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1
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Gupta AA, Soin AS. Complex Reconstruction of Right-Lobe Grafts on the Bench: Portal Vein, Anterior Sector Hepatic Veins, Inferior Hepatic Veins and Multiple Bile Ducts. J Clin Exp Hepatol 2025; 15:102411. [PMID: 39473448 PMCID: PMC11513800 DOI: 10.1016/j.jceh.2024.102411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 09/09/2024] [Indexed: 01/03/2025] Open
Abstract
Living donor liver transplantation (LDLT) employing right-lobe (RL) grafts has become indispensable amid limited deceased donor graft availability. RL grafts, while smaller, offer outcomes comparable with deceased donor grafts, prompting a surge in global RL LDLT. However, bench surgery in LDLT requires meticulous preparation to minimize warm ischaemia time and ensure optimal inflow and outflow reconstruction. This review combines an analysis of existing literature with a discussion of our technique, emphasizing the intricacies of RL graft bench reconstruction.
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Affiliation(s)
- Ankur A. Gupta
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, India
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2
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Kim JC, Hong SK, Lee KW, Lee S, Suh S, Hong SY, Han ES, Choi Y, Yi NJ, Suh KS. Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation. Liver Transpl 2023; 29:377-387. [PMID: 35989478 DOI: 10.1002/lt.26564] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 01/12/2023]
Abstract
In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.
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Affiliation(s)
- Jane Chungyoon Kim
- Department of Surgery , Seoul National University College of Medicine , Seoul , South Korea
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3
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Lee KW, Choi Y, Hong SK, Lee S, Hong SY, Suh S, Han ES, Yi NJ, Suh KS. Laparoscopic donor and recipient hepatectomy followed by robot-assisted liver graft implantation in living donor liver transplantation. Am J Transplant 2022; 22:1230-1235. [PMID: 34971490 DOI: 10.1111/ajt.16943] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/22/2021] [Accepted: 12/26/2021] [Indexed: 01/25/2023]
Abstract
Minimally invasive surgery has been introduced for liver transplantations. Although laparoscopic or robot-assisted living donor hepatectomy is being used, minimally invasive surgery is rarely performed in recipients during liver transplantation. A 63-year-old patient (body mass index: 21.9 kg/m2 ) with primary biliary cirrhosis underwent total laparoscopic explant hepatectomy, followed by robot-assisted liver engraftment using advanced technological innovations. The total operation time for the recipient was 12 h 20 min, including laparoscopic explant hepatectomy (140 min) and robot-assisted engraftment (220 min). Achieving hepatic and portal vein anastomoses consumed 35 and 28 min, respectively. The hepatic artery anastomosis and bile duct reconstruction took 83 and 66 min, respectively. The estimated blood loss was 3600 ml. The warm and cold ischemic times were 87 and 220 min, respectively. The patient received 10 units each of red blood cells and fresh frozen plasma during the surgery and recovered from early allograft dysfunction after liver transplantation. This case study suggests that laparoscopic explant hepatectomy followed by robot-assisted engraftment is feasible in selected recipients only. We obtained informed consent for this innovative procedure from the patient and from her living donor.
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Affiliation(s)
- Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Sola Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Sanggyun Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.,Seoul National University Hospital, Seoul, South Korea
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4
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Lin J, Ko CJ, Lin KH, Hung YJ, Chen YL. The Glissonian stitch traction for biliary duct manipulation in living donor liver transplantation. Transpl Int 2021; 34:2908-2909. [PMID: 34748667 DOI: 10.1111/tri.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/15/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Jan Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Hua Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Ju Hung
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Li Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan.,College of Nursing and Health Sciences, Dayeh University, Changhua City, Taiwan
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5
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Kim SM, Hwang S, Moon DB, Jung DH. Recipient liver splitting to facilitate piggyback hepatectomy in adult living donor liver transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:124-129. [PMID: 35769526 PMCID: PMC9235329 DOI: 10.4285/kjt.20.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/31/2020] [Accepted: 01/22/2021] [Indexed: 12/02/2022] Open
Abstract
Recipient hepatectomy for an enlarged stony-hard liver is a demanding procedure, thus it is often accompanied by massive blood loss. Recipient liver splitting under prolonged hepatic inflow occlusion would facilitate the piggyback recipient hepatectomy. We herein present a case of recipient liver splitting, which was used for living donor liver transplantation (LDLT). A 48-year-old male patient diagnosed with acute-on-chronic liver failure underwent LDLT. During the recipient operation, the native liver was stony-hard and heavily adherent to the retrohepatic inferior vena cava (IVC). During liver mobilization, diffuse oozing occurred due to disseminated intravascular coagulation. As a change in the concept, we decided to perform in situ liver splitting of the recipient liver to facilitate dissection of the retrohepatic IVC. Under hepatic inflow occlusion, right-left liver splitting was performed along the usual plane of extended left hepatectomy. The procedures time for recipient liver splitting and removal was 60 minutes. A modified right liver graft recovered from his daughter was implanted according to the standard procedures of LDLT. We think that recipient liver splitting is a feasible technical option for coping with difficult recipient hepatectomy, especially in patients with an enlarged stony-hard liver and heavy adhesion around the IVC.
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Affiliation(s)
- Sung-Min Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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6
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Lin J, Ko CJ, Lin KH, Lin PY, Hsieh CE, Chou CT, Chen YL, Hung YJ. Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation. Asian J Surg 2021; 44:742-748. [PMID: 33468384 DOI: 10.1016/j.asjsur.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/13/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND /Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. METHODS Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. RESULTS At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p = 0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p = 0.018). CONCLUSION This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.
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Affiliation(s)
- Joseph Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Jan Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Hua Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chia-En Hsieh
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chen-Te Chou
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Molecular Biotechnology, College of Biotechnology and Bioresources, Dayeh University, Changhua City, Taiwan; Department of Radiology, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yao-Li Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan; College of Nursing and Health Sciences, Dayeh University, Changhua City, Taiwan.
| | - Yu-Ju Hung
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.
