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Duct-to-duct biliary reconstruction for living donor liver transplantation: experience of 92 cases
Duct-to-Duct Biliary Reconstruction for Living Donor Liver Transplantation: Experience of 92 Cases Y. Sugawara, K. Sano, J. Kaneko, N. Akamatsu, Y. Kishi, N. Kokudo, and M. Makuuchi ABSTRACT Bile duct-to duct reconstruction is now performed in living donor liver transplantation (LDLT) for adult patients. To confirm the feasibility, the results after the reconstruction were retrospectively analyzed. The subjects were 92 adult patients who underwent LDLT at the University of Tokyo Hospital. During the observation period (median 546 days), biliary complications were observed in 28 cases (30%). The complications included bile juice leakage in 11, stenosis at the anastomotic site in 9, and tube trouble in 8. Of these, 20 patients required surgical revision. The results suggest that duct-to-duct reconstruction provides satisfactory results, although long-term observation will be necessary.
B
ILIARY tract complications have continued to be a significant cause of morbidity after liver transplantation. Living donor liver transplantation (LDLT) was initially performed for pediatrics patients with biliary atresia. As a result, the type of biliary anastomosis had been limited to hepatico-jejunostomy. LDLT is widely performed for adults and duct-to-duct biliary reconstruction was tried in some institutions.1– 4 Duct-to-duct biliary reconstruction may be advantageous over hepatico-jejunostomy, which can preserve physiological bilioenteric and bowel continuity, thus preventing delayed bowel movement. To confirm the feasibility, the results after the reconstruction were retrospectively analyzed in our series.
PATIENTS AND METHODS At the University of Tokyo Hospital, duct-to-duct biliary reconstruction was started in May 2000. Through March 2003, 92 patients received LDLT with the reconstruction. They were 49 men and 43 women with average age of 50 ⫾ 8 years. The most common indication was viral hepatitis and cirrhosis with or without hepatocellular carcinoma in 44; followed by cholestatic disease in 29, including primary biliary cirrhosis, autoimmune hepatitis and primary sclerosing cholangitis; fulminant hepatic failure in 9; cryptogenic cirrhosis in 6; and metabolic diseases in 4. The most commonly used graft type was right liver in 54, followed by left liver in 31, and right lateral sector in 7. The donors were 60 men and 32 women. They ranged in age from 20 to 61 years. Their relation to the patients consisted of 46 children, 16 siblings, 13 spouses, 5 parents, and others in 12. The technique was described previously.5 In brief, in the total hepatectomy of the patients, the hilar plate was dissected at the second-order branch of the bile ducts. The anastomosis was performed using an interrupted suture with an external stent tube. A C tube was inserted from the stump of the cystic duct and introduced into the duodenum.
RESULTS Donors
The average operation duration for the donors was 527 ⫾ 93 minutes. The average blood loss volume was 523 ⫾ 276 mL, which was replaced by 370 ⫾ 338 mL of autologous blood. No significant complications were recognized in the postoperative period. The mean postoperative hospitalization was 15 ⫾ 2 days. The donors have all returned to their normal daily activity. Recipients
The average operation duration for the recipients was 909 ⫾ 184 minutes. The duration for biliary reconstruction was 67 ⫾ 16 minutes. An average of 1.6 ⫾ 0.7 bile ducts in grafts were anastomosed using 13 ⫾ 4 threads. The average blood loss volume per body weight was 124 ⫾ 50 mL/kg. The mean graft weight was 576 ⫾ 177 g, which corresponded to 50% ⫾ 11% of recipients’ standard liver volume. During the observation period (median 546 days), biliary compliFrom Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Supported by a Grant-in-aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan, and a Grant-in-aid for Research on Human genome, Tissue engineering, Food biotechnology, Health sciences research grants, Ministry of Health, Labor and Welfare of Japan. Address reprint requests to Y. Sugawara, MD, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Japan. E-mail: [email protected]
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.10.046
Transplantation Proceedings, 35, 2981⫺2982 (2003)
2981
2982
cations were observed in 28 cases (30%). The complications included bile juice leakage in 11, anastomotic stenosis in 9, and tube trouble in 8. Of these, 20 patients required surgical revision. The rate of acute rejection and vascular complication was 30% and 2%, respectively. Three patients expired during the hospitalization and another three died in the later stage. DISCUSSION
Duct-to-duct reconstruction preserves the possibility of endoscopic diagnosis and management of most postoperative complications. Clearly the technique takes a shorter time than a hepaticojejunostomy. The major concern in biliary reconstruction with this method should be stricture of the anastomosis in the long-term observation period. One study6 using a high-resolution resin cast showed that the arterial supply to the duct is mainly (98%) in an axial peri-ductal fashion, consisting of that from the right hepatic, cystic, and left hepatic arteries (38%) and that from retro-duodenal, retro-portal, and gastroduodenal arteries (60%). This suggests that isolation of the common duct
SUGAWARA, SANO, KANEKO ET AL
from adjacent vessels can preserve axial vessels only if periductal connective tissue is preserved sufficiently. Preservation of axial periductal microcirculation may be a key factor for successful reconstruction. Biliary reconstruction with the present technique allowed our patients to recover with an acceptable morbidity rate. However, the follow-up period is still short, and long-term postoperative observation is mandatory to confirm the feasibility of this procedure.
