Biliary Complications After Liver Transplantation
Biliary Complications After Liver Transplantation
Biliary anastomotic complications are more frequently observed after LDLT than after full-size LT (except DCD). Therefore several specific issues concerning the prophylaxis of biliary complications after LDLT are to be discussed.
Bile leaks from the resection surface are occasionally observed after LDLT. Especially biliary branches from the caudate lobe are at considerable risk. These branches, 3–5 in number, mostly drain into the left hepatic duct, but sometimes into the right sectoral ducts or the right hepatic duct. Due to these anatomical variations careful dissection is mandatory. Moreover some authors recommend continuous suturing of the portal plate or U-stitches in the caudate region for the prevention of bile leaks in the donor as well as in the recipient.
Bile ducts are generally small and thin walled in LDLT. Moreover, the blood supply of the donor as well as the recipient bile duct is critical. Many technical refinements of the donor as well as the recipient operation are aiming at an optimal blood supply of the anastomotic region. In general, during the donor operation the arterial branches to the right respectively left hepatic duct are preserved by sparse dissection of the hepatic artery and especially by avoidance of dissection between the hilar plate and the artery to minimize injury to the communicating artery and the peribiliary plexus. Accordingly, during recipient hepatectomy only minimal dissection of the hilar region is recommended and methods like the 'high hilar dissection' technique are used to optimize the blood supply of the recipient duct in case of duct-to-duct anastomosis.
Flushing and perfusion of the hepatic artery are controversial in LDLT. It is not used in many centers because of potential injury to the intima and alternative techniques, e.g. with retrograde flushing of the arterial system have been postulated, but their clinical benefit remains to be confirmed.
It is well known, that size and number of donor bile ducts are the major determinants of biliary complications after LDLT. One analysis revealed even a sixfold increased risk of biliary complications in the case of more than one biliary orifice. However, since the donor biliary anatomy cannot be influenced, the increased risk can only be weight against the benefit of LDLT over potential alternatives.
In parallel to full-size LT, a preceding bile leak significantly increases the risk for a subsequent biliary stenosis. Also cold ischemic time seems to be an important predictor. Park et al. showed that only 10% of patients developed biliary complications if the cold ischemic time was ≤ 71 min compared to 35% in the case of more than 71 min cold ischemic time.
In most centers a duct to duct anastomosis has evolved as the standard technique after LDLT, as the incidence of AS is comparable or only slightly higher than after Roux-Y reconstruction. However, after duct-to-duct anastomosis complications are easier to manage using ERC. Only in the case of multiple or very small ducts, a Roux-Y reconstruction might be preferable. Again, the placement of transanastomotic drains is discussed controversially. Whereas some authors report a lower rate of biliary complications using transanastomotic stents others avoid stents due to the risk of infectious complications. However, for reconstruction of small bile ducts (<2 mm) it is used by most surgeons.
Nevertheless, the overall biliary morbidity in most series is still between 10% and 30%. A considerably lower rate has been reported in newer analyses; however long-term data remain to be awaited, since many stenoses manifest several years after LDLT.
Therapy of anastomotic complications is in general more difficult after LDLT, since often more than one orifice is involved. Nevertheless, the majority can be managed nonsurgically, and endoscopy remains the first treatment option after duct-to-duct anastomosis; PTC in the case of Roux-Y reconstruction or as reserve option after failure of endoscopic therapy. The final success rate of endoscopic therapy is 60–75% and thereby lower than after full-size LT.
In contrast, the rate of NAS is low after LDLT and those are mainly based on PSC recurrence, since major risk factors like long ischemic time, graft steatosis, old donor age, hemodynamic instability of the donor and especially the accumulation of several risk factors is absent in LDLT. In the case of failure of interventional therapy, surgical optinons are limited and technically demanding after LDLT. Conversion from duct-to-duct to Roux-Y might be useful in selected cases, in the case of severe graft damage retransplantation might be considered.