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7
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Biliary reconstruction and complications in living donor liver transplantation. Int J Surg 2020; 82S:138-144. [PMID: 32387205 DOI: 10.1016/j.ijsu.2020.04.069] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
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8
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Kim JD, Jwa EK, Choi DL. Novel Method for Reconstructing Multiple Graft Bile Ducts During Right Lobe Living Donor Liver Transplant: Dunking With Mucosal Eversion Technique. Transplant Proc 2020; 52:1807-1811. [PMID: 32448651 DOI: 10.1016/j.transproceed.2020.02.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/05/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Multiple graft bile ducts (BDs) and anastomoses have been considered as risk factors for biliary complications after living donor liver transplant (LDLT). Various surgical techniques have been introduced, and most surgeons perform unification ductoplasty for multiple adjacent BDs during LDLT. However, this could cause hemobilia and is difficult to perform when 2 ductal orifices are far apart or show a size discrepancy. METHODS Here, we introduce our novel reconstruction technique for multiple adjacent graft BDs and discuss its effects on postoperative outcomes compared with ductoplasty. We compared the clinical outcomes of 2 biliary reconstruction techniques by retrospectively reviewing 58 recipients who underwent LDLT with right lobe grafts using these 2 techniques at our institution between January 2013 and September 2018: group 1 (n = 20) received ductoplasty, and group 2 (n = 38) was treated with dunking with mucosal eversion technique. RESULTS Overall biliary complication rates were 20.0% in group 1 and 10.5% in group 2 (P = .32). Biliary stricture in group 2 was not frequent compared with that in group 1 (7.9% vs 15.0%, P = .398). Moreover, incidence of biliary stricture in group 2 was not different than that in the group using graft with single BD during the same period (P > .624). CONCLUSIONS Our novel technique could be a useful method for reconstructing adjacent BDs in LDLT and the best alternative to ductoplasty. Moreover, it seems to be a reasonable option when 2 orifices are far apart or show a size discrepancy.
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Affiliation(s)
- Joo Dong Kim
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea.
| | - Eun Kung Jwa
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Dong Lak Choi
- Division of Hepatobiliary Pancreas Surgery and Abdominal Organ Transplantation, Department of Surgery, Catholic University of Daegu College of Medicine, Daegu, Korea
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9
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Doskhanov MO, Skakbayev AS, Baimakhanov ZB, Baimakhanov BB, Kaniyev SA, Serikuly E, Seisembayev MA, Chormanov AT, Abdrashev EB, Sadykov CT, Abdiyev NM, Kausova GK. Biliary complications after liver transplantation. ANNALY KHIRURGICHESKOY GEPATOLOGII = ANNALS OF HPB SURGERY 2019; 24:80-90. [DOI: 10.16931/1995-5464.2019480-90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
Affiliation(s)
| | | | | | | | - Sh. A. Kaniyev
- Syzganov National Scientific Centre of Surgery,
Kazakstan’s Medical University “Higher School of Public Health”
| | - E. Serikuly
- Syzganov National Scientific Centre of Surgery
| | | | | | | | | | | | - G. K. Kausova
- Kazakstan’s Medical University “Higher School of Public Health”
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10
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Shehta A, Jeong J, Lee KW, Lee JM, Hong SK, Cho JH, Yi NJ, Suh KS. A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection. J Gastrointest Surg 2019; 23:2466. [PMID: 31313146 DOI: 10.1007/s11605-019-04281-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/18/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lee et al. (Liver Transpl 10(9):1158-1162, 2004) reported high hilar dissection (HHD) technique as a novel method for recipient hepatectomy to overcome limitations of conventional hilar dissection (CHD). HHD allowed performing multiple tension-free biliary anastomoses and easy reconstruction of double portal vein orifices. However, longer anhepatic phase is its main drawback. We describe a new modification of original HHD, called left portal vein flow preserving HHD (LFP-HHD). The new technique aims to gain the balance between CHD and original HHD. METHODS The detailed technique of recipient hepatectomy by LFP-HHD is shown in the electronic video file. It involves high intrahepatic division of hilar structures while maintaining portal drainage through maintained left portal vein (LPV). Control of right hemi-liver inflow allows for division of right hepatic vein, and safe dissection of inferior vena cava (IVC) and hilar structures. According to coordination with donor surgery, the liver could be easily explanted. DISCUSSION LFP-HHD has the same principle of original HHD allowing for multiple tension-free well-vascularized biliary anastomoses. LFP-HHD allows for shortening of anhepatic phase duration as portal venous drainage is continued through maintained LPV avoiding prolonged total portal clamping with bowel edema or the need for temporary porto-caval shunt. On the other hand, the number and the length of the hilar structures can be decreased compared with the original HHD technique. However, the level of division of the hilar structures is acceptable in most of the cases. CONCLUSION LFP-HHD is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions.
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Affiliation(s)
- Ahmed Shehta
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
- Liver Transplantation Unit, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - Jaehong Jeong
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
- Department of Surgery, School of Medicine, Soonchunhyang University, Bucheon, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea.
