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Duct-to-duct Biliary Reconstruction in Living-donor Liver Transplantation for Primary Sclerosing Cholangitis: Report of a Case
Duct-to-duct Biliary Reconstruction in Living-donor Liver Transplantation for Primary Sclerosing Cholangitis: Report of a Case T. Motomura, T. Yoshizumi*, H. Wang, A. Nagatsu, S. Itoh, N. Harada, N. Harimoto, T. Ikegami, H. Uchiyama, Y. Soejima, and Y. Maehara Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
ABSTRACT Although Roux-en Y hepaticojejunostomy was previously recommended for the biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC), some recent reports showed no difference in the graft survival between Roux-en Y and duct-toduct anastomosis in deceased-donor liver transplantation. On the other hand, considering the risk of recurrence and the short length of the bile duct of the graft, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor liver transplantation (LDLT) for PSC. A 45 year-old male underwent LDLT using a left-lobe graft donated from his brother. Cholangiography showed no lesion in his common bile duct and duct-to-duct anastomosis was chosen for him. Fifteen months later, he suffered cholangitis due to PSC recurrence and endoscopic retrograde cholangiography was performed. The stents were inserted into his B2 and B3, and he remains well. Because of the ability to easily manage biliary complication, duct-to-duct biliary reconstruction may become the first choice in LDLT for PSC without common bile duct lesions.
T
HE PREFERRED type of biliary reconstruction in liver transplantation (LT) for primary sclerosing cholangitis (PSC) remains unclear. Although Roux-en Y hepaticojejunostomy was previously recommended, because the patients’ native biliary ducts could be diminished, resulting in lower rates of biliary complications [1], graft survival did not differ significantly in groups of patients undergoing Roux-en Y and duct-to-duct biliary anastomosis [2e4]. However, a transplant from a related donor was shown to be a risk factor for PSC recurrence [5]. To our knowledge, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor LT (LDLT) for PSC. CASE 1
A 33-year-old man visited his family physician complaining of itch and jaundice and was diagnosed with PSC by endoscopic retrograde cholangiopancreatography. Endoscopic retrograde bile drainage (ERBD) and steroid treatment were ineffective, and his liver function deteriorated further. At age 45 years, he underwent LDLT using a left-lobe graft donated by his 47-year-old brother, as well as simultaneous splenectomy. The graft weight was 351 g and graft/standard liver volume was 31.9%. Biliary 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.03.069
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reconstruction was performed by duct-to-duct anastomosis with interrupted 5-0 polydioxanone sutures. A retrograde transhepatic bile drainage (RTBD) tube was inserted. Intraoperative cholangiography showed no stricture or irregularity (Fig 1A). The operation time was 527 minutes and blood loss was 1550 mL. The patient’s postoperative course was uneventful. He was started on immunosuppressive treatment with steroids, mycophenolate mofetil, and tacrolimus. Cholangiography on postoperative day (POD) 7 showed no biliary stricture, and he was discharged home on POD 17. Three months later, following confirmation of fistula formation, the RTBD tube was removed. Fifteen months after LDLT, he was re-admitted to our institute because of acute cholangitis. Endoscopic retrograde cholangiography (ERC) showed a biliary stricture (Fig 1B). An ERBD tube (8.5 Fr, 12 cm) was inserted into
*Address correspondence to Tomoharu Yoshizumi, MD, PhD, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan. E-mail: [email protected] ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 1196e1198 (2017)
DUCT-TO-DUCT BILIARY RECONSTRUCTION
1197
Fig 1. (A) Intraoperative cholangiography through the retrograde transhepatic bile drainage tube, showing no evidence of biliary stricture or bile leakage. White arrows indicate the site of anastomosis. (B) Primary sclerosing cholangitis recurrence and biliary stricture causing cholangitis 15 months after living-donor liver transplantation. (C) Endoscopic retrograde cholangiography was easily performed and the endoscopic retrograde bile drainage tube inserted into the B2 branch. (D) Following the recurrence of cholangitis, the sphincter was cut and another endoscopic retrograde bile drainage tube was inserted into the B3 branch.
