 ducts had an IDD less than or equal to the diameter of the smallest duct opening in the graft and a distant third duct had an IDD greater than the diameter of the smaller duct opening.
  4. In 2-in-1 and 1-to-1 mixed reconstruction, 2 of the 3 graft ducts were ductoplastied and reconstructed to a single opening in the recipient duct. The remaining duct was reconstructed to a jejunal Roux limb. The conduits (duct and jejunum) could be used interchangeably. This type of reconstruction was performed when there was only 1 duct available to accommodate 1 or 2 duct openings in the graft. It was likewise performed when 2 of the 3 ducts had an IDD less than or equal to the diameter of the smallest duct opening in the graft and a distant third duct had an IDD greater than the diameter of the smaller duct opening.

Statistical Analysis

Means, standard deviations, and ranges were used as measures for continuous variables, and proportions were used to express categorical variables. The Student t test was used for statistical comparisons of means, whereas Fisher's exact test was used for comparisons of proportions. Statistical analyses were performed with commercially available statistical software (Minitab 15, Minitab, Inc., State College, PA). A P value<0.05 was considered significant.

RESULTS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

One hundred seventy-seven grafts were transplanted into 174 recipients. Dual graft LT was performed for 3 patients. There were 125 male recipients (71.84%) and 49 female recipients (28.16%). The overall mean age was 42.63±20.82 years (range=4 months to 67 years). Thirty-four recipients (19.54%) were in the pediatric age group (<16 years old) with a mean age of 3.09±3.20 years (range=4 months to 10 years). The mean Model for End-Stage Liver Disease score was 13.28 (range=1–50). The mean Pediatric End-Stage Liver Disease score was 12.47 (range=−7 to 50). The indications for LT were HCC (41.95%), hepatitis B virus (HBV)–related cirrhosis (19.54%), hepatitis C virus (HCV)–related cirrhosis (8.04%), HBV- and HCV-related cirrhosis (1.15%), alcoholic cirrhosis (5.17%), biliary atresia (14.94%), and other (9.19%).

Overall, there were 130 right and 47 left lobe grafts. Single duct opening was noted in 127 (71.75%), two duct openings in 46 (25.99%) and three duct openings in 4 (2.26%) grafts. The mean size of the duct openings was 3.8 mm (range, 1-10 mm). The proportion of multiple duct openings was significantly higher in right lobe grafts (Table 1).

Table 1. Graft Characteristics
  1. a

    The data are presented as means and standard deviations (with ranges in parentheses).

Total grafts [n (%)]177 (100)
 Right lobe grafts130 (73.4)
 Left lobe grafts47 (26.6)
Single grafts [n (%)]171 (96.6)
 Right lobe grafts129
 Left lobe grafts42
Dual grafts [n (%)]6 (3.4)
 Right lobe grafts1
 Left lobe grafts5
Single duct opening [n (%)]127 (71.75)
 Right lobe grafts83
 Left lobe grafts44
Two duct openings [n (%)]46 (25.99)
 Right lobe grafts43
 Left lobe grafts3
Three duct openings [n (%)]4 (2.26)
 Right lobe grafts4
 Left lobe grafts0
Mean duct size (mm)a3.8±1.3 (1–10 mm)
Cold ischemia time (minutes)a55.80±77.24 (18–229)
Warm ischemia time (minutes)a50.91±14.39 (23–115)
BCs [n/N (%)]17/177 (9.6)
Right lobe grafts13/130 (10.0)
Left lobe grafts4/47 (8.51)