| | - Jeong-Moo Lee
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
| | - Suk Kyun Hong
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
| | - Jae-Hyung Cho
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
| | - Nam-Joon Yi
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, College of Medicine, Seoul National University, 28 Yongon-Dong, Chongno-gu, Seoul, 110-744, South Korea
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11
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Ikegami T, Yoshizumi T, Tsutsui Y, Harada N, Itoh S, Yoshiya S, Imai D, Uchiyama H, Mori M. Extensive Thrombectomy as a Legitimate Strategy in Living Donor Liver Transplantation With Advanced Portal Vein Thrombosis. Liver Transpl 2019; 25:1768-1777. [PMID: 31408578 DOI: 10.1002/lt.25623] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
Management of portal vein thrombosis (PVT), especially advanced PVT involving the superior mesenteric vein (SMV), in living donor liver transplantation (LDLT) is challenging. There were 514 adults who underwent LDLT between 2005 and 2018 included in this retrospective study, and PVT was observed in 67 (13.0%) patients. The LDLT recipients with PVT were characterized by increased portal pressure at laparotomy (26.1 ± 6.0 versus 24.3 ± 5.9 mm Hg; P = 0.03) and at closure (16.8 ± 3.9 versus 15.6 ± 3.6 mm Hg; P = 0.02), increased operative blood loss (14.6 ± 29.7 versus 5.7 ± 6.3 L; P < 0.01), and decreased 1-year graft survival (83.5% versus 92.8%; P = 0.04). Among the 18 patients with atrophic or vanished portal vein on pre-LDLT computed tomography, significant portal atrophy was actually observed only in 1 (5.6%) patient during LDLT surgery. For advanced PVT (n = 7) involving SMV in era 1, we performed nonanatomical inflow reconstruction using interposition grafts, resulting in significant inflow problems in 4 (57.1%) patients. Thus, for the patients with advanced PVT (n = 4) in era 2, we abandoned nonanatomical reconstruction and applied extensive thrombectomy under ultrasound guidance with secure shunt ligation, resulting in no inflow problems and no graft loss. In conclusion, even for advanced PVT involving SMV, extensive thrombectomy under sonogram guidance followed by anatomical inflow reconstruction and shunt ligation is a legitimate strategy in adult LDLT with PVT.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuriko Tsutsui
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Yoshiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Imai
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Chok KS, Fung JY, Dai WC, Sin SL, Ma KW, Chan AC, Cheung TT, Lo CM. Donor ductal anomaly is not a contraindication to right liver lobe donation. Hepatobiliary Pancreat Dis Int 2019; 18:343-347. [PMID: 31230961 DOI: 10.1016/j.hbpd.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 06/04/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Data of living-donor liver transplantation (LDLT) suggested that donor ductal anomaly may contribute to postoperative biliary complications in recipients and in donors. This retrospective study aimed to determine if the occurrence of postoperative biliary stricture in donors or recipients in right-lobe LDLT (RLDLT) is related to donor biliary anatomy type. METHODS We analyzed our RLDLT recipients' clinical data and those of their graft donors. The recipients were divided into 2 groups: with and without postoperative biliary stricture. The 2 groups were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates. RESULTS Totally 127 patients were included in the study; 25 (19.7%) of them developed biliary anastomotic stricture. In these 25 patients, 16 had type A biliary anatomy, 3 had type B, 2 had type C, 3 had type D, and 1 had type E. In the 127 donors, 96 (75.6%) had type A biliary anatomy, 13 (10.2%) had type B, 6 (4.7%) had type C, 10 (7.9%) had type D, and 2 (1.6%) had type E. Biliary stricture was seen in 2 donors, who had type A biliary anatomy. None of the recipients or donors developed bile leakage. No association between the occurrence of postoperative biliary stricture and donor biliary anatomy type was found (P = 0.527). CONCLUSIONS The incidence of biliary stricture in donors or recipients after RLDLT was not related to donor biliary anatomy type. As postoperative complications were similar in whatever type of donor bile duct anatomy, donor ductal anomaly should not be considered a contraindication to donation of right liver lobe.
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Affiliation(s)
- Kenneth Sh Chok
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - James Yy Fung
- State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; Department of Medicine, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Sui Ling Sin
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Ka Wing Ma
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Albert Cy Chan
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China; State Key Laboratory for Liver Research, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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13
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Choi JU, Hwang S, Ahn CS, Moon DB, Ha TY, Kim KH, Song GW, Jung DH, Park GC, Lee SG. Prolonged occlusion of the hepatoduodenal ligament to reduce risk of bleeding and tumor spread during recipient hepatectomy for living donor liver transplantation. Ann Hepatobiliary Pancreat Surg 2019; 23:61-64. [PMID: 30863809 PMCID: PMC6405371 DOI: 10.14701/ahbps.2019.23.1.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 12/30/2018] [Accepted: 01/10/2019] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Prevention of excessive bleeding during liver transplantation (LT) operations presents a major challenge. Compared to deceased donor LT, living donor LT (LDLT) is more vulnerable to bleeding because of additional dissection procedures. We herein introduce our technique for prolonged occlusion of the hepatoduodenal ligament applied to recipient hepatectomy for LDLT. Methods Simulated assessment of splanchnic hemodynamics on prolonged occlusion of the hepatoduodenal ligament showed that patients with cirrhotic liver appeared to tolerate the procedure as like in the patients with normal liver. We accumulated experience on the prolonged Pringle maneuver with curved intestinal clamps. Results This technique was applied to more than 60 cases of adult LDLT operations from early 2014 until the end of 2018. Initially, application of this technique was limited to patients showing heavy bleeding during perihilar mobilization. Thereafter, this technique was applied at the start of liver mobilization and stopped after complete mobilization of the retro-hepatic vena cava. Recently, this technique was also applied during dissection of the hepatoduodenal ligament. The mean total occlusion duration was 67±13 minutes. No patient suffered from major serosal peritoneal tearing-associated bleeding or hepatic artery problems. Intentional prolonged occlusion over two hours was applied to five patients who had advanced hepatocellular carcinoma. Conclusions We believe that prolonged occlusion of the hepatoduodenal ligament is a simple effective method to reduce intraoperative bleeding, and that it has potential benefit to reduce the risk of intraoperative tumor spread during LDLT operations.
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Affiliation(s)
- Jin-Uk Choi
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Hong SY, Hu XG, Lee HY, Won JH, Kim JW, Shen XY, Wang HJ, Kim BW. Longterm Analysis of Biliary Complications After Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantations. Liver Transpl 2018; 24:1050-1061. [PMID: 29633539 DOI: 10.1002/lt.25074] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
Biliary complication (BC) is still regarded as the Achilles' heel of a living donor liver transplantation (LDLT). This study aims to evaluate the longterm outcomes of the duct-to-duct (DD) biliary reconstruction using 7-0 suture and to identify the risk factors of BCs after LDLTs. Data of 140 LDLTs between 2006 and 2015 were analyzed. All biliary reconstructions were performed as DD anastomoses using 7-0 suture: 102 for the right lobe, 20 for the left lobe, and 18 for right posterior sector grafts. BC was defined as a bile leakage (BL) or a biliary stricture (BS), and the median follow-up time after LDLT was 65 months. A total of 19 recipients (13.5%) developed BCs (8 BLs and 16 BSs) after LDLT. The survival rates between recipients with and without BCs were 83% and 86.7%, respectively (P = 0.88). In univariate analyses, the risk factors for BC were small diameter of the graft's bile duct, long warm ischemic time, small graft-to-recipient weight ratio, and no use of external biliary stent (EBS). The graft's bile duct diameter ≤ 3 mm and no use of EBS were determined as independent risk factors (hazard ratios of 9.74 and 7.68, respectively) in multivariate analyses. The 116 recipients with EBS had no BL, 11 had BSs (9%), while 24 without EBS had 8 BLs (33%) and 5 BSs (21%). After a propensity score match between the recipients with and without EBS, the EBS group (24) developed only 1 BS (4%). In conclusion, DD anastomosis using 7-0 suture combined with EBS could provide favorable longterm outcomes after LDLT, which should thus be considered the surgical technique of choice for LDLTs.