the B2 branch (Fig 1C). There were no complications and his cholangitis improved rapidly. He was discharged home on day 3. However, PSC recurrence worsened and the biliary stricture extended into the B3 branch. Cholangitis occurred 1 month later and another ERBD tube was inserted into the B3 branch (Fig 1D). There were no complications and the patient remains well. CASE 2
A 25-year-old female who has had a history of liver dysfunction due to PSC was referred to our department. She underwent LDLT using a right-lobe graft donated from her 57-year-old father and simultaneous splenectomy. The graft weight was 410 g and graft/standard liver volume was 38.4%. Because both preoperative cholangiography and intraoperative findings showed her common bile duct was normal (Fig 2A), biliary reconstruction was performed by duct-to-duct anastomosis with interrupted 5-0 polydioxanone sutures. A RTBD tube was inserted. The operation time was 639 minutes and blood loss was 3150 mL. She suffered controllable ascites and was discharged on POD 27. The cholangiography at 3 months after LDLT showed no stricture or irregularity
(Fig 2B). Five months have passed and she has been well and shown no biliary complication or PSC recurrence so far. DISCUSSION
Despite recent technical and scientific developments in LT, the recurrence rate of PSC after LT is as high as 11% to 37% [5]. Roux-en Y hepaticojejunostomy has been preferred after LT for PSC [1] because duct-to-duct biliary anastomosis involves the retention of the recipients’ bile ducts, which has been thought responsible for PSC recurrence and biliary complications. The PSC recurrence rate after LT, however, was found to be similar after Roux-en Y reconstruction and duct-to-duct anastomosis, as were graft survival and biliary complication rates [2e4]. Moreover, one study found that the incidence of cholangitis was lower after duct-to-duct reconstruction, perhaps because the ampulla of Vater was retained [2]. Earlier reports evaluated patients who underwent deceased-donor LT (DDLT). To our knowledge, the patient described here is the first to undergo duct-to-duct biliary anastomosis during LDLT for PSC since a report published in 2004 [1]. The patient described in this report experienced PSC recurrence and cholangitis with a biliary stricture, but
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Fig 2. (A) Preoperative cholangiography showed irregularity and diffuse stenosis on the intrahepatic bile duct, but no lesion of common bile duct. White arrows indicate the level of resection. (B) The cholangiography performed 3 months after living-donor liver transplantation showed no biliary stricture or primary sclerosing cholangitis recurrence. White arrows indicate the level of anastomosis.
ERC and ERBD tube insertion were easily performed, improving both the primary disease and graft function. In contrast to DDLT, the graft bile duct is short in LDLT. That is, the length of the remnant recipient’s bile duct should be long enough for anastomosis. Preoperative ERC of our patient showed no stricture or irregularity of the common bile duct, which was confirmed intraoperatively to be soft enough without fibrosis. These findings suggested that duct-to-duct anastomosis would be safe and effective in this patient. Another advantage of duct-to-duct biliary anastomosis also is the ability to perform endoscopic retrograde cholangiopancreatography and to easily manage biliary complication. According to the reports describing among DDLT cases, Roux-en Y reconstruction could not improve the rates of PSC recurrence or biliary complication after all, and needs percutaneous transhepatic bile drainage tube if happened which would be very harmful for patients. Ductto-duct biliary reconstruction may become the first choice even in LDLT for PSC without common bile duct lesions.
REFERENCES [1] Welsh FK, Wigmore SJ. Roux-en-Y choledochojejunostomy is the method of choice for biliary reconstruction in liver transplantation for primary sclerosing cholangitis. Transplantation 2004;77:602e4. [2] Pandanaboyana S, Bell R, Bartlett AJ, McCall J, Hidalgo E. Meta-analysis of duct-to-duct versus Roux-en-Y biliary reconstruction following liver transplantation for primary sclerosing cholangitis. Transpl Int 2015;28:485e91. [3] Wells MM, Croome KP, Boyce E, Chandok N. Roux-en-Y choledochojejunostomy versus duct-to-duct biliary anastomosis in liver transplantation for primary sclerosing cholangitis: a metaanalysis. Transplant Proc 2013;45:2263e71. [4] Sutton ME, Bense RD, Lisman T, van der Jagt EJ, van den Berg AP, Porte RJ. Duct-to-duct reconstruction in liver transplantation for primary sclerosing cholangitis is associated with fewer biliary complications in comparison with hepaticojejunostomy. Liver Transpl 2014;20:457e63. [5] Egawa H, Ueda Y, Ichida T, Teramukai S, Nakanuma Y, Onishi S, et al. Risk factors for recurrence of primary sclerosing cholangitis after living donor liver transplantation in Japanese registry. Am J Transplant 2011;11:518e27.