MBR Outcomes Based on Classification

Table 2 summarized the biliary reconstructions based on our classification. 1-to-1 reconstruction was performed in 127 (71.75%) [98 (55.37%) with the recipient duct and 29 (16.38%) with the jejunum]. 2-in-1 reconstruction was performed in 26 (14.69%). This group consisted of 23 (12.99%) 2-in-1 duct-to-duct and 3 (1.69%) 2-in-1 duct-to-jejunum reconstructions. 2-to-2 unmixed reconstruction was performed in 19 (10.73%). This group comprised of 18 (10.17%) 2-to-2 duct-to-duct and 1 (0.56%) 2-to-2 duct-to-jejunum reconstructions. 2-to-2 mixed reconstruction was performed in 1 (0.56%). 3-in-1 reconstruction was used in 1 (0.56%) where recipient duct was utilized as conduit. 3-to-3 unmixed reconstruction was performed in 2 (1.13%) where all utilized the recipient duct as conduit. 2-in-1 duct-to-duct and 1-to-1 duct-to-duct unmixed reconstruction was performed in 1 (0.56%).

Table 2. Types of Biliary Reconstruction Based on the Number of Graft Duct Openings and the Types of Recipient Conduits Used for Reconstruction
  1. a

    The data are presented as means and standard deviations (with ranges in parentheses).

Total grafts (n)177
Single duct opening in donor graft [n (%)]127 (71.75)
 1-to-1 reconstruction127 (71.75)
 1-to-1 duct-to-duct reconstruction101 (57.06)
 1-to-1 duct-to-jejunum reconstruction29 (16.38)
Two duct openings in donor graft [n (%)]46 (25.99)
 2-in-1 reconstruction23 (12.99)
 2-in-1 duct-to-duct reconstruction20 (11.30)
 2-in-1 duct-to-jejunum reconstruction3 (1.69)
 2-to-1 duct-to-duct reconstruction0 (0)
 2-to-2 unmixed reconstruction19 (10.73)
 2-to-2 duct-to-duct reconstruction18 (10.17)
 2-to-2 duct-to-jejunum reconstruction1 (0.56)
 2-to-2 mixed reconstruction1 (0.60)
Three duct openings in donor graft [n (%)]4 (2.26)
 3-in-1 duct-to-duct reconstruction1 (0.56)
 3-to-3 duct-to-duct unmixed   reconstruction2 (1.13)
 2-in-1 duct-to-duct and 1-to-1 duct-to-  duct unmixed reconstruction1 (0.56)
Total duct-to-duct and duct-to-jejunum anastomoses (n)202
Total duct-to-duct anastomoses [n (%)]167 (82.67)
Total duct-to-jejunum anastomoses [n (%)]35 (17.33)
Total size discrepancy in duct-to-duct anastomoses [n (%)]118 (70.66)
Size of duct discrepancy (mm)a1.17±0.74 (0.5-4.5)

Overall, duct-to-duct anastomosis was performed in 167 (82.67%) and duct-to-jejunum Roux limb in 35 (17.33%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 118 (70.66%) reconstructions. The mean size of these discrepancies was 1.17 mm (range, 0.5-4.5 mm).

Overall BCs

The overall number of BCs was 17 (9.6%). There were 16 early BCs (9.0%); these included 11 bile leaks (6.2%) and 5 biliary strictures (2.8%). The complications consisted of bile leaks (n=4), bile leaks with biloma formation (n=7), bile leaks followed by biliary strictures (n=2), and strictures (n=3). The mean time to the detection of bile leakage was 13 days (range=8–17 days). The mean time to the detection of a biloma was 30.9 days (range=10–57 days). The mean time to the detection of strictures was 194.2 days (range=10–600 days). The number of days to the detection of a stricture was skewed by a recipient who developed hepatic artery thrombosis and another recipient who developed a late BC following late-onset portal vein thrombosis. In the 2 recipients who developed bile leakage and then a stricture, the mean time to the detection of leakage was 12 days (range=8–16 days). The strictures followed after a mean interval of 31.5 days (range=16–47 days).

