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Zeair S, Mamos M, Hirchy-Żak J, Modelewski P, Stasiuk R, Post M, Uździcki A, Witkowski M, Łakomiak A, Wawrzynowicz-Syczewska M. An Inadequate Blood Supply Is a Risk Factor of Anastomotic Biliary Strictures After Liver Transplantation-A Single-Center Study. J Clin Med 2025; 14:1365. [PMID: 40004895 PMCID: PMC11856134 DOI: 10.3390/jcm14041365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2025] [Revised: 02/11/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
Background: Anastomotic biliary strictures (BSs) are among the most common complications after liver transplantation (LT), accounting for 5-15% of adult recipients after deceased-donor transplantation. For some reason, this percentage increased in our center in recent years, and the goal of this study was to find out the reasons behind this to avoid this complication in the future. Material and Methods: We retrospectively analyzed the occurrence of anastomotic biliary strictures in 230 cadaveric-donor LTs performed in our center between January 2019 and December 2023. Many variables related to the donor, recipient, and surgical procedure were compared between patients who experienced BS and those without this complication. Statistical analysis was performed using Fisher's exact test, a one-way ANOVA test, and Pearson's correlation coefficient. Results: Altogether, 51 patients (22.17%) developed BSs. This percentage was especially high in 2023 (32%). The only significant differences found in study group compared to the control group were the requirement of additional doses of vasopressors during surgery (45 (86.53%) vs. 138 (77.09%), p = 0.0001) and more frequent instances of reperfusion syndrome (8/51 (15.68%) vs. 11/179 (6.11%), p = 0.00001). Conclusions: We conclude that ischemia during LT has an advantage over technical parameters in the development of BSs after LT. Appropriate blood volume resuscitation as opposed to inotropic treatment may reduce the risk of this complication.
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Affiliation(s)
- Samir Zeair
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Marek Mamos
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Julia Hirchy-Żak
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Patryk Modelewski
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Robert Stasiuk
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Mariola Post
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Artur Uździcki
- Department of Internal Medicine and Gastroenterology, Pomeranian Regional Hospital, 71-455 Szczecin, Poland;
| | - Michał Witkowski
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Agata Łakomiak
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Marta Wawrzynowicz-Syczewska
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
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Chiche L, Marichez A, Rayar M, Simon A, Mohkam K, Muscari F, Boudjema K, Mabrut JY, Adam JP, Laurent C. Liver transplantation: Do not abandon T-tube drainage-a multicentric retrospective study of the ARCHET research group. Updates Surg 2025; 77:65-75. [PMID: 39541088 DOI: 10.1007/s13304-024-02008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/25/2024] [Indexed: 11/16/2024]
Abstract
Biliary complications remain a real issue in liver transplantation (LT). Despite meta-analyses, the anastomosis technique, especially the use of biliary drain as T-Tube drain (TT) or transcystic drain, remains controversial. This study conducted by the ARCHET research group examine the incidence and types of biliary complications (BC) after LT according to the presence or absence of a biliary drain. 1485 patients with LT surgery between 2009 to 2015 in 4 LT centers were included, divided into 3 groups: no drain (ND n = 442), transcystic drain (TCD, n = 169) and TT(n = 874).The T-Tube group includes 3 techniques: transanastomotic, subanastomotic and tunneled retroperitoneal. Fistula and biliary stricture (AS) rates were studied. The risk factors of BC were investigated by multivariate analysis. The BC rate was lower in the TT group (17% TT, 25% TCD, 31% ND, p < 0.05), the complication rate Dindo-Clavien grade ≥ III is higher in the ND group (24% vs. 10% TT p < 0.05). Arterial complication has been found as a risk factor of BC with the multivariate analysis (p < 0.01, OR 1.86 [1.20-2.84]). In addition, the TT decreased by 5 the risk of AS (p < 0.05, OR 0.19 [0.12-0.28]). The fistula rate does not differ regardless of the reconstruction mode. In this study, biliary drain decreases the rate of BC. The findings confirmed the role of T-tube insertion in prevention of AS regardless of the way it is set up.
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Affiliation(s)
- Laurence Chiche
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France.
- Inserm, UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France.
| | - Arthur Marichez
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
- Inserm, UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France
| | - Michel Rayar
- Department of Hepatobiliary and Digestive Surgery, CHU Rennes, Rennes, France
- Department of Research INSERM CIC 1414, University Rennes, Rennes, France
| | - Agathe Simon
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Kayvan Mohkam
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse CHU Lyon, Lyon, France
- Department of Research, INSERM Unit U1052, Cancer Research Center of Lyon, Lyon, France
| | - Fabrice Muscari
- Department of Digestive Surgery, Toulouse University Hospital, 31059, Toulouse, France
- Department of Research, INSERM, CRCT, University Toulouse, Toulouse, France
| | - Karim Boudjema
- Department of Digestive Surgery, Toulouse University Hospital, 31059, Toulouse, France
- Department of Research, INSERM, CRCT, University Toulouse, Toulouse, France
| | - Jean-Yves Mabrut
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse CHU Lyon, Lyon, France
- Department of Research, INSERM Unit U1052, Cancer Research Center of Lyon, Lyon, France
| | - Jean-Philippe Adam
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Christophe Laurent
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
- Inserm UMR 1312, Team 8 "Biotherapy Genetics and Oncology", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France
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Semash KO. Post-liver transplant biliary complications. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2024; 26:72-90. [DOI: 10.15825/1995-1191-2024-3-72-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Biliary complications (BCs) are the most frequent complications following liver transplantation (LT). They are a major source of morbidity after LT. The incidence of BCs after LT is reported to range from 5% to 45%. The main post-LT biliary complications are strictures, biliary fistulas and bilomas, cholelithiasis, sphincter of Oddi dysfunction, hemobilia, and mucocele. Risk factors for biliary complications are diverse. In this article we seek to review the main types of biliary complications and modern approaches to their diagnosis and treatment.