ABSTRACT Although Roux-en Y hepaticojejunostomy was previously recommended for the biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC), some recent reports showed no difference in the graft survival between Roux-en Y and duct-toduct anastomosis in deceased-donor liver transplantation. On the other hand, considering the risk of recurrence and the short length of the bile duct of the graft, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor liver transplantation (LDLT) for PSC. A 45 year-old male underwent LDLT using a left-lobe graft donated from his brother. Cholangiography showed no lesion in his common bile duct and duct-to-duct anastomosis was chosen for him. Fifteen months later, he suffered cholangitis due to PSC recurrence and endoscopic retrograde cholangiography was performed. The stents were inserted into his B2 and B3, and he remains well. Because of the ability to easily manage biliary complication, duct-to-duct biliary reconstruction may become the first choice in LDLT for PSC without common bile duct lesions.
T
HE PREFERRED type of biliary reconstruction in liver transplantation (LT) for primary sclerosing cholangitis (PSC) remains unclear. Although Roux-en Y hepaticojejunostomy was previously recommended, because the patients’ native biliary ducts could be diminished, resulting in lower rates of biliary complications [1], graft survival did not differ significantly in groups of patients undergoing Roux-en Y and duct-to-duct biliary anastomosis [2e4]. However, a transplant from a related donor was shown to be a risk factor for PSC recurrence [5]. To our knowledge, duct-to-duct biliary anastomosis has never been reported in a patient undergoing living-donor LT (LDLT) for PSC. CASE 1
A 33-year-old man visited his family physician complaining of itch and jaundice and was diagnosed with PSC by endoscopic retrograde cholangiopancreatography. Endoscopic retrograde bile drainage (ERBD) and steroid treatment were ineffective, and his liver function deteriorated further. At age 45 years, he underwent LDLT using a left-lobe graft donated by his 47-year-old brother, as well as simultaneous splenectomy. The graft weight was 351 g and graft/standard liver volume was 31.9%. Biliary 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.03.069
1196
reconstruction was performed by duct-to-duct anastomosis with interrupted 5-0 polydioxanone sutures. A retrograde transhepatic bile drainage (RTBD) tube was inserted. Intraoperative cholangiography showed no stricture or irregularity (Fig 1A). The operation time was 527 minutes and blood loss was 1550 mL. The patient’s postoperative course was uneventful. He was started on immunosuppressive treatment with steroids, mycophenolate mofetil, and tacrolimus. Cholangiography on postoperative day (POD) 7 showed no biliary stricture, and he was discharged home on POD 17. Three months later, following confirmation of fistula formation, the RTBD tube was removed. Fifteen months after LDLT, he was re-admitted to our institute because of acute cholangitis. Endoscopic retrograde cholangiography (ERC) showed a biliary stricture (Fig 1B). An ERBD tube (8.5 Fr, 12 cm) was inserted into
*Address correspondence to Tomoharu Yoshizumi, MD, PhD, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan. E-mail: [email protected] ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 1196e1198 (2017)
DUCT-TO-DUCT BILIARY RECONSTRUCTION
1197
Fig 1. (A) Intraoperative cholangiography through the retrograde transhepatic bile drainage tube, showing no evidence of biliary stricture or bile leakage. White arrows indicate the site of anastomosis. (B) Primary sclerosing cholangitis recurrence and biliary stricture causing cholangitis 15 months after living-donor liver transplantation. (C) Endoscopic retrograde cholangiography was easily performed and the endoscopic retrograde bile drainage tube inserted into the B2 branch. (D) Following the recurrence of cholangitis, the sphincter was cut and another endoscopic retrograde bile drainage tube was inserted into the B3 branch.
