Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial

Kumar, K.Y. Santosh; Mathew, Johns Shaji; Balakrishnan, Dinesh; Bharathan, Viju Kumar; Amma, Binoj Sivasankara Pillai Thankamony; Gopalakrishnan, Unnikrishnan; Ramachandran, Riju; Dhar, Puneet; Vayoth, Sudheer Othiyil; Sudhindran, S.

doi:10.1016/j.jamcollsurg.2017.08.024

Cited by 31 publications

(18 citation statements)

References 27 publications

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“…Biliary anastomotic stricture is one of the major complications of LT, and endoscopic biliary drainage is the primary treatment . In this study, all of the patients underwent adequate bile duct drainage more than once during follow‐up, and resolution was confirmed in approximately two‐thirds of the patients, which is consistent with the findings of a recent clinical study . Final resolution was achieved with unilateral biliary drainage only in a quarter of all the patients; most of the patients needed bilateral biliary drainage at least once during follow‐up.…”

Section: Discussionsupporting

confidence: 88%

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Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

et al. 2019

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Right lobe (RL) living donor liver transplantation (LDLT) usually includes 2 bile duct anastomosis sites, namely, the right anterior and the right posterior segmental ducts. This study aimed to evaluate the optimal treatment for biliary strictures following RL LDLT with respect to unilateral or bilateral drainage techniques. From January 2005 to December 2017, 883 patients at Seoul National University Hospital underwent RL LDLT. Of these, 110 patients were enrolled who had 2 duct‐to‐duct anastomosis sites and who were considered at risk of developing biliary anastomotic strictures. Unilateral or bilateral biliary drainage during the follow‐up period was identified by endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD). The clinical success, complication, and 180‐day mortality rates were compared between the unilateral and bilateral biliary drainage groups according to the initial ERCP findings. The mean age at the time of LDLT was 54.2 ± 8.2 years. The median time from LDLT to initial biliary anastomotic strictures was 177 (interquartile range, 18‐1085) days. At the initial ERCP, unilateral drainage was performed in 55 (50.0%) patients, and bilateral drainage was performed in 11 (10.0%) patients. Of the patients who underwent unilateral drainage, 35 (63.6%) patients required conversion to bilateral drainage during follow‐up. Overall, 71 (64.5%) patients required bilateral drainage more than once, whereas only 27 (24.5%) patients reached a resolution with unilateral biliary drainage. In this study, most patients required bilateral biliary drainage more than once during follow‐up. An active attempt should be made to drain bilaterally in patients with biliary anastomotic strictures following RL LDLT.

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Section: Discussionsupporting

confidence: 88%

“…When reconstructing bile ducts during LDLT, duct‐to‐duct anastomosis is most frequently applied because it is physiologic and enables an endoscopic approach if biliary complications occur after surgery . A recent clinical randomized study reported a 14.1% occurrence of biliary anastomotic strictures after LDLT with duct‐to‐duct biliary reconstruction …”

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confidence: 99%

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

et al. 2019

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“…A preceding bile leak was also identified as a risk factor for the development of biliary stricture (HR, 8.84; 95% CI, 3.2‐24.46; P < 0.001). This was previously shown in a randomized controlled trial conducted by our unit as well by other eminent researchers . The periductal inflammatory reaction that ensues from a biliary leak is probably what sets the stage for the subsequent development of biliary strictures in the future.…”

Section: Discussionsupporting

confidence: 63%

“…The randomization sequence was generated by the trial statistician. Stratified random sampling was done based on the number of ducts for anastomosis because previous studies from our unit showed multiple donor bile ducts to be a risk factor for biliary complications …”

Section: Methodsmentioning

confidence: 99%

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial

et al. 2019

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Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine‐tryptophan‐ketoglutarate solution either via both the HA and portal vein (DP group, n = 62) or only through the portal vein (standard perfusion [SP] group, n = 62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09‐0.95; P = 0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2 groups. The 3‐year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P = 0.004 and P = 0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P = 0.04 and P < 0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

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“…None of the patients in the stent group developed biliary strictures; however, the sample size was small, and long term follow-up was not reported [ 15 ]. Most recently, the first randomized control trial assessing the efficacy of prophylactic transanastomotic stenting for duct-to-duct biliary reconstruction in LT was performed [ 16 ]. Santosh Kumar et al randomized LT recipients to either receive a transanastomotic, transpapillary 3-5 Fr ureteric stent or no stent; the authors reported a trend towards higher stricture formation in the stent group compared to the nonstent group (22.6% versus 6.1%), although this was not statistically significant [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

Anastomotic Biliary Stricture Development after Liver Transplantation in the Setting of Retained Prophylactic Intraductal Pediatric Feeding Tube: Case and Review

Koo

Medici

Tabibian

2018

Case Reports in Hepatology

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The biliary anastomosis remains a common site of postoperative complications in liver transplantation (LT). Biliary complications have indeed been termed the “Achilles' heel” of LT, and while their prevention, diagnosis, and treatment have continued to evolve over the last two decades, various challenges and uncertainties persist. Here we present the case of a 33-year-old man who, 10 years after undergoing LT for idiopathic recurrent intrahepatic cholestasis, was noted to have developed pruritus and abnormalities in serum liver biochemistries during routine post-liver transplant follow-up. Abdominal ultrasound revealed a linear, 1.5 mm hyperechoic filling defect in the common bile duct; magnetic resonance cholangiopancreatography demonstrated a curvilinear filling defect at the level of the choledochocholedochostomy, corresponding to the ultrasound finding, as well as an anastomotic biliary stricture (ABS). On endoscopic retrograde cholangiography (ERC), a black tubular stricture with overlying sludge was encountered and extracted from the common bile duct, consistent with a retained 5 Fr pediatric feeding tube originally placed at the time of LT. The patient experienced symptomatic and biochemical relief and successfully underwent serial ERCs with balloon dilatation and maximal biliary stenting for ABS management. With this case, we emphasize the importance of ensuring spontaneous passage or removal of intraductal prostheses placed prophylactically at the time of LT in order to minimize the risk of chronic biliary inflammation and associated sequelae, including cholangitis and ABS formation. We also provide herein a brief review of the use of prophylactic internal transanastomotic prostheses, including biliary tubes and stents, during LT.

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Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial

Cited by 31 publications

References 27 publications

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

Optimal Biliary Drainage for Patients With Biliary Anastomotic Strictures After Right Lobe Living Donor Liver Transplantation

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial

Anastomotic Biliary Stricture Development after Liver Transplantation in the Setting of Retained Prophylactic Intraductal Pediatric Feeding Tube: Case and Review

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