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Wang L, Yang B, Jiang H, Wei L, Zhao Y, Chen Z, Chen D. Individualized Biliary Reconstruction Techniques in Liver Transplantation: Five Years' Experience of a Single Institution. J Gastrointest Surg 2023; 27:1188-1196. [PMID: 36977864 DOI: 10.1007/s11605-023-05657-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/03/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND To summarize the experience of individualized biliary reconstruction techniques in deceased donor liver transplantation and explore potential risk factors for biliary stricture. METHODS We retrospectively collected medical records of 489 patients undergoing deceased donor liver transplantation at our center between January 2016 and August 2020. According to anatomical and pathological conditions of donor and recipient biliary ducts, patients' biliary reconstruction methods were divided into six types. We summarized the experience of six different reconstruction methods and analyzed the biliary complications' rate and risk factors after liver transplantation. RESULTS Among 489 cases of biliary reconstruction methods during liver transplantation, there were 206 cases of type I, 98 cases of type II, 96 cases of type III, 39 cases of type IV, 34 cases of type V, and 16 cases of type VI. Biliary tract anastomotic complications occurred in 41 cases (8.4%), including 35 cases with biliary stricture (7.2%), 9 cases with biliary leakage (1.8%), 19 cases with biliary stones (3.9%), 1 case with biliary bleeding (0.2%), and 2 cases with biliary infection (0.4%). One of 41 patients died of biliary tract bleeding and one died of biliary infection. Thirty-six patients significantly improved after treatment, and 3 patients received secondary transplantation. Compared with patients without biliary stricture, a higher warm ischemic time was observed in patients with non-anastomotic stricture and more leakage of bile in patients with an anastomotic stricture. CONCLUSION The individualized biliary reconstruction methods are safe and feasible to decrease perioperative anastomotic biliary complications. Biliary leakage may contribute to anastomotic biliary stricture and cold ischemia time to non-anastomotic biliary stricture.
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Affiliation(s)
- Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China
| | - Bo Yang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China
| | - Hongmei Jiang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China
| | - Lai Wei
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China
| | - Yuanyuan Zhao
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China
| | - Zhishui Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China.
| | - Dong Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Huazhong University of Science and Technology, 1905 Jiefang Avenue, Wuhan City, Hubei Province, China.
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Wang J, Cui SP, Lyu SC, Chen Q, Huang JC, Wang HX, He Q, Lang R. Application of cholecystic duct plasty in the prevention of biliary complications following orthotopic liver transplantation. Front Surg 2023; 10:1087327. [PMID: 37206346 PMCID: PMC10189116 DOI: 10.3389/fsurg.2023.1087327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The purpose was aimed to evaluate the safety and effectiveness of cholecystic duct plasty (CDP) and biliary reconstruction techniques preventing biliary complications following orthotopic liver transplantation (OLT) first proposed by our center. METHODS 127 enrolled patients who underwent LT in our center from January 2015 to December 2019 were analyzed retrospectively. According to the mode of biliary tract reconstruction, patients were divided into CDP group (Group 1, n = 53) and control group (Group 2, n = 74). The differences of perioperative general data, biliary complications and long-term prognosis between two groups were compared and analyzed. RESULTS All patients completed the operation successfully, the incidence of perioperative complications was 22.8%. There was no significant difference in perioperative general data and complications between the two groups. Follow-up ended in June 2020, with a median follow-up period of 31 months. During the follow-up period, biliary complications occurred in 26 patients, with an overall incidence of 20.5%. The overall incidence of biliary complications and anastomotic stenosis in Group 1 was lower than that in Group 2 (P < 0.05). There was no significant difference in overall prognosis between the two groups (P = 0.274), however, the cumulative incidence of biliary complications in Group 1 was lower than that in Group 2 (P = 0.035). CONCLUSION Reconstruction of common bile duct by CDP represents considerable safety and practicability, particularly for patients with small diameter of common bile duct or wide discrepancy of bile duct size between donor and recipient.
