Long-term incidence, risk factors, and management of biliary complications after adult living donor liver transplantation

Abstract

A considerable proportion of adult living donor liver transplantation (LDLT) recipients experience biliary complication (BC), but there are few reports regarding BC based on long-term studies of a large LDLT population. The present study examined BC incidence, risk factors and management using single-center data from 259 adult patients (225 right liver and 34 left liver grafts) between 2000 and 2002. The mean follow-up period was 46 Ϯ 14 months. Biliary reconstruction included single duct-to-duct anastomosis (DD, n ϭ 141), double DD (n ϭ 19), single hepaticojejunostomy (HJ, n ϭ 67), double HJ (n ϭ 28), and combined DD and HJ (n ϭ 4). There were 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. Most leaks occurred within the first month, whereas stenosis occurred over 3 yr. Most stenoses were successfully treated using radiological intervention. Cumulative 1-, 3-, and 5-yr BC rates were 12.9%, 18.2%, and 20.2%, respectively. BC occurred much more frequently in right liver grafts compared to left liver grafts (P ϭ 0.024). Stenosis-free survival curves for right liver graft recipients were similar for all reconstruction groups. When right liver graft recipients with single biliary reconstructions were grouped according to graft duct size and type of biliary reconstruction, DD involving a small-sized duct (less than 4 mm in diameter) was found to be a BC risk factor (P ϭ 0.015), whereas HJ involving such duct sizes was not found to be associated with a higher risk (P ϭ 0.471). In conclusion, close surveillance for BC appears necessary for at least the first 3 yr after LDLT. We found that most BC could be successfully controlled using radiological intervention. In terms of anastomotic stenosis risk, HJ appears a better choice than DD for right liver grafts involving ducts less than 4 mm in diameter. Liver Transpl 12: 831-838, 2006. © 2006 AASLD. Received October 19, 2005 accepted November 29, 2005. Patient survival rates for living donor liver transplantation (LDLT) to adult recipients became favorable due to innovative surgical techniques that have overcome the anatomical limitations associated with such partial liver grafts. However, a high incidence of biliary complication (BC) remains the most intractable problem associated with LDLT.

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

“…It is well known, that size and number of donor bile ducts are the major determinants of biliary complications after LDLT (100,101). One analysis revealed even a sixfold increased risk of biliary complications in the case of more than one biliary orifice (102).…”

“…However, after duct-to-duct anastomosis complications are easier to manage using ERC. Only in the case of multiple or very small ducts, a Roux-Y reconstruction might be preferable (101). Again, the placement of transanastomotic drains is discussed controversially.…”

“…In most centers a duct to duct anastomosis has evolved as the standard technique after LDLT, as the incidence of AS is comparable or only slightly higher than after Roux-Y reconstruction (101,103,104). However, after duct-to-duct anastomosis complications are easier to manage using ERC.…”

Las complicaciones biliares en el trasplante hepático de donante vivo no afectan los resultados a largo plazo

“…Las anastomosis biliares en el THDV se caracterizan por la presencia frecuente de más de un pequeño conducto biliar, cuya localización además complica la anastomosis por la proximidad a la vena porta y a la arteria hepática del injerto. Todos estos aspectos tienden a incrementar la complejidad del procedimiento y hacen el ulterior tratamiento de las complicaciones significativamente más difícil [8][9][10][11][12] . Sin embargo, y a pesar de esta elevada incidencia de complicaciones biliares, recientemente se han publicado series donde no hay repercusión en los resultados a largo plazo 13 .…”

Use of a metallic-wall stent in the magnet compression anastomosis technique for bile duct obstruction after liver transplantation

“…1,2 The magnet compression anastomosis technique (MCT), which was first described in 1998 by Yamanouchi et al, 3 provides a simple treatment alternative for patients with biliary stenosis. 4 The clinical feasibility, safety, and usefulness of MCT have been established and demonstrated in various stenoses and occlusions, and this spares the patient from another surgery.…”