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Affiliation(s)
- Sung Yeon Hong
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Xu-Guang Hu
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University School of Medicine, Suwon, Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Xue-Yin Shen
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hee-Jung Wang
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Bong-Wan Kim
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
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15
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Kamachi H, Kamiyama T, Tsuruga Y, Orimo T, Wakayama K, Shimada S, Kakisaka T, Yokoo H, Yamashita K, Taketomi A. Transparenchymal glissonean approach: a novel surgical technique for advanced perihilar bile duct cancer. Langenbecks Arch Surg 2018; 403:387-394. [PMID: 29063245 DOI: 10.1007/s00423-017-1633-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 10/10/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE To increase the surgical opportunities for locally advanced perihilar bile duct cancers that require left-sided hepatectomies, we developed the transparenchymal glissonean approach (TGA); it comprises intra-hepatic exposure and dissection of the Glisson's sheath to gain access to the hepatic artery and portal vein for reconstruction. METHODS Following skeletonization of the hepatoduodenal ligament, the proximal portions of invaded vessels are exposed. If extra-hepatic attempts to access the distal portions of the invaded vessels fail, TGA can be used. The distal portion of the invaded right or right posterior Glisson's sheath is exposed following liver transection. The anterior portion of the wall of bile duct is cut and transected circumferentially including the fibrous plate tissue. The non-invaded portal vein and hepatic artery are isolated and dissected towards the hepatic hilum until the invaded distal portion of the vessels, and vascular reconstructions are performed. RESULTS TGA was performed in 9 patients; 5 patients underwent left hemihepatectomy and 4 underwent left tri-sectionectomy. Eight patients needed vascular reconstruction. Clavien-Dindo classification (CDC) grades IIIa and IIIb were recorded in 6 and 1 patients, respectively. No patients had CDC grades IV and V disease. Pathologically, all cases were pT4; 3 cases were R0, 5 were R1 with microscopic positive margin, and 2 were R1 with microscopic metastasis. The overall median survival time was 25.0 months. CONCLUSIONS TGA is feasible with acceptable prognosis and expands the surgical opportunities.
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Affiliation(s)
- Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan.
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Yousuke Tsuruga
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Kenji Wakayama
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Shingo Shimada
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Hideki Yokoo
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Kenichiro Yamashita
- Department of Transplant Surgery, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Graduated School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, Hokkaido, 060-0838, Japan
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16
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Rammohan A, Govil S, Vargese J, Kota V, Reddy MS, Rela M. Changing pattern of biliary complications in an evolving liver transplant unit. Liver Transpl 2017; 23:478-486. [PMID: 28152569 DOI: 10.1002/lt.24736] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/23/2016] [Accepted: 01/14/2017] [Indexed: 01/11/2023]
Abstract
Biliary complications (BCs) remain a significant cause of morbidity following liver transplantation (LT). This series of 640 LT recipients with a blend of living and deceased donor transplants was analyzed to determine the incidence, risk factors, management protocol, and outcomes in these patients. Review of a prospectively collected database of transplant recipients operated between August 2009 and June 2016 was performed. Patients were divided into those with and without BCs and data analyzed. The 640 LT recipients from both living (n = 481) and deceased donors (n = 159) were evaluated for BCs. The overall incidence of BCs was 13.7%. It reduced from 23% to 5% (P = 0.003) over a 6-year period. Risk factors for BCs on multivariate analysis were living donor liver transplantation, prolonged time to rearterialization, recipient age above 16 years, prolonged cold ischemia time (CIT) after deceased donor liver transplantation, and biliary reconstruction performed by anyone but the senior author. One-fifth of bile leaks progressed to strictures, and 40% of strictures followed leaks. Endoscopic therapy resolved 60% of the strictures. Surgical repair of strictures was successful in 90% of those in whom endoscopy failed, those who could not undertake the follow-up schedules endoscopic therapy entails, and those presenting with late strictures. BCs significantly prolonged hospital stay but did not alter survival after LT. BCs affect 1 in 7 recipients, although they are not associated with increased mortality. The frequency of these complications is influenced by potentially modifiable factors like evolving surgical expertise and CIT. Liver Transplantation 23 478-486 2017 AASLD.
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Affiliation(s)
- Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Sanjay Govil
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Joy Vargese
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Venugopal Kota
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Mettu S Reddy
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Global Hospitals and Health City, Chennai, India.,Institute of Liver Studies, King's College Hospital, London, United Kingdom
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17
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Karakas S, Sarici KB, Ozdemir F, Ersan V, Ince V, Baskiran A, Kayaalp C, Kutlu R, Yilmaz S. Telescopic Biliary Reconstruction in Patients Undergoing Liver Transplantation With 1-Year Follow-up. Transplant Proc 2017; 49:562-565. [PMID: 28340833 DOI: 10.1016/j.transproceed.2017.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary complications are important during liver transplantation because of their effect on recipient and graft survival, incidence, and the long treatment period. These complications are associated with 50% morbidity and 30% mortality rates in recent studies. One of the most important reasons for biliary anastomosis complications is arterial ischemia. We present the results of our telescopic biliary anastomosis technique performed on the mucosa of the main biliary duct. PATIENTS AND METHODS Fifty-six cases of telescopic biliary reconstruction were performed in 203 patients during 2015. Fifty cases and 52 patients who underwent standard reconstruction were chosen and compared. All patients had been scanned retrospectively. Statistical analyses were conducted with χ2 and Mann-Whitney U tests for the complications that occurred during the first 3 months. A P value <.05 was considered significant. RESULTS No clinical or demographic differences were detected between the groups. About 90% of both groups were living donor liver transplantation cases. Five (10%) anastomotic leaks occurred in telescopic reconstruction group (n = 50), and 13 (25%) occurred in the standard reconstruction group (n = 52; P < .05). CONCLUSION The arterial blood supply is better if the biliary anastomosis is made on the mucosal side of the main biliary duct. Early period anastomotic leaks may decrease significantly.