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Affiliation(s)
- Jing Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
- Department of Thoracic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Song-ping Cui
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Shao-cheng Lyu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Qing Chen
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Jin-can Huang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Han-xuan Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
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Martinino A, Pereira JPS, Spoletini G, Treglia G, Agnes S, Giovinazzo F. The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review. Transplant Rev (Orlando) 2022; 36:100711. [PMID: 35843181 DOI: 10.1016/j.trre.2022.100711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/23/2022]
Abstract
Biliary complications are one of the main concerns after liver transplantation, and to avoid these, the use of a T-tube has been advocated in biliary reconstruction. Most liver transplantation centres perform a biliary anastomosis without a T-tube to avoid the risk of complications and T-tube-related costs. Several meta-analyses have reached discordant conclusions regarding the benefits of using the T-tube. An umbrella review was performed to summarise quantitative measures about overall biliary complications, biliary leaks, biliary strictures and cholangitis associated with the T-tube use after liver transplantation. Published systematic reviews and meta-analyses related to the use of T-Tube in liver transplantation were searched and analysed. From the comprehensive literature search from PubMed, EMBASE and Cochrane Library databases on the 25th of October 2021, 104 records were retrieved. Seven meta-analyses and two systematic reviews were included in the final analysis. All the meta-analyses of RCT stated no differences in overall biliary complications and biliary leaks when using T-tube for a liver transplant (I2 ≥ 90% and I2 range 0-76%, respectively). The meta-analysis of the RCTs evaluating the risks of biliary strictures after liver transplantation showed that T-tube protects from the complication (I2 range 0-80%). Biliary anastomosis without a T-tube has equivalent overall biliary complications and bile leaks compared to the T-tube reconstruction. The incidence of biliary strictures is attenuated in patients with T-tubes, and most meta-analyses of RCTs have very low heterogeneity. Therefore, the present umbrella review suggests a selective T-tube use, particularly in small biliary ducts or transplants with marginal grafts at high risk of post-LT strictures.
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Affiliation(s)
| | | | - Gabriele Spoletini
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giorgio Treglia
- Academic Education, Research and Innovation Area, General Directorate, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland; Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900 Lugano, Switzerland
| | - Salvatore Agnes
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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Kalisvaart M, de Jonge J, Abt P, Orloff S, Muiesan P, Florman S, Spiro M, Raptis DA, Eghtesad B. The role of T-tubes and abdominal drains on short-term outcomes in liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14719. [PMID: 35596705 PMCID: PMC10078006 DOI: 10.1111/ctr.14719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036). RESULTS Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (six RCTs) assessed the use of T-tubes and four regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend toward more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used. CONCLUSIONS Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation).
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Affiliation(s)
- Marit Kalisvaart
- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeroen de Jonge
- Erasmus MC Transplant Institute, Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter Abt
- Department of Surgery, Division of Transplantation, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/ Hepatobiliary Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paolo Muiesan
- Policlinico di Milano Ospedale Maggiore
- Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Sander Florman
- The Recanati Miller Transplantation Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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Duct-to-duct biliary reconstruction with or without an Intraductal Removable Stent in Liver Transplantation: The BILIDRAIN-T Multicentric Randomized Trial. JHEP Rep 2022; 4:100530. [PMID: 36082313 PMCID: PMC9445377 DOI: 10.1016/j.jhepr.2022.100530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/26/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background & Aims Biliary complications (BC) following liver transplantation (LT) are responsible for significant morbidity. No technical procedure during reconstruction has been associated with a risk reduction of BC. The placement of an intraductal removable stent (IRS) during reconstruction followed by its endoscopic removal showed feasibility and safety in a preliminary study. This multicentric randomised controlled trial aimed at evaluating the impact of an IRS on BC following LT. Methods This multicentric randomised controlled trial was conducted in 7 centres from April 2015 to February 2019. Randomisation was done during LT when a duct-to-duct anastomosis was confirmed with at least 1 of the stump diameters ≤7 mm. In the IRS group, a custom-made segment of a T-tube was placed into the bile duct to act as a stake during healing and was removed endoscopically 4 to 6 months post LT. The primary endpoint was the incidence of BC (fistulae and strictures) within 6 months post LT. The secondary criteria were complications related to the IRS placement or extraction, including endoscopic retrograde cholangio-pancreatography (ERCP)-related complications. Results In total, 235 patients were randomised: 117 in the IRS group and 118 in the control group. BC occurred in 31 patients (26.5%) in the IRS group vs. 24 (20.3%) in the control group (p = 0.27), including 16 (13.8%) and 15 (12.8%) strictures, respectively. IRS migration occurred in 24 patients (20.5%), cholangitis in 1 (0.9%), acute pancreatitis in 2 (1.8%), and difficulty during endoscopic extraction in 19 (19.4%). No predictive factor for BC was identified. Conclusions IRS does not prevent BC after LT and may require specific endoscopic expertise for removal. Trial registration number (ClinicalTrials.gov) NCT02356939 (https://clinicaltrials.gov/ct2/show/NCT02356939?term=NCT02356939&draw=2&rank=1). Lay summary Liver transplantation is a life-saving treatment for many patients with end-stage liver disease. However, it can be associated with complications involving the bile duct reconstruction. Herein, the placement of a specific stent called an intraductal removable stent was trialled as a way of reducing bile duct complications in patients undergoing liver transplantation. Unfortunately, it did not help preventing such complications.
An IRS was placed during biliary reconstruction in bile ducts ≤7 mm; ERCP removal was 4–6 months post LT. The primary endpoint was the incidence of biliary complications (fistulae and strictures) within 6 months post LT. Biliary complications occurred in 31 patients (26.5%) in the IRS vs. 24 (20.3%) in the control group (p = 0.27). IRS migrated in 24 (20.5%) patients, and extraction was difficult in 19 (19.4%). No predictive factor for biliary complications was identified.