Eight of the 11 patients with bile leaks experienced spontaneous resolution, 2 underwent a revision of the biliary reconstruction, and 1 required pigtail drainage. All 6 patients with biliary strictures underwent percutaneous transhepatic or endoscopic dilatation and stenting. Overall, 9 patients (5.2%) required intervention for BCs. When the learning-curve phase of the first 15 cases was excluded, the BC rate decreased significantly to 6.79 (n=11); furthermore, only 4 patients (2.5%) required interventions. There were no significant differences between right and left lobes. There was no mortality associated with early BCs.

As for late BCs, 1 biliary stricture (0.6%) developed after a late-onset portal vein complication in an adult patient 20 months after LT. No new anastomotic BCs were noted more than 2 years after LT (Table 3). In the long term, there has been no mortality related to BCs since the start of routine MBR in 2006.

Table 3. BCs
LDLT CaseDiagnosisReconstructionComplicationsInterval to ComplicationsInterventionCase Range
  1. a

    Hepatic artery intimal dissection.

  2. b

    Hepatic artery thrombosis.

  3. c

    Late-onset portal vein thrombosis.

252Urea cycle defectDuct-to-ductLeak13 daysRevised to Roux-en-Y[UPWARDS ARROW]First 15 cases
256HBVDuct-to-duct (2-in-1)Stricture25 daysPTCD
262HBV/HCCDuct-to-duct (2-to-2)Leak and biloma30 daysResolved spontaneously
263HBV/HCCDuct-to-duct (2-in-1)Leak/stricture16/16 daysPTCD
264HBV/HCV/HCCDuct-to-duct (3-in-1)Leak/stricture8/47 daysPTCD
265HCV/HCCaDuct-to-ductLeak and biloma27 daysPigtail drainage/T-tube
269HCVDuct-to-ductLeak and biloma57 daysResolved spontaneously[UPWARDS ARROW]85 cases
274Biliary atresiaRoux-en-YLeak and biloma19 daysResolved spontaneously
280HBV/HCCaDuct-to-duct (2-to-2)Stricture10 daysPTCD
297PFICbDuct-to-ductStricture142 daysRevised to Roux-en-Y/PTCD
301HBVDuct-to-ductLeak17 daysResolved spontaneously
328HCVDuct-to-duct, Roux-en-YLeak and biloma33 daysResolved spontaneously
341AlcoholDuct-to-duct (2-to-2)Leak8 daysResolved spontaneously[UPWARDS ARROW]174 cases
348HBV/HCCDuct-to-duct (2-to-2)Leak and biloma10 daysPigtail drainage
360HBVDuct-to-duct (2-in-1)Leak14 daysResolved spontaneously
378HCVcDuct-to-ductStricture20 monthsStent
396HBV/HCCDuct-to-ductLeak and biloma40 daysResolved spontaneously

Comparison of Complications Before and After Modifications in the Technique

There were 167 duct-to-duct and 35 duct-to-jejunum reconstructions. The recipients who underwent duct-to-duct anastomoses were significantly older (50.8±11.2 years vs. 8.9±17.0 years; P <0.001), with more right lobe grafts utilized [127 (88.9%) vs. 3 (8.9%); P<0.001], longer cold (59.4±26.7 min vs. 39.5±22.8 min; P<0.001) and warm ischemia (51.4±13.9 min vs. 45.9±12.3 min; P=0.03) times, and larger duct openings (3.9±1.4 mm vs. 3.1±0.8 mm; P<0.001). Expectedly, duct size (graft-to-recipient) discrepancy occurred only in duct-to-duct reconstructions. The other variables which included frequency of multiple duct openings and Model for End-stage Liver Disease scores were comparable between the two groups. The BC rates were not significantly higher in patients who underwent duct-to-duct reconstruction [15 (10.5%) vs. 2 (5.9%), P=0.53].

There was a notable drop in the number of duct-to-duct BC after the institution of modifications to the technique [from 15 (8.97%) pre-modification to 9 (5.88%) post-modification]. The BC rate between duct-to-duct and duct-to-jejunum anastomoses after the modification remained comparable [9 (7.0%) vs 2 (6.3%), P >0.99].

