Reducing biliary complications in adult-to-adult living donor liver transplantation using right lobe graft: experience of 124 cases

Frontiers of Medicine in China 06/2008; 2(2):130-133. DOI: 10.1007/s11684-008-0024-z


The aim of this paper is to summarize our experience of using right lobe liver grafts to reduce biliary complications in adult-to-adult
(A-A) living donor liver transplantation (LDLT). From January 2002 to October 2007, 124 adult patients underwent living donor
liver transplantation using right lobe grafts at the West China Hospital, Sichuan University Medical School, China. There
was no death in all donors. Biliary reconstruction for 178 hepatic duct orifices from 124 donor grafts was performed which
included 106 reconstructions of duct-to-duct anastomoses and 72 cholangiojejunostomy. Nine recipients had biliary complications
including six bile leakages (four from the anastomotic site and two from the cut surface of the liver graft) and three biliary
strictures. With the improved techniques for biliary reconstruction, we have achieved good results in 124 recipients of A-A
LDLT. We ascribe our success to the introduction of microsurgical techniques and the use of fixed operators which help in
decreasing the biliary complications of LDLT.

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    ABSTRACT: Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.
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    ABSTRACT: Biliary complications after living donor liver transplantation (LDLT) continue to be problematic. For reducing the biliary complications, the authors applied an intrahepatic Glissonian approach to the recipient hepatectomy. We called this Glissonian dissection technique at the high hilar level high hilar dissection (HHD). In this study, we introduced this HHD technique and evaluated its outcome in 31 recipients of a living donor liver transplant (LDLT). With total occlusion of hepatoduodenal ligament Glissonia pedicles were divided at the intrahepatic level at the third level of pedicles or beyond. After portal vein and hepatic artery were isolated from the hepatoduodenal ligament, unused bile ducts and bleeding were controlled with continuous suture of the hilar plate. Single duct anastomosis was performed in about 21 and dual duct anastomosis in 10 recipients. Bile leakage of the biliary anastomosis did not occur. There were 6 biliary complications in five patients; 2 bile leaks from the cut liver surface and 4 biliary strictures of which one of unknown etiology. In none of the patients with biliary complications, conversion to a hepaticojejunostomy was necessary. This new HHD technique during recipient hepatectomy may contribute to reduce the biliary complications in duct-to-duct anastomosis by allowing a tension free anastomosis and preserving adequate blood supply to the bile duct. Moreover, it facilitates multiple ductal anastomoses without difficult surgical manipulation.
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    ABSTRACT: Biliary reconstruction represents one of the most challenging parts of right lobe (RL) living donor liver transplantations (LDLTs). Different causes, surgical techniques, and treatments have been suggested but are incompletely defined. Between June 1999 and January 2002, 96 RL LDLTs were performed in our center. We reviewed the incidence of biliary complications in all the recipients. Roux-en-Y reconstruction was performed in 53 cases (55.2%) and duct-to-duct was performed in 39 cases (40.6%). Both procedures were performed in 4 cases (4.2%). Multiple ducts (> or =2) were found in 58 grafts (60.4%). Thirty-nine recipients (40.6%) had 43 biliary complications: 21 had bile leaks, 22 had biliary strictures, and 4 had both complications. Patients with multiple ducts had a higher incidence of bile leaks than those patients with a single duct (P=0.049). No significant differences in complications were found between Roux-en-Y or duct-to-duct reconstructions. Freedom from biliary complications was 59% at 1 year and 55% at 2 years. The overall 1-year and 2-year survival rates for patients were 86% and 81%, respectively. The overall 1-year and 2-year survival rates for grafts were 80% and 77%, respectively. Occurrence of bile leaks affected patient and graft survival (76% and 65% 2-year patient and graft survival, respectively, vs. 89% and 85% for those without biliary leaks, P=0.07). Despite technical modifications and application of various surgical techniques, biliary complications remain frequent after RL LDLT. Patients with multiple biliary reconstructions had a higher incidence of bile leaks. Patients who developed leaks had lower patient and graft survival rates.
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