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Vest M, Ciobanu C, Nyabera A, Williams J, Marck M, Landry I, Sumbly V, Iqbal S, Shah D, Nassar M, Nso N, Rizzo V. Biliary Anastomosis Using T-tube Versus No T-tube for Liver Transplantation in Adults: A Review of Literature. Cureus 2022; 14:e24253. [PMID: 35602800 PMCID: PMC9117859 DOI: 10.7759/cureus.24253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/06/2022] Open
Abstract
The T-tube-directed biliary anastomosis in orthotopic liver transplantation (OLT) aims to minimize preventable biliary complications, including bile leaks and strictures. Biliary complications in patients with OLT increase the risk of morbidity and mortality. This review paper evaluated the current evidence on the routine use of T-tube reconstruction in OLT cases. A review of prospective, retrospective, observational, cohort studies as well as systematic reviews, meta-analyses, review papers, and opinion papers has been conducted to evaluate the therapeutic potential of T tube-based biliary anastomosis in cases of OLT. Our finding showed a bile leak incidence of 16.6% and 6.6% in T-tube and non-T-tube groups, respectively. The results indicated a lower incidence of anastomotic fistulae in the non-T-tube group (0.6%) compared to the T-tube group (4%). The findings negated statistically significant differences in the three-year actuarial survival rates based on biliary anastomosis with and without T-tube intervention (62.5% vs. 69.8%). The studies revealed a 6-11% and 2-11% incidence of cholangitis in OLT patients with T-tube-based reconstruction and those without a T-tube, respectively, and 26% and 20% incidence of total biliary complications in OLT patients with and without T-tube, respectively. In addition, the findings ruled out the influence of a T-tube on the incidence of perioperative complications, endoscopies, and reoperations in OLT cases. The current evidence correlates the increased incidence of bile leaks, cholangitis, and overall biliary complications with the use of a T-tube during OLT. In addition, T-tube-guided reconstruction has no impact on perioperative complications, overall survival, endoscopies, and reoperations in OLT cases.
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Affiliation(s)
- Mallorie Vest
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | | | - Akwe Nyabera
- Internal Medicine, New York City Health and Hospitals/Queens, New York City, USA
| | - John Williams
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Matthew Marck
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Ian Landry
- Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Vikram Sumbly
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Saba Iqbal
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Deesha Shah
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Mahmoud Nassar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Nso Nso
- Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
| | - Vincent Rizzo
- Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, USA
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10
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Spoletini G, Bianco G, Franco A, Frongillo F, Nure E, Giovinazzo F, Galiandro F, Tringali A, Perri V, Costamagna G, Avolio AW, Agnes S. Pediatric T-tube in adult liver transplantation: Technical refinements of insertion and removal. World J Gastrointest Surg 2021; 13:1628-1637. [PMID: 35070068 PMCID: PMC8727192 DOI: 10.4240/wjgs.v13.i12.1628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/17/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the increasing use of extended-criteria donor organs, the interest around T-tubes in liver transplantation (LT) was restored whilst concerns regarding T-tube-related complications persist. AIM To describe insertion and removal protocols implemented at our institution to safely use pediatric rubber 5-French T-tubes and subsequent outcomes in a consecutive series of adult patients. METHODS Data of consecutive adult LT patients from brain-dead donors, treated from March 2017 to December 2019, were collected (i.e., biliary complications, adverse events, treatment after T-Tube removal). Patients with upfront hepatico-jejunostomy, endoscopically removed T-tubes, those who died or received retransplantation before T-tube removal were excluded. RESULTS Seventy-two patients were included in this study; T-tubes were removed 158 d (median; IQR 128-206 d) after LT. In four (5.6%) patients accidental T-tube removal occurred requiring monitoring only; in 68 (94.4%) patients Nelaton drain insertion was performed according to our protocol, resulting in 18 (25%) patients with a biliary output, subsequently removed after 2 d (median; IQR 1-4 d). Three (4%) patients required endoscopic retrograde cholangiopancreatography (ERCP) due to persistent Nelaton drain output. Three (4%) patients developed suspected biliary peritonitis, requiring ERCP with sphincterotomy and nasobiliary drain insertion (only one revealing contrast extravasation); no patient required percutaneous drainage or emergency surgery. CONCLUSION The use of pediatric rubber 5-French T-tubes in LT proved safe in our series after insertion and removal procedure refinements.