Difference Between Grafts Containing Single and Multiple Ducts

There were 127 recipients with grafts containing single duct openings (including 3 patients with dual grafts) and 50 recipients with grafts containing multiple duct openings. The mean diameter of the grafts with a single duct opening was significantly larger than the mean diameter of the grafts with multiple duct openings. Excluding the learning curve (first 15 cases), there was no significant difference in the BC rate between recipients with grafts containing a single duct opening and recipients with grafts containing multiple duct openings [7/114 (6.14%) versus 4/45 (8.89%), P=0.50].

DISCUSSION

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Complications related to biliary reconstruction have resulted in a considerable number of graft failures and deaths among LT recipients.[10, 13] Hence, investigators have relentlessly delved into their causes and created several innovations to overcome BCs. Some of these advances include the acquisition of a comprehensive understanding of the liver, the biliary tree, and its blood supply[17-21]; the creation of novel techniques for hepatic dissection and biliary reconstruction[5, 8, 10, 11, 22-24]; the use of T-tubes and stents[8, 25, 26, 28, 29]; and the application of microsurgical techniques to biliary reconstruction.[15]

The scarcity of organs for LT has resulted in the widespread acceptance of partial liver grafts. However, the early use of these grafts resulted in a mounting rate of biliary adversities.[30] The reported rate of BCs from earlier series ranged from 16% to 67%.[3-5, 8-14] The problem has often been attributed to the disparity in the bile duct anatomy of partial liver grafts. In contrast to whole organ LT, the bile duct in reduced size grafts—particularly right lobe grafts—is conspicuously small, and at times, there are multiple ducts.[11, 30] Furthermore, the sizes of the duct openings in reduced grafts are often divergent from (frequently smaller than) the size of the recipient duct. These predicaments add up to difficulties in biliary reconstruction and a greater risk of BC development in LDLT.[3, 8, 11] For this reason, some surgeons have performed duct-to-duct reconstruction in select grafts to secure a single bile duct anastomosis.[12, 31] Such an impasse could result in the exclusion of otherwise suitable living liver donors.

Currently, biliary reconstruction with a microsurgical technique is one of the most important innovations for lowering the number of BCs.[15] This approach has the technical advantage of enhanced visualization of the operative field under magnification, which helps to prevent physical trauma to the bile duct epithelium and allows more precise placement of stitches during the creation of the anastomosis. Our team has used MBR routinely since March 2006. Our report comparing this technique to the conventional method showed that the risk of developing BCs with MBR was reduced after ample experience and refinements of the technique; in contrast, complications with the conventional method increased even after the procedure had been performed for years.[15] The outcomes of this current series demonstrated a further decline in BCs with microsurgical techniques, and the rate at which interventions were required to treat complications was further lowered to 2.5%.

In a recent review of bile duct anastomotic strictures after adult-to-adult LDLT by Chok et al.,[32] warm and cold ischemia times, stent use, postoperative acute cellular rejection, and University of Wisconsin solution use were shown by univariate analyses to be factors associated with strictures; according to a multivariate analysis, the cold ischemia time and acute cellular rejection were significant factors. In that series, the number of graft openings and the sizes of the bile ducts were not significant factors for BCs. This may have been because the median size of the smallest bile duct in their series was 5 mm. In comparison, our mean bile duct size was smaller at 3.8 mm. Also, in contrast to other studies,[13, 31] the number and sizes of the duct openings did not prove to be significant factors in BC development in our series. These findings robustly suggest that the microsurgical technique is capable of surmounting the difficulties due to the small size and multiple ducts of reduced size grafts[15] as well as the discrepancies in the duct sizes of the recipient and graft ducts.