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Affiliation(s)
- S Karakas
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey.
| | - K B Sarici
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - F Ozdemir
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - V Ersan
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - V Ince
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - A Baskiran
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - C Kayaalp
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - R Kutlu
- Department of Radiology, Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - S Yilmaz
- Department of Surgery, Inonu University Institute of Liver Transplantation, Malatya, Turkey
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18
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Living Donor Liver Transplantation: A Western Perspective. Int Anesthesiol Clin 2017; 55:135-147. [PMID: 28288032 DOI: 10.1097/aia.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Eversion Technique to Prevent Biliary Stricture After Living Donor Liver Transplantation in the Universal Minimal Hilar Dissection Era. Transplantation 2017; 101:e20-e25. [DOI: 10.1097/tp.0000000000001533] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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20
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Bae SJ, Han DH, Choi GH, Choi JS. The Role of Bile Duct Probe for Bile Duct Division during Donor Right Hemihepatectomy. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.4.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Soong June Bae
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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21
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Biliary Anastomotic Stricture After Adult Living Donor Liver Transplantation With Duct-to-Duct Reconstruction. Transplantation 2016; 100:1500-6. [DOI: 10.1097/tp.0000000000001187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Abstract
Living donor liver transplant (LDLT) accounts for a small volume of the transplants in the USA. Due to the current liver allocation system based on the model for end-stage liver disease (MELD), LDLT has a unique role in providing life-saving transplantation for patients with low MELD scores and significant complications from portal hypertension, as well as select patients with hepatocellular carcinoma (HCC). Donor safety is paramount and has been a topic of much discussion in the transplant community as well as the general media. The donor risk appears to be low overall, with a favorable long-term quality of life. The latest trend has been a gradual shift from right-lobe grafts to left-lobe grafts to reduce donor risk, provided that the left lobe can provide adequate liver volume for the recipient.
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Affiliation(s)
- Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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23
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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24
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Abu-Gazala S, Olthoff KM, Goldberg DS, Shaked A, Abt PL. En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation. J Gastrointest Surg 2016; 20:765-71. [PMID: 26676929 DOI: 10.1007/s11605-015-3047-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/25/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Techniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants. METHODS This was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection. RESULTS A total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3%, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs. 23.5%., respectively, p = 0.049). CONCLUSION En bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.
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Affiliation(s)
- Samir Abu-Gazala
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA.
| | - Kim M Olthoff
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - David S Goldberg
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Abraham Shaked
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Peter L Abt
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
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25
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Nam JH, Yang SJ, Lee JG, Joo DJ, Han DH, Choi GH, Choi JS. Single Center Experience of Biliary Reconstruction in Living Donor Liver Transplantation: Duct-to-Duct Anastomosis. KOREAN JOURNAL OF TRANSPLANTATION 2016. [DOI: 10.4285/jkstn.2016.30.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jin Hoon Nam
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Jeong Yang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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26
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Vij V, Makki K, Chorasiya VK, Sood G, Singhal A, Dargan P. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:14-23. [PMID: 26390361 DOI: 10.1002/lt.24343] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/19/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.
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Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Kausar Makki
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Vishal Kumar Chorasiya
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Gaurav Sood
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Puneet Dargan
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
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27
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Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: An evidence-based review. World J Gastrointest Endosc 2015; 7:606-616. [PMID: 26078829 PMCID: PMC4461935 DOI: 10.4253/wjge.v7.i6.606] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/21/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