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Affiliation(s)
- Gabriele Spoletini
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Bianco
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Antonio Franco
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Francesco Frongillo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Erida Nure
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Federica Galiandro
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Alfonso Wolfango Avolio
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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11
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Pavicevic S, Uluk D, Reichelt S, Fikatas P, Globke B, Raschzok N, Schmelzle M, Öllinger R, Schöning W, Eurich D, Pratschke J, Lurje G. Hypothermic oxygenated machine perfusion for extended criteria donor allografts-Preliminary experience with extended organ preservation times in the setting of organ reallocation. Artif Organs 2021; 46:306-311. [PMID: 34724239 DOI: 10.1111/aor.14103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/04/2021] [Accepted: 10/28/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND In times of critical organ shortage, poor organ pool utilization and increased use of extended-criteria donor (ECD) allografts remain a major problem. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a promising and feasible strategy in ECD liver transplantation (LT). However, potential safety limits regarding the duration of perfusion are yet to be explored. Besides marginal allograft quality (steatosis), prolonged cold ischemia time remains the most important factor for a high number of liver allografts being declined for transplantation. PATIENTS AND METHODS Two ECD-allografts were each allocated to two recipients, who proved to be unsuitable to receive the assigned allograft upon arrival at the transplant center. The organs were reallocated by Eurotransplant and accepted by our center for two different backup patients. During that time, HOPE was commenced and continued until the recipient hepatectomy was completed. Postoperative allograft function was assessed by serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and International Normalized Ratio. Incidence of early allograft dysfunction (EAD), postoperative complications, and length of hospital stay were analyzed. RESULTS HOPE was applied for 4 h 35 min and 4 h 20 min, resulting in a total cold preservation time of 17 h 29 min and 15 h 20 min, respectively. Both recipients displayed decreasing serum transaminases and bilirubin levels postoperatively. No EAD or major postoperative complications occurred in either patient. Serum ALT and AST levels were within the normal range at discharge. CONCLUSIONS Extended HOPE enables the safe extension of preservation time for up to 18 h in human LT. End-ischemic HOPE may significantly improve organ pool utilization, while simultaneously facilitating operating room logistics and preventing organ injury.
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Affiliation(s)
- Sandra Pavicevic
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Deniz Uluk
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Reichelt
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Panagiotis Fikatas
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Brigitta Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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12
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Song S, Lu T, Yang W, Gong S, Lei C, Yang J, Feng L, Tian H, Yang K, Guo T. T-tube or no T-tube for biliary tract reconstruction in orthotopic liver transplantation: an updated systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:1201-1213. [PMID: 33720798 DOI: 10.1080/17474124.2021.1903874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: Biliary tract reconstruction with or without T-tube is commonly used in orthotopic liver transplantation (OLT). However, the efficacy and safety of T-tube usage remain controversial. This meta-analysis was conducted to assess the latest evidence of clinical outcomes.Methods: Embase, Cochrane Library, PubMed, and Web of Science were systematically searched from inception to 20 January 2021 for eligible studies. The analyses were performed using Review Manager and Stata.Results: A total of 24 trials involving 3320 participants were included in the meta-analysis. Compared with the no T-tube group, there was a higher incidence of overall biliary complications (OR:1.54; 95%CI, 1.06-2.24; P = 0.02), bile leaks (OR:2.34; 95%CI,1.57-3.48; P < 0.0001), cholangitis (OR:2.78; 95%CI,1.19-6.51; P = 0.002), and longer cold ischemia time (MD:22.27; 95%CI,0.80-43.74; P = 0.04) in the T-tube group. Furthermore, the no T-tube group had significantly higher odds of biliary strictures than the T-tube group (OR:0.60; 95%CI, 0.47-0.78; P = 0.0001).Conclusion: T-tube is still not routinely recommended, but is a good choice for OLT patients at high risk of biliary strictures. Notably, the higher rate of biliary complications in the T-tube group did not translate into an increase in endoscopic or re-operative interventions.
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Affiliation(s)
- Shaoming Song
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tingting Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Institution of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, China
| | - Wenwen Yang
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Shiyi Gong
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Caining Lei
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jia Yang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Lufang Feng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hongwei Tian
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
| | - Tiankang Guo
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
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13
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Zhao JZ, Qiao LL, Du ZQ, Zhang J, Wang MZ, Wang T, Liu WM, Zhang L, Dong J, Wu Z, Wu RQ. T-tube vsno T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis. World J Gastroenterol 2021; 27:1507-1523. [DOI: https:/dx.doi.org/10.3748/wjg.v27.i14.1507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2025] Open
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14
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Zhao JZ, Qiao LL, Du ZQ, Zhang J, Wang MZ, Wang T, Liu WM, Zhang L, Dong J, Wu Z, Wu RQ. T-tube vs no T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis. World J Gastroenterol 2021; 27:1507-1523. [PMID: 33911471 PMCID: PMC8047534 DOI: 10.3748/wjg.v27.i14.1507] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/29/2020] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation (OLT) remains a debatable question. Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures. Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications. Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated. AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT. METHODS In the electronic databases MEDLINE, PubMed, Scopus, ClinicalTrials.gov, the Cochrane Library, the Cochrane Hepato-Biliary Group Controlled Trails Register, and the Cochrane Central Register of Controlled Trials, we identified 17 studies (eight randomized controlled trials and nine comparative studies) from January 1995 to October 2020. The data of the studies before and after 2010 were separately extracted. We chose the overall biliary complications, bile leaks or fistulas, biliary strictures (anastomotic or non-anastomotic), and cholangitis as outcomes. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to describe the results of the outcomes. Furthermore, the test for overall effect (Z) was used to test the difference between OR and 1, where P ≤ 0.05 indicated a significant difference between OR value and 1. RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis. The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010 (P = 0.012, OR = 0.62, 95%CI: 0.42-0.90), while the same benefit was not seen in studies after 2010 (P = 0.60, OR = 0.76, 95%CI: 0.27-2.12). No significant difference in the incidence of overall biliary complications (P = 0.37, OR = 1.41, 95%CI: 0.66-2.98), bile leaks (P = 0.89, OR = 1.04, 95%CI: 0.63-1.70), and cholangitis (P = 0.27, OR = 2.00, 95%CI: 0.59-6.84) was observed between using and not using a T-tube before 2010. However, using a T-tube appeared to increase the incidence of overall biliary complications (P = 0.049, OR = 1.49, 95%CI: 1.00-2.22), bile leaks (P = 0.048, OR = 1.91, 95%CI: 1.01-3.64), and cholangitis (P = 0.02, OR = 7.21, 95%CI: 1.37-38.00) after 2010. A random-effects model was used in biliary strictures (after 2010), overall biliary complications (before 2010), and cholangitis (before 2010) due to their heterogeneity (I 2 = 62.3%, 85.4%, and 53.6%, respectively). In the sensitivity analysis (only RCTs included), bile leak (P = 0.66) lost the significance after 2010 and a random-effects model was used in overall biliary complications (before 2010), cholangitis (before 2010), bile leaks (after 2010), and biliary strictures (after 2010) because of their heterogeneity (I 2 = 92.2%, 65.6%, 50.9%, and 80.3%, respectively). CONCLUSION In conclusion, the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.