the B2 branch (Fig 1C). There were no complications and his cholangitis improved rapidly. He was discharged home on day 3. However, PSC recurrence worsened and the biliary stricture extended into the B3 branch. Cholangitis occurred 1 month later and another ERBD tube was inserted into the B3 branch (Fig 1D). There were no complications and the patient remains well. CASE 2
A 25-year-old female who has had a history of liver dysfunction due to PSC was referred to our department. She underwent LDLT using a right-lobe graft donated from her 57-year-old father and simultaneous splenectomy. The graft weight was 410 g and graft/standard liver volume was 38.4%. Because both preoperative cholangiography and intraoperative findings showed her common bile duct was normal (Fig 2A), biliary reconstruction was performed by duct-to-duct anastomosis with interrupted 5-0 polydioxanone sutures. A RTBD tube was inserted. The operation time was 639 minutes and blood loss was 3150 mL. She suffered controllable ascites and was discharged on POD 27. The cholangiography at 3 months after LDLT showed no stricture or irregularity
(Fig 2B). Five months have passed and she has been well and shown no biliary complication or PSC recurrence so far. DISCUSSION
Despite recent technical and scientific developments in LT, the recurrence rate of PSC after LT is as high as 11% to 37% [5]. Roux-en Y hepaticojejunostomy has been preferred after LT for PSC [1] because duct-to-duct biliary anastomosis involves the retention of the recipients’ bile ducts, which has been thought responsible for PSC recurrence and biliary complications. The PSC recurrence rate after LT, however, was found to be similar after Roux-en Y reconstruction and duct-to-duct anastomosis, as were graft survival and biliary complication rates [2e4]. Moreover, one study found that the incidence of cholangitis was lower after duct-to-duct reconstruction, perhaps because the ampulla of Vater was retained [2]. Earlier reports evaluated patients who underwent deceased-donor LT (DDLT). To our knowledge, the patient described here is the first to undergo duct-to-duct biliary anastomosis during LDLT for PSC since a report published in 2004 [1]. The patient described in this report experienced PSC recurrence and cholangitis with a biliary stricture, but
1198
MOTOMURA, YOSHIZUMI, WANG ET AL
Fig 2. (A) Preoperative cholangiography showed irregularity and diffuse stenosis on the intrahepatic bile duct, but no lesion of common bile duct. White arrows indicate the level of resection. (B) The cholangiography performed 3 months after living-donor liver transplantation showed no biliary stricture or primary sclerosing cholangitis recurrence. White arrows indicate the level of anastomosis.
ERC and ERBD tube insertion were easily performed, improving both the primary disease and graft function. In contrast to DDLT, the graft bile duct is short in LDLT. That is, the length of the remnant recipient’s bile duct should be long enough for anastomosis. Preoperative ERC of our patient showed no stricture or irregularity of the common bile duct, which was confirmed intraoperatively to be soft enough without fibrosis. These findings suggested that duct-to-duct anastomosis would be safe and effective in this patient. Another advantage of duct-to-duct biliary anastomosis also is the ability to perform endoscopic retrograde cholangiopancreatography and to easily manage biliary complication. According to the reports describing among DDLT cases, Roux-en Y reconstruction could not improve the rates of PSC recurrence or biliary complication after all, and needs percutaneous transhepatic bile drainage tube if happened which would be very harmful for patients. Ductto-duct biliary reconstruction may become the first choice even in LDLT for PSC without common bile duct lesions.
REFERENCES [1] Welsh FK, Wigmore SJ. Roux-en-Y choledochojejunostomy is the method of choice for biliary reconstruction in liver transplantation for primary sclerosing cholangitis. Transplantation 2004;77:602e4. [2] Pandanaboyana S, Bell R, Bartlett AJ, McCall J, Hidalgo E. Meta-analysis of duct-to-duct versus Roux-en-Y biliary reconstruction following liver transplantation for primary sclerosing cholangitis. Transpl Int 2015;28:485e91. [3] Wells MM, Croome KP, Boyce E, Chandok N. Roux-en-Y choledochojejunostomy versus duct-to-duct biliary anastomosis in liver transplantation for primary sclerosing cholangitis: a metaanalysis. Transplant Proc 2013;45:2263e71. [4] Sutton ME, Bense RD, Lisman T, van der Jagt EJ, van den Berg AP, Porte RJ. Duct-to-duct reconstruction in liver transplantation for primary sclerosing cholangitis is associated with fewer biliary complications in comparison with hepaticojejunostomy. Liver Transpl 2014;20:457e63. [5] Egawa H, Ueda Y, Ichida T, Teramukai S, Nakanuma Y, Onishi S, et al. Risk factors for recurrence of primary sclerosing cholangitis after living donor liver transplantation in Japanese registry. Am J Transplant 2011;11:518e27.