However, such improvements can be attained only if MBR is employed along with the technical refinements instituted to prevent BCs. Our findings also show that in conjunction with the use of the microsurgical technique, we have devised a classification scheme and guidelines for comprehensively defining the types of biliary reconstruction to be employed in each particular case. The decision on the way in which a duct should be reconstructed relies on the type of conduit (duct or jejunum), the number of ducts present in the graft, and the IDD when multiple ducts (2 or more) are encountered. The improvement may also be due to switching from a general or LT surgeon to a microsurgeon in addition to the use of a microscope. The differences in the techniques employed by the microsurgeon in reduction ductoplasty and the use of the IDD in determining when to perform ductoplasty could be associated with the decreasing number of BCs. These were crucial when we modified our MBR technique.

Duct-to-duct anastomosis was preferred in the majority of the cases. However, Roux-en-Y jejunal reconstruction was performed in patients with diseased or absent extrahepatic bile ducts (eg, patients with biliary atresia or primary sclerosing cholangitis) and when the recipient duct was unfit for reconstruction (ie, it was devascularized and short). When there were multiple duct openings in a graft, the decision to perform ductoplasty or make a separate anastomosis relied utterly on the IDD. Ductoplasty was performed when the IDD between the ducts was equal to or less than the diameter of the smaller opening. On the other hand, separate duct anastomoses were performed when the IDD was greater than the diameter of the smaller opening. These techniques are to be performed by a microsurgeon.

Our technical experience has shown that the rate of BCs in LDLT can be reduced remarkably not only by preserving the blood supply of the biliary tree but also by planning the appropriate type of biliary reconstruction and properly aligning the anastomosis of the graft and recipient hepatic ducts. The latter objective is achieved through the modifications that have been instituted in our techniques.

In summary, the routine use of MBR capably surmounts the difficulties due to anatomical variations and size discrepancies between graft and recipient hepatic ducts with excellent outcomes. The routine use of MBR can decrease the number of early and long-term anastomotic BCs in LDLT.