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Affiliation(s)
- Jun-Zhou Zhao
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Lin-Lan Qiao
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Zhao-Qing Du
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jia Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Meng-Zhou Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Tao Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Wu-Ming Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Lin Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jian Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Rong-Qian Wu
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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15
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Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr 2021; 10:76-92. [PMID: 33575291 DOI: 10.21037/hbsn.2019.09.01] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
Importance Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation. Objective The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT. Evidence Review a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment. Findings Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks. Conclusions and Relevance BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.
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Affiliation(s)
- Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
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16
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria.
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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17
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Mittler J, Chavin KD, Heinrich S, Kloeckner R, Zimmermann T, Lang H. Surgical Duct-to-Duct Reconstruction: an Alternative Approach to Late Biliary Anastomotic Stricture After Deceased Donor Liver Transplantation. J Gastrointest Surg 2021; 25:708-712. [PMID: 32728823 PMCID: PMC7940287 DOI: 10.1007/s11605-020-04735-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/01/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bilio-enteric diversion is the current surgical standard in patients after deceased donor liver transplantation (DDLT) with a biliary anastomotic stricture failing interventional treatment and requiring surgical repair. In contrast to this routine, the aim of this study was to show the feasibility and safety of a duct-to-duct biliary reconstruction. PATIENTS Between 2012 and 2019, we performed a total of 308 DDLT in 292 adult patients. The overall biliary complication rate was 20.5%. Patients with non-anastomotic or combined strictures were excluded from this analysis. Out of 273 patients after a primary duct-to-duct reconstruction, 20 (7.3%) developed late isolated AS. Seven of these patients failed interventional biliary treatment and required a surgical repair. RESULTS Duct-to-duct reconstruction was feasible and successful in all patients. Liver function tests fully normalized and no patient required any form of biliary intervention after surgery. One patient with intraoperative cholangiosepsis was ICU bound for 5 days, and another patient with a subhepatic abscess required percutaneous drainage. There was no perioperative death. The median length of hospital stay was 8 (5-17) days. The median time of follow-up after relaparotomy was 1593 (434-2495) days. CONCLUSION Duct-to-duct reconstruction is a feasible and safe option in selected patients requiring surgical repair for isolated AS after DDLT. This approach preserves the biliary anatomy and avoids the potential side effects of a bilio-enteric diversion.
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Affiliation(s)
- Jens Mittler
- Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Kenneth D. Chavin
- University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047 USA
| | - Stefan Heinrich
- Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Tim Zimmermann
- First Medical Department, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral, and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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18
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Girard E, Chagnon G, Broisat A, Dejean S, Soubies A, Gil H, Sharkawi T, Boucher F, Roth GS, Trilling B, Nottelet B. From in vitro evaluation to human postmortem pre-validation of a radiopaque and resorbable internal biliary stent for liver transplantation applications. Acta Biomater 2020; 106:70-81. [PMID: 32014582 DOI: 10.1016/j.actbio.2020.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022]
Abstract
The implantation of an internal biliary stent (IBS) during liver transplantation has recently been shown to reduce biliary complications. To avoid a potentially morbid ablation procedure, we developed a resorbable and radiopaque internal biliary stent (RIBS). We studied the mechanical and radiological properties of RIBS upon in vivo implantation in rats and we evaluated RIBS implantability in human anatomical specimens. For this purpose, a blend of PLA50-PEG-PLA50 triblock copolymer, used as a polymer matrix, and of X-ray-visible triiodobenzoate-poly(ε-caprolactone) copolymer (PCL-TIB), as a radiopaque additive, was used to design X-ray-visible RIBS. Samples were implanted in the peritoneal cavity of rats. The radiological, chemical, and biomechanical properties were evaluated during degradation. Further histological studies were carried out to evaluate the degradation and compatibility of the RIBS. A human cadaver implantability study was also performed. The in vivo results revealed a decline in the RIBS mechanical properties within 3 months, whereas clear and stable X-ray visualization of the RIBS was possible for up to 6 months. Histological analyses confirmed compatibility and resorption of the RIBS, with a limited inflammatory response. The RIBS could be successfully implanted in human anatomic specimens. The results reported in this study will allow the development of trackable and degradable IBS to reduce biliary complications after liver transplantation. STATEMENT OF SIGNIFICANCE: Biliary reconstruction during liver transplantation is an important source of postoperative morbidity and mortality although it is generally considered as an easy step of a difficult surgery. In this frame, internal biliary stent (IBS) implantation is beneficial to reduce biliary anastomosis complications (leakage, stricture). However, current IBS are made of non-degradable silicone elastomeric materials, which leads to an additional ablation procedure involving potential complications and additional costs. The present study provides in vitro and human postmortem implantation data related to the development and evaluation of a resorbable and radiopaque internal biliary stent (RIBS) that could tackle these drawbacks.