REFERENCES 1. Kiuchi T, Ishiko T, Nakamura T, et al: Transplant Proc 33:1320, 2001 2. Shokouh-Amiri MH, Grewal HP, Vera SR, et al: J Am Coll Surg 192:798, 2001 3. Azoulay D, Marin-Hargreaves G, Castaing D, et al: Arch Surg 136:1197, 2001 4. Soejima Y, Shimada M, Suehiro T, et al: Transplantation 75:557, 2003 5. Sugawara Y, Makuuchi M, Sano K, et al: Transplantation 73:1349, 2002 6. Northover JM, Terblanche J: Br J Surg 66:379, 1979
B
ILIARY tract complications have continued to be a significant cause of morbidity after liver transplantation. Living donor liver transplantation (LDLT) was initially performed for pediatrics patients with biliary atresia. As a result, the type of biliary anastomosis had been limited to hepatico-jejunostomy. LDLT is widely performed for adults and duct-to-duct biliary reconstruction was tried in some institutions.1– 4 Duct-to-duct biliary reconstruction may be advantageous over hepatico-jejunostomy, which can preserve physiological bilioenteric and bowel continuity, thus preventing delayed bowel movement. To confirm the feasibility, the results after the reconstruction were retrospectively analyzed in our series.
PATIENTS AND METHODS At the University of Tokyo Hospital, duct-to-duct biliary reconstruction was started in May 2000. Through March 2003, 92 patients received LDLT with the reconstruction. They were 49 men and 43 women with average age of 50 ⫾ 8 years. The most common indication was viral hepatitis and cirrhosis with or without hepatocellular carcinoma in 44; followed by cholestatic disease in 29, including primary biliary cirrhosis, autoimmune hepatitis and primary sclerosing cholangitis; fulminant hepatic failure in 9; cryptogenic cirrhosis in 6; and metabolic diseases in 4. The most commonly used graft type was right liver in 54, followed by left liver in 31, and right lateral sector in 7. The donors were 60 men and 32 women. They ranged in age from 20 to 61 years. Their relation to the patients consisted of 46 children, 16 siblings, 13 spouses, 5 parents, and others in 12. The technique was described previously.5 In brief, in the total hepatectomy of the patients, the hilar plate was dissected at the second-order branch of the bile ducts. The anastomosis was performed using an interrupted suture with an external stent tube. A C tube was inserted from the stump of the cystic duct and introduced into the duodenum.
RESULTS Donors
The average operation duration for the donors was 527 ⫾ 93 minutes. The average blood loss volume was 523 ⫾ 276 mL, which was replaced by 370 ⫾ 338 mL of autologous blood. No significant complications were recognized in the postoperative period. The mean postoperative hospitalization was 15 ⫾ 2 days. The donors have all returned to their normal daily activity. Recipients
The average operation duration for the recipients was 909 ⫾ 184 minutes. The duration for biliary reconstruction was 67 ⫾ 16 minutes. An average of 1.6 ⫾ 0.7 bile ducts in grafts were anastomosed using 13 ⫾ 4 threads. The average blood loss volume per body weight was 124 ⫾ 50 mL/kg. The mean graft weight was 576 ⫾ 177 g, which corresponded to 50% ⫾ 11% of recipients’ standard liver volume. During the observation period (median 546 days), biliary compliFrom Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Supported by a Grant-in-aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan, and a Grant-in-aid for Research on Human genome, Tissue engineering, Food biotechnology, Health sciences research grants, Ministry of Health, Labor and Welfare of Japan. Address reprint requests to Y. Sugawara, MD, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Japan. E-mail: [email protected]
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/03/$–see front matter doi:10.1016/j.transproceed.2003.10.046
Transplantation Proceedings, 35, 2981⫺2982 (2003)
2981
2982
cations were observed in 28 cases (30%). The complications included bile juice leakage in 11, anastomotic stenosis in 9, and tube trouble in 8. Of these, 20 patients required surgical revision. The rate of acute rejection and vascular complication was 30% and 2%, respectively. Three patients expired during the hospitalization and another three died in the later stage. DISCUSSION
Duct-to-duct reconstruction preserves the possibility of endoscopic diagnosis and management of most postoperative complications. Clearly the technique takes a shorter time than a hepaticojejunostomy. The major concern in biliary reconstruction with this method should be stricture of the anastomosis in the long-term observation period. One study6 using a high-resolution resin cast showed that the arterial supply to the duct is mainly (98%) in an axial peri-ductal fashion, consisting of that from the right hepatic, cystic, and left hepatic arteries (38%) and that from retro-duodenal, retro-portal, and gastroduodenal arteries (60%). This suggests that isolation of the common duct
SUGAWARA, SANO, KANEKO ET AL
from adjacent vessels can preserve axial vessels only if periductal connective tissue is preserved sufficiently. Preservation of axial periductal microcirculation may be a key factor for successful reconstruction. Biliary reconstruction with the present technique allowed our patients to recover with an acceptable morbidity rate. However, the follow-up period is still short, and long-term postoperative observation is mandatory to confirm the feasibility of this procedure.
REFERENCES 1. Kiuchi T, Ishiko T, Nakamura T, et al: Transplant Proc 33:1320, 2001 2. Shokouh-Amiri MH, Grewal HP, Vera SR, et al: J Am Coll Surg 192:798, 2001 3. Azoulay D, Marin-Hargreaves G, Castaing D, et al: Arch Surg 136:1197, 2001 4. Soejima Y, Shimada M, Suehiro T, et al: Transplantation 75:557, 2003 5. Sugawara Y, Makuuchi M, Sano K, et al: Transplantation 73:1349, 2002 6. Northover JM, Terblanche J: Br J Surg 66:379, 1979