Optimal Intervention for Initial Treatment of Anastomotic Biliary Complications After Right Lobe Living Donor Liver Transplantation

Abstract

Background: This study evaluated endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) as interventions for patients with anastomotic biliary complications (ABC) after living donor liver transplantation (LDLT). Methods: Prospectively collected data of patients who were diagnosed with ABC after LDLT between January 2013 and June 2017 were retrospectively reviewed. Results: There were 57 patients who underwent LDLT with a right liver graft using duct-to-duct biliary reconstruction and experienced ABC. Among the patients with RAD involvement, there were no significant differences in the intervention success (p = 0.271) and patency rates (p = 0.267) between ERCP and PTBD. Similarly, among the patients with RPD involvement, there were no significant differences in the intervention success (p = 0.148) and patency rates (p = 0.754) between the two procedures. Graft bile duct variation (p = 0.013) and a large angle between the recipient and graft bile duct (R-G angle) (p = 0.012) significantly increased the likelihood of failure of ERCP in the RAD. When the R-G angle was greater than 47.5°, the likelihood of ERCP failure increased. Conclusion: We recommend PTBD when graft bile duct variation is presented in patients with RAD involvement and/or when the R-G angle is greater than 47.5°.

Keywords: anastomotic biliary complications; endoscopic retrograde cholangiography; living donor liver transplantation; percutaneous transhepatic biliary drainage; right anterior hepatic duct; right posterior hepatic duct.

FIGURE 1

The employed process for patient exclusion and data classification. LDLT, living donor liver transplantation; ABC, anastomotic biliary complications; RAD, right anterior hepatic duct; RPD, right posterior hepatic duct; ERCP, endoscopic retrograde cholangiopancreatography; PTBD, percutaneous transhepatic biliary drainage.

FIGURE 2

The angle between the recipient and graft bile ducts (R-G angle). The R-G angle is measured as the angle between the two straight yellow lines, shown on fluoroscopic imaging (A) during endoscopic retrograde cholangiopancreatography and (B) during percutaneous transhepatic biliary drainage.

FIGURE 3

A receiver operating characteristic curve analysis for the angle between the graft and recipient bile ducts and likelihood of endoscopic retrograde cholangiopancreatography failure. ROC, receiver operating characteristic.