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Gad EH, Alsebaey A, Lotfy M, Eltabbakh M, Sherif AA. Complications and mortality after adult to adult living donor liver transplantation: A retrospective cohort study. Ann Med Surg (Lond) 2015; 4:162-171. [PMID: 26005570 PMCID: PMC4434206 DOI: 10.1016/j.amsu.2015.04.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/02/2015] [Accepted: 04/20/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIMS Living donor liver transplantation (LDLT) is widely performed for patients to resolve the critical shortage of organs from cadavers. Despite rapid implementation of the procedure, both complications and mortality of LDLT are annoying problems. The aim of this study was to analyze complications and mortality of patients after adult to adult LDLT (A-ALDLT) in a single center. METHODS Between April 2003 and November 2013, 167 (A-ALDLT) recipients in National Liver Institute, Egypt were included. We retrospectively analyzed complications and mortality in them. RESULTS The overall incidence of complications was 86.2% (n = 144) and classified as biliary 43.7% (n = 73), vascular 21.6% (n = 36), Small for size syndrome (SFSS) 12.6% (n = 21), Gastrointestinal tract (GIT) 19.8% (n = 33), wound 12.6% (n = 21), chest 19.8% (n = 33), neurological 26.3% (n = 44), renal 21% (n = 35), intra abdominal collection 21.6% (n = 36), recurrent hepatitis C virus (HCV) 16.8% (n = 28), recurrent hepatocellular carcinoma (HCC) 2.4% (n = 4), acute rejection 19.2% (n = 32). 65 (45.1%) of 144 complicated patients died, while 10 (43.5%) of 23 non complicated died. The incidence of whole, in hospital and late mortalities were 44.9%, 28.7% and 16.2% respectively. CONCLUSIONS Mortality was higher among complicated cases where vascular complications and SFSS had significant effect on it so prevention and treatment of them is required for improving outcome.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Ayman Alsebaey
- Hepatology Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Maha Lotfy
- Anesthesia Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Mohamed Eltabbakh
- Hepatology Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Ahmed Alshawadfy Sherif
- Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
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Gad EH, Alsebaey A, Lotfy M, Eltabbakh M, Sherif AA. Complications and mortality after adult to adult living donor liver transplantation: A retrospective cohort study. Ann Med Surg (Lond) 2015. [DOI: https:/doi.org/10.1016/j.amsu.2015.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Gad EH, Alsebaey A, Lotfy M, Eltabbakh M, Sherif AA. Complications and mortality after adult to adult living donor liver transplantation: A retrospective cohort study. Ann Med Surg (Lond) 2015. [DOI: https://doi.org/10.1016/j.amsu.2015.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Gad EH, Alsebaey A, Lotfy M, Eltabbakh M, Sherif AA. Complications and mortality after adult to adult living donor liver transplantation: A retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2015. [PMID: 26005570 DOI: 10.1016/j.amsu.2015.04.021.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
BACKGROUND AND AIMS Living donor liver transplantation (LDLT) is widely performed for patients to resolve the critical shortage of organs from cadavers. Despite rapid implementation of the procedure, both complications and mortality of LDLT are annoying problems. The aim of this study was to analyze complications and mortality of patients after adult to adult LDLT (A-ALDLT) in a single center. METHODS Between April 2003 and November 2013, 167 (A-ALDLT) recipients in National Liver Institute, Egypt were included. We retrospectively analyzed complications and mortality in them. RESULTS The overall incidence of complications was 86.2% (n = 144) and classified as biliary 43.7% (n = 73), vascular 21.6% (n = 36), Small for size syndrome (SFSS) 12.6% (n = 21), Gastrointestinal tract (GIT) 19.8% (n = 33), wound 12.6% (n = 21), chest 19.8% (n = 33), neurological 26.3% (n = 44), renal 21% (n = 35), intra abdominal collection 21.6% (n = 36), recurrent hepatitis C virus (HCV) 16.8% (n = 28), recurrent hepatocellular carcinoma (HCC) 2.4% (n = 4), acute rejection 19.2% (n = 32). 65 (45.1%) of 144 complicated patients died, while 10 (43.5%) of 23 non complicated died. The incidence of whole, in hospital and late mortalities were 44.9%, 28.7% and 16.2% respectively. CONCLUSIONS Mortality was higher among complicated cases where vascular complications and SFSS had significant effect on it so prevention and treatment of them is required for improving outcome.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Ayman Alsebaey
- Hepatology Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Maha Lotfy
- Anesthesia Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Mohamed Eltabbakh
- Hepatology Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
| | - Ahmed Alshawadfy Sherif
- Hepatobiliary Surgery Department, National Liver Institute, Menoufiya University, Shibin El-Kom, Menoufiya, Egypt
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Kim PTW, Marquez M, Jung J, Cavallucci D, Renner EL, Cattral M, Greig PD, McGilvray ID, Selzner M, Ghanekar A, Grant DR. Long-term follow-up of biliary complications after adult right-lobe living donor liver transplantation. Clin Transplant 2015; 29:465-74. [PMID: 25740227 DOI: 10.1111/ctr.12538] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Long-term biliary complications after living donor liver transplantation (LDLT) are not well described in the literature. This study was undertaken to determine the long-term impact of biliary complications after adult right-lobe LDLT. METHODS This retrospective review analyzed an 11-yr experience of 344 consecutive right-lobe LDLTs with at least two yr of follow-up. RESULTS Biliary leaks occurred in 50 patients (14.5%), and strictures occurred in 67 patients (19.5%). Cumulative biliary complication rates at 1, 2, 5, and 10 yr were 29%, 32%, 36%, and 37%, respectively. Most early biliary leaks were treated with surgical drainage (N = 29, 62%). Most biliary strictures were treated first with endoscopic retrograde cholangiography (42%). There was no association between biliary strictures and the number of ducts (hazard ratio [HR] 1.017 [0.65-1.592], p = 0.94), but freedom from biliary stricture was associated with a more recent era (2006-2010) (HR 0.457 [0.247-0.845], p = 0.01). Long-term graft survival did not differ between those who had or did not have biliary complications (66% vs. 67% at 10 yr). CONCLUSIONS Biliary strictures are common after LDLT but may decline with a center's experience. With careful follow-up, they can be successfully treated, with excellent long-term graft survival rates.
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Beneficial Impact of Temporary Portocaval Shunt in Living-Donor Liver Transplantation With a Difficult Total Hepatectomy. Transplant Proc 2015; 47:694-9. [DOI: 10.1016/j.transproceed.2014.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 12/24/2022]
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Lauterio A, Di Sandro S, Giacomoni A, De Carlis L. The role of adult living donor liver transplantation and recent advances. Expert Rev Gastroenterol Hepatol 2015; 9:431-445. [PMID: 25307897 DOI: 10.1586/17474124.2015.967762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.