Special Issues in LDLT
Biliary anastomotic complications are more frequently observed after LDLT than after full-size LT (except DCD). Therefore several specific issues concerning the prophylaxis of biliary complications after LDLT are to be discussed.
Prophylaxis of Biliary Complications in LDLT
Bile leaks from the resection surface are occasionally observed after LDLT. Especially biliary branches from the caudate lobe are at considerable risk. These branches, 3–5 in number, mostly drain into the left hepatic duct, but sometimes into the right sectoral ducts or the right hepatic duct. Due to these anatomical variations careful dissection is mandatory. Moreover some authors recommend continuous suturing of the portal plate or U-stitches in the caudate region for the prevention of bile leaks in the donor as well as in the recipient.
Bile ducts are generally small and thin walled in LDLT. Moreover, the blood supply of the donor as well as the recipient bile duct is critical. Many technical refinements of the donor as well as the recipient operation are aiming at an optimal blood supply of the anastomotic region. In general, during the donor operation the arterial branches to the right respectively left hepatic duct are preserved by sparse dissection of the hepatic artery and especially by avoidance of dissection between the hilar plate and the artery to minimize injury to the communicating artery and the peribiliary plexus. Accordingly, during recipient hepatectomy only minimal dissection of the hilar region is recommended and methods like the 'high hilar dissection' technique are used to optimize the blood supply of the recipient duct in case of duct-to-duct anastomosis.
Flushing and perfusion of the hepatic artery are controversial in LDLT. It is not used in many centers because of potential injury to the intima and alternative techniques, e.g. with retrograde flushing of the arterial system have been postulated, but their clinical benefit remains to be confirmed.
It is well known, that size and number of donor bile ducts are the major determinants of biliary complications after LDLT. One analysis revealed even a sixfold increased risk of biliary complications in the case of more than one biliary orifice. However, since the donor biliary anatomy cannot be influenced, the increased risk can only be weight against the benefit of LDLT over potential alternatives.
In parallel to full-size LT, a preceding bile leak significantly increases the risk for a subsequent biliary stenosis. Also cold ischemic time seems to be an important predictor. Park et al. showed that only 10% of patients developed biliary complications if the cold ischemic time was ≤ 71 min compared to 35% in the case of more than 71 min cold ischemic time.
Anastomotic Complications After LDLT
In most centers a duct to duct anastomosis has evolved as the standard technique after LDLT, as the incidence of AS is comparable or only slightly higher than after Roux-Y reconstruction. However, after duct-to-duct anastomosis complications are easier to manage using ERC. Only in the case of multiple or very small ducts, a Roux-Y reconstruction might be preferable. Again, the placement of transanastomotic drains is discussed controversially. Whereas some authors report a lower rate of biliary complications using transanastomotic stents others avoid stents due to the risk of infectious complications. However, for reconstruction of small bile ducts (<2 mm) it is used by most surgeons.
Nevertheless, the overall biliary morbidity in most series is still between 10% and 30%. A considerably lower rate has been reported in newer analyses; however long-term data remain to be awaited, since many stenoses manifest several years after LDLT.
Therapy of anastomotic complications is in general more difficult after LDLT, since often more than one orifice is involved. Nevertheless, the majority can be managed nonsurgically, and endoscopy remains the first treatment option after duct-to-duct anastomosis; PTC in the case of Roux-Y reconstruction or as reserve option after failure of endoscopic therapy. The final success rate of endoscopic therapy is 60–75% and thereby lower than after full-size LT.
Nonanastomotic Complications After LDLT
In contrast, the rate of NAS is low after LDLT and those are mainly based on PSC recurrence, since major risk factors like long ischemic time, graft steatosis, old donor age, hemodynamic instability of the donor and especially the accumulation of several risk factors is absent in LDLT. In the case of failure of interventional therapy, surgical optinons are limited and technically demanding after LDLT. Conversion from duct-to-duct to Roux-Y might be useful in selected cases, in the case of severe graft damage retransplantation might be considered.
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