REFERENCES

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
    Calne RY. A new technique for biliary drainage in orthotopic liver transplantation utilizing the gall bladder as a pedicle graft conduit between the donor and recipient common bile ducts. Ann Surg 1976;184:605609.
  • 2
    Starzl TE, Putnam CW, Hansbrough JF, Porter KA, Reid HA. Biliary complications after liver transplantation: with special reference to the biliary cast syndrome and techniques of secondary duct repair. Surgery 1977;81:212221.
  • 3
    Ishiko T, Egawa H, Kasahara M, Nakamura T, Oike F, Kaihara S, et al. Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft. Ann Surg 2002;236:235240.
  • 4
    Liu CL, Lo CM, Chan SC, Fan ST. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage. Transplantation 2004;77:726732.
  • 5
    Fan ST, Lo CM, Liu CL, Tso WK, Wong J. Biliary reconstruction and complications of right lobe live donor liver transplantation. Ann Surg 2002;236:676683.
  • 6
    Vallera RA, Cotton PB, Clavien PA. Biliary reconstruction for liver transplantation and management of biliary complications: overview and survey of current practices in the United States. Liver Transpl Surg 1995;1:143152.
  • 7
    Greif F, Bronsther OL, Van Thiel DH, Casavilla A, Iwatsuki S, Tzakis A, et al. The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation. Ann Surg 1994;219:4045.
  • 8
    Kasahara M, Egawa H, Takada Y, Oike F, Sakamoto S, Kiuchi T, et al. Biliary reconstruction in right lobe living–donor liver transplantation: comparison of different techniques in 321 recipients. Ann Surg 2006;243:559566.
  • 9
    Scatton O, Meunier B, Cherqui D, Boillot O, Sauvanet A, Boudjema K, et al. Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 2001;233:432437.
  • 10
    Icoz G, Kilic M, Zeytunlu M, Celebi A, Ersoz G, Killi R, et al. Biliary reconstructions and complications encountered in 50 consecutive right-lobe living donor liver transplantations. Liver Transpl 2003;9:575580.
  • 11
    Dulundu E, Sugawara Y, Sano K, Kishi Y, Akamatsu N, Kaneko J, et al. Duct-to-duct biliary reconstruction in adult living-donor liver transplantation. Transplantation 2004;78:574579.
  • 12
    Kawachi S, Shimazu M, Wakabayashi G, Hoshino K, Tanabe M, Yoshida M, et al. Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction. Surgery 2002;132:4856.
  • 13
    Gondolesi GE, Varotti G, Florman SS, Muñoz L, Fishbein TM, Emre SH, et al. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 2004;77:18421848.
  • 14
    Lee KW, Joh JW, Kim SJ, Choi SH, Heo JS, Lee HH, et al. High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation. Liver Transpl 2004;10:11581162.
  • 15
    Lin TS, Concejero AM, Chen CL, Chiang YC, Wang CC, Wang SH, et al. Routine microsurgical biliary reconstruction decreases early anastomotic complications in living donor liver transplantation. Liver Transpl 2009;15:17661775.
  • 16
    Lin TS, Chiang YC. Combined microvascular anastomosis: experimental and clinical experience. Ann Plast Surg 2000;45:280283.
  • 17
    Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical complications. Br J Surg 1979;66:379384.
  • 18
    Northover J, Terblanche J. Bile duct blood supply. Its importance in human liver transplantation. Transplantation 1978;26:6769.
  • 19
    Terblanche J, Allison HF, Northover JM. An ischemic basis for biliary strictures. Surgery 1983;94:5257.
  • 20
    Stapleton GN, Hickman R, Terblanche J. Blood supply of the right and left hepatic ducts. Br J Surg 1998;85:202207.
  • 21
    Shokouh-Amiri MH, Grewal HP, Vera SR, Stratta RJ, Bagous W, Gaber AO. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation. Am Coll Surg 2001;192:798803.
  • 22
    Sugawara Y, Makuuchi M, Sano K, Ohkubo T, Kaneko J, Takayama T. Duct-to-duct biliary reconstruction in living-related liver transplantation. Transplantation 2002;73:13481350.
  • 23
    Sugawara Y, Makuuchi M, Takayama T, Imamura H, Kaneko J, Ohkubo T. Safe donor hepatectomy for living related liver transplantation. Liver Transpl 2002;8:5862.
  • 24
    Grewal HP, Shokouh-Amiri MH, Vera S, Stratta R, Bagous W, Gaber AO. Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction. Ann Surg 2001;233:502508.
  • 25
    Testa G, Malagó M, Valentín-Gamazo C, Lindell G, Broelsch CE. Biliary anastomosis in living related liver transplantation using the right liver lobe: techniques and complications. Liver Transpl 2000;6:710714.
  • 26
    Marcos A, Fisher RA, Ham JM, Shiffman ML, Sanyal AJ, Luketic VA, et al. Right lobe living donor liver transplantation. Transplantation 1999;68:798803.
  • 27
    Shaked A. Use of T tube in liver transplantation. Liver Transpl Surg 1997;3(suppl 1):S22S23.
  • 28
    Roberts JP. T tube or no T tube? Liver Transpl Surg 1997;3(suppl 1):S20S21.
  • 29
    Egawa H, Inomata Y, Uemoto S, Asonuma K, Kiuchi T, Fujita S, et al. Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 2001;25:13001307.
  • 30
    Heffron TG, Emond JC, Whitington PF, Thistlethwaite JR Jr, Stevens L, Piper J, et al. Biliary complications in pediatric liver transplantation. A comparison of reduced-size and whole grafts. Transplantation 1992;53:391395.
  • 31
    Malagó M, Testa G, Hertl M, Lang H, Paul A, Frilling A, et al. Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis. Langenbecks Arch Surg 2002;387:3744.
  • 32
    Chok KS, Chan SC, Cheung TT, Sharr WW, Chan AC, Lo CM, Fan ST. Bile duct anastomotic stricture after adult-to-adult right lobe living donor liver transplantation. Liver Transpl 2011;17:4752.