Biliary reconstruction and complications of right lobe live donor liver transplantation

Abstract

Objective: To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications.

Summary background data: Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined.

Methods: From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors.

Results: The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered.

Conclusions: With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.

Figure 1. Operative cholangiogram of a 56-year-old donor. (A) This film was taken in an anteroposterior position. Interpretation was difficult because the liver was relatively small and had rotated into the right subphrenic cavity. (B) By rotating the x-ray tube to obtain a right antero-oblique view, two separate right hepatic ducts were clearly seen. The Liga clip (arrow) marks the proposed position of the division of the right anterior hepatic duct.

Figure 2. (A) Operative cholangiogram of a donor obtained in the anteroposterior position. A fine hepatic duct (arrows) crossed the right hepatic duct and was suspected to be the segment 6 hepatic duct joining the left hepatic duct. (B) By rotating the x-ray tube, the hepatic duct was seen clearly joining the confluence of segment 2 and 3 ducts and was actually a segment 4a hepatic duct (arrows).

Figure 3. Line of liver transection at the inferior surface of the liver. The line deviated to the left side of the gallbladder fossa to meet the point of division of the right hepatic duct as determined by operative cholangiography. The asterisk indicates the point where dissection for the right hepatic artery must stop.

Figure 4. Approximation of two adjacent right hepatic duct orifices to form a single orifice. Simply joining the medial wall creates tension and narrowing of the lumen. The newly created septum should be divided vertically and sutured transversely to create a large opening.

Figure 5. Outcome of the first 37 patients.