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Affiliation(s)
- Edouard Girard
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Département de chirurgie digestive et de l'urgence, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France; Laboratoire d'anatomie des Alpes françaises (LADAF), UFR de médecine de Grenoble, Université de Grenoble-Alpes, F-38700 Grenoble, France.
| | - Grégory Chagnon
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France
| | - Alexis Broisat
- INSERM, Unité 1039, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Stéphane Dejean
- IBMM, Université de Montpellier, CNRS, ENSCM, Montpellier, France
| | - Audrey Soubies
- INSERM, Unité 1039, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Hugo Gil
- Département d'anatomopathologie et cytologie, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France
| | - Tahmer Sharkawi
- ICGM, Université de Montpellier, CNRS, ENSCM, Montpellier, France
| | - François Boucher
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Gaël S Roth
- Institute for Advanced Biosciences, INSERM U1209/CNRS UMR 5309, Université Grenoble-Alpes, F-38700 Grenoble, France; Clinique universitaire d'Hépato-gastroentérologie et Oncologie digestive, CHU Grenoble-Alpes, Grenoble 38043, France
| | - Bertrand Trilling
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Département de chirurgie digestive et de l'urgence, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France; Laboratoire d'anatomie des Alpes françaises (LADAF), UFR de médecine de Grenoble, Université de Grenoble-Alpes, F-38700 Grenoble, France
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de Oliveira Filho JJ, Riera R, Matos D, Kleinubing DR, Linhares MM. Biliary anastomosis using T-tube versus no T-tube for liver transplantation in adults. Hippokratia 2019. [DOI: 10.1002/14651858.cd013289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Rachel Riera
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Cochrane Brazil; Rua Borges Lagoa, 564 cj 63 São Paulo SP Brazil 04038-000
| | - Delcio Matos
- Escola Paulista de Medicina, Universidade Federal de São Paulo; Department of Gastroenterological Surgery; Rua Edison 278, Apto 61 Campo Belo São Paulo São Paulo Brazil 04618-031
| | - Diego R Kleinubing
- Universidade Federal do Pampa; Department of Surgery, Faculty of Medicine; Uruguaiana Rio Grande do Sul Brazil
| | - Marcelo Moura Linhares
- Universidade Federal de São Paulo; Department of Surgery; Rua Leandro Dupre, 334. Ap-21 Sao Paulo SP Brazil 04025011
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Lattanzi B, Ott P, Rasmussen A, Kudsk KR, Merli M, Villadsen GE. Ischemic Damage Represents the Main Risk Factor for Biliary Stricture After Liver Transplantation: A Follow-Up Study in a Danish Population. In Vivo 2019; 32:1623-1628. [PMID: 30348725 DOI: 10.21873/invivo.11423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary complications (BC) are frequently observed following liver transplantation. The aim of the present retrospective study, conducted at an outpatients' tertiary care hospital, was to determine the incidence of biliary complications and risk factors associated with their development in liver transplantation (lT) patients. MATERIALS AND METHODS The medical records were reviewed for all patients who underwent liver transplantation at the Rigshospitalet, Copenhagen, Denmark, from 2000 to 2011 and were referred to the Aarhus University Hospital for follow-up. Patients who died within 3 months of surgery or had incomplete clinical information were excluded. All data for demographic characteristics and possible risk factors for development of biliary stricture were collected. Fifty-one patients were included. RESULTS The median age at transplantation was 40 (range=7-64) years, and 53% of patients were males. Biliary complications occurred in 18 patients (35%), the majority of whom developed strictures (12 patients, 24%). Univariate and multivariate analyses revealed that cytomegalovirus infection (p=0.008), hepatic artery obstruction (p=0.03) and hepatic artery graft abnormalities (p=0.03) were independent risk factors for the development of biliary strictures. CONCLUSION One-third of patients presented biliary complications after liver transplantation, among which biliary strictures were the most common. Cytomegalovirus infection, hepatic artery stenosis and anatomical abnormality of the graft's hepatic artery are independent risk factors for the development of biliary stricture.
