American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace.

This month's feature article is titled: “Persistent Bile Leak After Deceased Donor Split Liver Transplantation.”

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians.

Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Need

Sepsis in the postoperative period is a common cause of morbidity and mortality in patients following liver transplantation. The risk of sepsis is compounded by the immunosuppressed state. Recurrent sepsis warranting repeated hospital admissions could be a challenging problem. The source of sepsis may be biliary in a number of patients, and this activity aims to address the knowledge gap that may be present in diagnosis and management of recurrent sepsis following a split liver transplant.

Purpose of Activity

The purpose of this activity is to improve competence by creating awareness of anomalous intrahepatic biliary anatomy and its relevance in split liver transplantation. The activity will also highlight the value of considering the graft anatomy in dealing with postoperative problems in liver transplant patients.

Identification of Practice Gap

This case will assist surgeons and physicians in processing the decision-making in a patient with septic physiology after split liver transplant, with the intention of improving practice and outcomes, particularly in the management of bile leak.

Learning Objectives

Upon completion of this educational activity, participants will be able to:

  • Identify a cause of recurrent intra-abdominal sepsis in a liver transplant patient.
  • Recognize the clinical importance of biliary anatomy, the use of appropriate imaging and its interpretation in liver transplant patients.
  • Formulate a management plan for a post–liver transplant patient with biliary sepsis.

Target Audience

This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation.


No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.


Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose.


Sandy Feng, MD, PhD, discloses stock and/or equity interest in Abbott, Amgen, Charles River Labs, Eli Lily, GlaxoSmithKline, Hospira, Johnson & Johnson, Express Scripts, Medco, Merck, Pfizer and Stryker; research support from Cumberland and Quark; and research support and consulting work for Novartis.

Douglas W. Hanto, MD, PhD, has no relevant financial relationships to disclose.


M. P. Senthil Kumar, MS, FRCS, M. Thamara P. R. Perera, MS, FRCS, John Isaac, MS, FRCS, and Darius F. Mirza, MS, FRCS, have no relevant financial relationships to disclose.

ASTS Staff

Mina Behari, Director of Education, has no relevant financial relationships to disclose.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Instructions on Receiving CME Credit

This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Follow these steps to participate, answer the questions and claim your CME credit:

  • Log on to
  • Read the learning objectives, target audience and activity disclosures.
  • Read the article in print or online format.
  • Reflect on the article.
  • Access the CME Exam, and choose the best answer to each question.
  • Complete the required evaluation and print your CME certificate.

A 36-year-old female with cirrhosis from autoimmune hepatitis underwent a liver transplantation with an extended right lobe graft containing segments I + IV–VIII. The graft from a brain dead donor was split ex situ. The postero-anterior view back table cholangiogram is shown in Figure 1. Parenchymal transection was performed by Kelly-clasia. The extended right lobe graft retained the main portal vein, the common bile duct and the right hepatic artery. The hilar plate at the transection plane of the right lobe graft was sutured in continuity. Implantation was standard, and the graft was perfused via portal vein, followed by the hepatic artery with inflow from an aortic conduit. Direct duct-to-duct biliary anastomosis was performed over a T-tube according to the routine practice, and this was clamped on day 5 after a cholangiogram that ruled out anastomotic or cut surface leak. Her initial postoperative course was uneventful and she was discharged home on day 8.


Figure 1. Postero-anterior view back table cholangiogram prior to ex situ split of the liver graft. ASD, anterior sectoral duct; LHD, left hepatic duct; RPSD, right posterior sectoral duct; S IV, segment IV bile duct.

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She was re-admitted 12 days posttransplant with abdominal pain, distension and pyrexia. A CT scan of the abdomen showed a large perihepatic collection which was bilious on drainage. The hepatic artery was patent. This persisted with daily output between 300–500cc, and over the course of the next 3 months she had multiple admissions with recurrent sepsis. Percutaneous drainage was continued and appropriate broad spectrum antibiotics were instituted initially. A T-tube cholangiogram (Figure 2) and an MRI with MRCP (Figure 3) were obtained to delineate the cause of the persistent leak.

  • M. P. Senthil Kumar*, M. T. P. R. Perera, J. Isaac and D. F. Mirza

  • The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom

  • *Corresponding author: M. P. Senthil Kumar,


Figure 2. Postoperative T-tube cholangiogram. Note the percutaneously placed drain in the right upper quadrant.

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Figure 3. MRCP performed 3 months after transplantation in the presence of persistent bile leak. C1 and C2, intra-abdominal collections; CBD, common bile duct; RPSD, right posterior sectoral duct.

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  1. Top of page
  2. Questions
  1. With reference to the cholangiogram of whole liver graft before splitting (Figure 1), which of the following statements is appropriate:
    1. The pattern of the intrahepatic biliary tree is conventional with no anomalies.
    2. The right posterior sectoral duct is joining the left main hepatic duct.
    3. The right anterior sectoral duct is absent.
    4. The right anterior sectoral duct is draining into the left main duct.
    5. It is likely that the donor had situs inversus.
  2. With respect to bile leaks after liver transplantation, which of the following statements is correct:
    1. Hepatic arterial thrombosis presents with deranged liver biochemistry, but the presentation does not include bile leaks.
    2. Leaks from the transection surface in a split liver graft are common and are always seen on a T-tube cholangiogram.
    3. If the patient presents with recurrent bile collections, then it is best to clamp the T-tube.
    4. The T-tube should be left unclamped allowing free external drainage.
    5. The T-tube should be removed at the earliest opportunity and an external drain placed.
  3. With regard to the use of imaging modalities in investigating biliary complications in liver transplant patients:
    1. In a patient with a biliary enteric anastomosis, an ERCP should be the investigation of choice.
    2. A CT angiogram will provide enough anatomical detail of the bile ducts.
    3. A T-tube cholangiogram is useful only if it demonstrates a leak.
    4. An MRI with MRCP will show ducts even if they are not in continuity with the main ducts.
    5. A radionuclide scan such as a TIBIDA scan is often very sensitive and specific.
  4. Which of the following is an appropriate interpretation of the postoperative T-tube cholangiogram (Figure 2):
    1. The cholangiogram shows a normal pattern of intrahepatic and extrahepatic bile ducts consistent with a split extended right lobe graft and duct-to-duct biliary anastomosis. No leak is demonstrated.
    2. The extrahepatic bile ducts appear abnormal, while the intrahepatic biliary tree is within normal limits for a split extended right lobe graft, and a leak is demonstrated.
    3. The extrahepatic bile ducts appear normal and nondilated, while the intrahepatic biliary tree is abnormal for an extended right lobe graft, but no leak is demonstrated.
    4. Both the extrahepatic bile ducts and the intrahepatic biliary tree are abnormal and dilated, with a site of bile leak demonstrated.
    5. The extrahepatic bile ducts and the intrahepatic biliary tree are inadequately filled for an extended right lobe graft, and a site of bile leak is demonstrated.
  5. Which among the options listed below is the most appropriate long-term definitive management option in this patient, given the clinical course:
    1. Conservative management, long-term broad-spectrum antibiotics and antifungals with appropriate reduction in immunosuppression.
    2. Percutaneous transhepatic biliary drainage and long-term percutaneous drainage of any recurrent collections.
    3. Percutaneous transhepatic stenting of the right posterior sectoral duct.
    4. Preoperative percutaneous drainage and re-exploration with intent to biliary enteric anastomosis of the right posterior sectoral duct.
    5. Re-transplantation.

To complete this activity and earn credit, please go to