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Affiliation(s)
- Andrea Lauterio
- Transplant Center, Department of Surgery and Abdominal Transplantation, Niguarda Cà Granda Hospital, Milan, Italy
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Kim H, Lee KW, Yi NJ, Lee H, Choi Y, Suh SW, Jeong J, Suh KS. Outcome and Technical Aspects of Liver Retransplantation: Analysis of 25-Year Experience in a Single Major Center. Transplant Proc 2015; 47:727-9. [DOI: 10.1016/j.transproceed.2014.12.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/31/2014] [Indexed: 12/29/2022]
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Choi Y, Lee KW, Kim H, Suh SW, Hong G, Lee HW, Yi NJ, Suh KS. Identification of a safe and adequate division point of the left-sided bile duct with magnetic resonance cholangiography during donor left lateral sectionectomy. Surgery 2015; 157:785-91. [DOI: 10.1016/j.surg.2014.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 10/05/2014] [Accepted: 11/17/2014] [Indexed: 01/28/2023]
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Iwasaki J, Iida T, Mizumoto M, Uemura T, Yagi S, Hori T, Ogawa K, Fujimoto Y, Mori A, Kaido T, Uemoto S. Donor morbidity in right and left hemiliver living donor liver transplantation: the impact of graft selection and surgical innovation on donor safety. Transpl Int 2014; 27:1205-1213. [DOI: 10.1111/tri.12414] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/29/2013] [Accepted: 07/28/2014] [Indexed: 01/14/2023]
Affiliation(s)
- Junji Iwasaki
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Taku Iida
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Masaki Mizumoto
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Tadahiro Uemura
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Shintaro Yagi
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Tomohide Hori
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Kohei Ogawa
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Yasuhiro Fujimoto
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Akira Mori
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Toshimi Kaido
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Shinji Uemoto
- Division of Hepatobiliary Pancreatic and Transplant Surgery; Department of Surgery; Graduate School of Medicine; Kyoto University; Kyoto Japan
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Kim JM, Cho W, Kwon CHD, Joh JW, Park JB, Ko JS, Gwak MS, Kim GS, Kim SJ, Lee SK. Bile duct reconstruction by a young surgeon in living donor liver transplantation using right liver graft. Medicine (Baltimore) 2014; 93:e84. [PMID: 25255023 PMCID: PMC4616285 DOI: 10.1097/md.0000000000000084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Biliary strictures and bile leaks account for the majority of biliary complications after living donor liver transplantation (LDLT). The aim of this study was to examine differences in biliary complications after adult LDLTs were performed by an experienced senior surgeon and an inexperienced junior surgeon. Surgeries included bile duct reconstruction after adult LDLT using a right liver graft, and risk factors for biliary stricture were identified. We retrospectively reviewed the medical records of 136 patients who underwent LDLT in order to identify patients who developed biliary complications. The senior surgeon performed 102 surgeries and the junior surgeon performed 34 surgeries. The proportion of patients with biliary stricture was similar between the senior and the junior surgeons (27.5% vs 26.5%; P = 0.911). However, the incidence of biliary leakage was higher in patients of the junior surgeon than in those of the senior surgeon (23.5% vs 2.9%; P = 0.001). The frequency of percutaneous drainage was also higher for the junior surgeon than the senior surgeon because of the junior surgeon's high leakage rate of the drainage. When the junior surgeon performed bile duct anastomosis, biliary leakage occurred in 7 patients between the 11th and 20th cases. However, biliary leakage occurred in only 1 case thereafter. Bile duct reconstruction performed by beginner surgeons in LDLT using right lobe grafts should be cautiously monitored and observed by a senior surgeon until an inexperienced junior surgeon has performed at least 20 cases, because of the high incidence of biliary leakage related to surgeon's inexperience in bile duct reconstructions in LDLT.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center (JMK, WC, CHDK, J-WJ, JBP, SJK, SKL); and Department of Anesthesiology and Pain Medicine (JSK, MSG, GSK), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Song ATW, Avelino-Silva VI, Pecora RAA, Pugliese V, D’Albuquerque LAC, Abdala E. Liver transplantation: Fifty years of experience. World J Gastroenterol 2014; 20:5363-5374. [PMID: 24833866 PMCID: PMC4017051 DOI: 10.3748/wjg.v20.i18.5363] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Since 1963, when the first human liver transplantation (LT) was performed by Thomas Starzl, the world has witnessed 50 years of development in surgical techniques, immunosuppression, organ allocation, donor selection, and the indications and contraindications for LT. This has led to the mainstream, well-established procedure that has saved innumerable lives worldwide. Today, there are hundreds of liver transplant centres in over 80 countries. This review aims to describe the main aspects of LT regarding the progressive changes that have occurred over the years. We herein review historical aspects since the first experimental studies and the first attempts at human transplantation. We also provide an overview of immunosuppressive agents and their potential side effects, the evolution of the indications and contraindications of LT, the evolution of survival according to different time periods, and the evolution of methods of organ allocation.
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Section 9. Technical Details of Microsurgical Biliary Reconstruction in Living Donor Liver Transplantation. Transplantation 2014; 97 Suppl 8:S34-6. [DOI: 10.1097/01.tp.0000446273.13310.77] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Rendezvous ductoplasty for biliary anastomotic stricture after living-donor liver transplantation. Transplantation 2013; 95:1278-83. [PMID: 23492991 DOI: 10.1097/tp.0b013e31828a9450] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Biliary anastomotic stricture (BAS) after living-donor liver transplantation (LDLT) is difficult to manage. We used rendezvous ductoplasty (RD) to treat BAS after LDLT. METHODS We retrospectively analyzed 53 patients with BAS after adult-to-adult LDLT with duct-to-duct biliary reconstruction. RESULTS BAS was classified according to endoscopic retrograde cholangiography findings after normal-pressure contrast injection: type I (n=32) in which the stricture was visualized; type II (n=13) in which the common hepatic duct and graft intrahepatic ducts were visualized, but the stricture was not visualized; or type III (n=8) in which the stricture and graft intrahepatic ducts were not visualized. In right lobe grafts, types II and III occurred more frequently than type I (P=0.0023). Type I had significantly shorter cold ischemic time (76±11 vs. 118±12 min; P=0.0155) and warm ischemic time (38±2 vs. 49±3 min; P=0.0069) than types II and III. The number of attempts to pass the guidewire through the stricture was significantly lower in type I (1.2±0.2 attempts) than type II (2.2±0.2 attempts; P=0.0018) or type III (2.8±0.3 attempts; P<0.0001). The treatment success rate was 78.1% for type I, 38.5% for type II, and 50.0% for type III (P=0.0282). RD was the first successful treatment in a higher proportion of types II and III patients than type I patients (66.7% vs. 6.3%; P<0.0001). Cumulative treatment success rates were not significantly different between the RD and the non-RD groups (P=0.0920). CONCLUSIONS RD was a useful treatment for difficult cases of BAS after LDLT and achieved successful outcomes.
