Spectrum of biliary complications following live donor liver transplantation

Abstract

Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.

Keywords: Bile leak; Biliary stricture; Liver transplantation.

Figure 1

Arterial supply of the biliary tree[19] (reprinted with permission from Elsevier).

Figure 2

Endoscopic retrograde cholangiograms from a patient with an anastomotic leak after live donor liver transplantation. A: Cholangiogram demonstrating leak (extravasation of contrast) coming off the anastomosis after right lobe live donor liver transplant; B: Cholangiogram with plastic stent deployed across the anastomosis to heal the leak; C: Cholangiogram showing resolution of the leak several months later.

Figure 3

Endoscopic retrograde cholangiograms from a patient with an anastomotic stricture after live donor liver transplantation. A: Cholangiogram demonstrating complex anastomotic stricture after right lobe live donor liver transplant; B: Cholangiogram with plastic stent deployed across the stricture; C: Cholangiogram showing marked improvement in stricture after multiple dilation and stenting.

Figure 4

Endoscopic retrograde cholangiograms from a patient with a non-anastomotic stricture after live donor liver transplantation complicated by biliary cast formation (endoscopic image). A: Cholangiogram demonstrating non-anastomotic stricture after right lobe live donor liver transplant with irregular filling defects (casts) in a dilated segment (running at 8 o’clock in the image); B: Cholangiogram demonstrating clearance of the filling defects; C: Cholangiogram demonstrating two plastic stents deployed into the right anterior and right posterior systems after the casts were removed. Note how well the biliary tree has drained; D: Endoscopic image of the cast material being removed through the ampulla.

Figure 5

Endoscopic retrograde cholangiogram from a patient with a leak from the remnant right common hepatic duct a few days after right lobe live donor liver transplantation. The drain to the left can be seen filling when contrast is injected into the right common hepatic duct. This was managed successfully by a transpapillary stent.

Figure 6

Stricture in donor after right lobe live donor liver transplantation. A: Endoscopic retrograde cholangiogram showing minimal filling of the left system a few weeks after right lobe live donor liver transplantation; B: Percutaneous transhepatic cholangiogram from the same patient in Figure 4A demonstrating a tight stricture at the take off the left common hepatic duct.