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The right posterior bile duct anatomy of the donor is important in biliary complications of the recipients after living-donor liver transplantation. Ann Surg 2013; 257:702-7. [PMID: 23474585 DOI: 10.1097/sla.0b013e318268a5d5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the influence of the anatomy of the right posterior bile duct (RPBD) of the donor on biliary complications in the recipients after living-donor liver transplantation (LDLT) using right hemi-liver grafts. BACKGROUND DATA During living-donor right hepatectomy, the RPBD was often exposed to the dissection plane. We hypothesized that biliary complications after anastomosis were increased in these cases because of potential injury to the RPBD. METHODS A total of 169 LDLTs using right hemi-liver grafts, with type I (typical) and type II (trifurcation) anatomy in conventional biliary classification, were retrospectively investigated. The patients were newly classified based on the confluence pattern of the RPBD. The patients were firstly divided into infraportal (IP, n = 12) and supraportal (SP, n = 157) types. SP type was subdivided into 3 groups: type A [ultrashort right bile duct (RBD), n = 20], type B (short RBD, n = 128), and type C (long RBD, n = 9). Type B was further subdivided into B-S (short caudal segment of the RPBD, n = 109) and B-L (long caudal segment of the RPBD, n = 19). RESULTS The biliary complication rate was 0% in type IP and type C, 40% in type A, 17.6% in type B-S, and 52.6% in type B-L (P < 0.01). In multivariate analysis, a new grouping of the RBD was a significant risk factor for biliary complications in LDLT. CONCLUSIONS The anatomy of the RPBD of the donor influenced the biliary outcome in the recipients. A short RBD and a long caudal segment of the RPBD of the donor were significant risk factors for biliary complications in LDLT.
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Lin TS, Chen CL, Concejero AM, Yap AQ, Lin YH, Liu CY, Chiang YC, Wang CC, Wang SH, Lin CC, Yong CC, Cheng YF. Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation. Liver Transpl 2013. [PMID: 23197399 DOI: 10.1002/lt.23582] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Tsan-Shiun Lin
- Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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Selvakumar N, Saha BA, Naidu SCS. Is Duct to Duct biliary Anastomosis the Rule in Orthotopic Liver Transplantation? Indian J Surg 2012; 75:368-72. [PMID: 24426478 DOI: 10.1007/s12262-012-0521-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Accepted: 05/16/2012] [Indexed: 01/29/2023] Open
Abstract
Biliary complications after Liver Transplantation continue to be the major cause of morbidity in 11-25 % of patients. Biliary complications in patients who underwent orthotopic liver transplantation (OLT) at our institute between March 2007 and June 2010 were analyzed retrospectively. 32 patients underwent Deceased Donor Liver Transplantation (DDLT) and in 12 patients Living Donor Liver Transplantation (LDLT) was done. No patients were lost to follow up. Follow up ranged between 4 and 44 months. During the study period, 44 patients underwent orthotopic liver transplantation. Patients were divided into two groups: Biliary Complications group (BC) n = 5 and Non Biliary Complications group (NBC) n = 39. Biliary complications occurred in 15.9 % of patients. Bile leaks accounted for majority of biliary complications. Fifteen variables were analyzed as possible risk factors for biliary complications. Of these, split grafts, duct to duct biliary anastomosis and total blood loss were statistically significant (P < 0.05) for biliary complications. Endoscopic treatment was successful in managing biliary complications in 75 % of patients. Biliary complications are the most common major complications in orthotopic liver transplantation. Significant risk factors are split liver grafts and duct to duct biliary anastomosis. Increased blood loss is a predictor for post operative biliary complications. These complications should be managed by endoscopic interventions. Surgery is indicated following failure of endoscopic interventions.
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Affiliation(s)
- N Selvakumar
- Department of GI Surgery and Liver Transplantation, Army Hospital (Research & Referral), Delhi Cantt, Delhi, 110010 India
| | - Brig Anupam Saha
- Department of GI Surgery and Liver Transplantation, Army Hospital (Research & Referral), Delhi Cantt, Delhi, 110010 India
| | - Surg Capt Sudeep Naidu
- Department of GI Surgery and Liver Transplantation, Army Hospital (Research & Referral), Delhi Cantt, Delhi, 110010 India
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Ochiai T, Ikoma H, Inoue K, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, Nakanishi M, Ichikawa D, Fujiwara H, Okamoto K, Kokuba Y, Sonoyama T, Otsuji E. Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications. J Gastrointest Surg 2011; 15:2159-64. [PMID: 21956431 DOI: 10.1007/s11605-011-1681-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Accepted: 09/07/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND In living-donor liver transplantation, biliary tract complications are a serious problem for recipients and donors. METHODS We applied intraoperative real-time cholangiography using a C-arm and/or C-tube drainage to reduce biliary tract complications in donor hepatectomy. From 2003 to 2010, intraoperative real-time cholangiography and C-tube drainage was applied to 39 and 19 donor cases, respectively. Fifteen donor cases had both procedures. RESULTS We confirmed the division line of the hepatic duct by visualizing a stricture on the monitor of the C-arm by pulling a thread and dissecting the proper site of the bile duct. The number of hepatic ducts of the graft to be anastomosed was 1 in 11 cases and 2 or 3 in 8 of the 19 cases without intraoperative real-time cholangiography, and it was 1 in 32 cases and 2 in 7 of the 39 cases with intraoperative real-time cholangiography. Bile leakage from the resection occurred in seven donors without, and in none of those with, C-tube drainage. CONCLUSION In living-donor liver transplantation, intraoperative real-time cholangiography enables effective determination of the precise division line of the hepatic duct. Moreover, C-tube drainage is effective for reducing bile leakage from the resected surface of the liver of donors.
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Affiliation(s)
- Toshiya Ochiai
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Minimal Hilar Dissection Prevents Biliary Anastomotic Stricture After Living Donor Liver Transplantation. Transplantation 2011; 92:1147-51. [DOI: 10.1097/tp.0b013e3182336073] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.
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Affiliation(s)
- Shao Fa Wang
- Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation. Clin Transplant 2011; 25:504-510. [PMID: 21070364 DOI: 10.1111/j.1399-0012.2010.01338.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. METHODS Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. RESULTS Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). CONCLUSIONS In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.
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Affiliation(s)
- Hatem Khalaf
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
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50
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Kirimlioglu V, Tatli F, Ince V, Aydin C, Ersan V, Ara C, Aladag M, Kutlu R, Kirimlioglu H, Yilmaz S. Biliary complications in 106 consecutive duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation performed in 1 year in a single center: a new surgical technique. Transplant Proc 2011; 43:917-920. [PMID: 21486628 DOI: 10.1016/j.transproceed.2010.11.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu. METHODS Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis. RESULTS All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed. CONCLUSION We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.
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Affiliation(s)
- V Kirimlioglu
- General Surgery Department, Yeni Yuzyil University School of Medicine, Uskudar, Istanbul, Turkey.
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