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Affiliation(s)
- Barbara Lattanzi
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Raben Kudsk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuela Merli
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
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21
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Selective Indication of T-Tube in Liver Transplantation: Prospective Validation of the Results of a Randomized Controlled Trial. Transplant Proc 2019; 51:44-49. [DOI: 10.1016/j.transproceed.2018.03.133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 01/03/2023]
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22
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Abdel Wahab M, Shehta A, Adly R, Elshoubary M, Salah T, Yassen AM, Elmorshedi M, Emara MM, Abdelkhalek M, Elsedeiq M, Shiha U, Elghawalby AN, Eldesoky M, Monier A, Said R. Internal hernia of the small intestine around biliary catheter after living-donor liver transplantation: A case report. Int J Surg Case Rep 2018; 49:158-162. [PMID: 30007264 PMCID: PMC6068080 DOI: 10.1016/j.ijscr.2018.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Biliary reconstruction is a cornerstone of living-donor liver transplantation (LDLT). The routine uses of trans-anastomotic biliary catheters in biliary reconstruction had been a controversial issue. We describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter. PRESENTATION A 42 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Biliary reconstruction was done by single duct-to-duct anastomosis over trans-anastomotic biliary catheter. The patient was doing well apart from early postoperative ascites that was managed medically. Three weeks after surgery, the patient developed severe agonizing central abdominal pain not responding to anti-spasmodics and analgesics. The decision was to proceed for surgical exploration. Exploration revealed internal herniation of the small bowel loops around the trans-anastomotic biliary catheter without strangulation. Reduction of the internal hernia was done by releasing the fixation of the biliary catheter from the anterior abdominal wall. Small bowel resection was not required. The patient had smooth postoperative course and was discharged 10 days after surgery. DISCUSSION Awareness regarding this rare complication plus early surgical intervention can prevent the development of postoperative morbidity and mortality. To the best of our knowledge this is the first report to describe such are complication after LDLT. CONCLUSION We report the first case of internal herniation of small bowel around biliary catheter early after LDLT.
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Affiliation(s)
- Mohamed Abdel Wahab
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed Shehta
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt.
| | - Reham Adly
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Mohamed Elshoubary
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Tarek Salah
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Amr M Yassen
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Mohamed Elmorshedi
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Moataz M Emara
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Mostafa Abdelkhalek
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Mahmoud Elsedeiq
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Usama Shiha
- Diagnostic & Interventional Radiology Department, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed N Elghawalby
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Mohamed Eldesoky
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed Monier
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
| | - Rami Said
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Egypt
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23
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Internal biliary stenting in liver transplantation. Langenbecks Arch Surg 2018; 403:487-494. [DOI: 10.1007/s00423-018-1669-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
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24
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Senter-Zapata M, Khan AS, Subramanian T, Vachharajani N, Dageforde LA, Wellen JR, Shenoy S, Majella Doyle MB, Chapman WC. Patient and Graft Survival: Biliary Complications after Liver Transplantation. J Am Coll Surg 2018; 226:484-494. [PMID: 29360615 DOI: 10.1016/j.jamcollsurg.2017.12.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary complications (BCs) affect up to to 34% of liver transplant recipients and are a major source of morbidity and cost. This is a 13-year review of BCs after liver transplantation (LT) at a tertiary care center. STUDY DESIGN We conducted a single-center retrospective review of our prospective database to assess BCs in adult (aged 18 years or older) liver transplant recipients during a 13-year period (2002 to 2014). Biliary complications were divided into 3 subgroups: leak alone (L), stricture alone (S), and both leak and strictures (LS). Controls (no BCs) were used for comparison. RESULTS There were 1,041 adult LTs performed during the study period; BCs developed in 239 (23%) of these patients: 55 (23%) L, 148 (62%) S, and 36 (15%) LS. One hundred and two (43%) were early (less than 30 d). Surgical revision was required in 42 cases (17%) (30 L, 10 LS, and 2 S), while the remaining 197 (83%) were managed nonsurgically (25 L, 26 LS, and 146 S), with a mean of 4.2 interventions/patient. One-, 3-, and 5-year overall patient and graft survival was significantly reduced in patients with bile leaks (84%, 71%, and 68% and 76%, 67%, and 64%, respectively) compared with controls (90%, 84%, and 78% and 88%, 81%, and 76%, respectively [p < 0.05]). Patients with BCs had higher incidence of cholestatic liver disease, higher pre-LT bilirubin, higher use of T-tubes, higher use of donor after cardiac death grafts, and higher rates of acute rejection (p < 0.05). Patients with BCs had longer ICU and hospital stays and higher rates of 30- and 90-day readmissions (p < 0.01). Multivariate analysis identified cholestatic liver disease, Roux-en-Y anastomosis, donor risk index >2, and T-tubes as independent BC predictors. CONCLUSIONS Biliary complications after LT can significantly decrease patient and graft survival rates. Careful donor and recipient selection and attention to anastomotic technique can reduce BCs and improve outcomes.
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Affiliation(s)
- Michael Senter-Zapata
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Adeel S Khan
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Tanvi Subramanian
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Neeta Vachharajani
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Leigh Anne Dageforde
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Jason R Wellen
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Surendra Shenoy
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Maria B Majella Doyle
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - William C Chapman
- Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO.
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25
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Santosh Kumar KY, Mathew JS, Balakrishnan D, Bharathan VK, Thankamony Amma BSP, Gopalakrishnan U, Narayana Menon R, Dhar P, Vayoth SO, Sudhindran S. Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial. J Am Coll Surg 2017; 225:747-754. [PMID: 28916322 DOI: 10.1016/j.jamcollsurg.2017.08.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/29/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT. STUDY DESIGN Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak. RESULTS Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003). CONCLUSIONS Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications.
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Affiliation(s)
- K Y Santosh Kumar
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Johns Shaji Mathew
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India.
| | - Dinesh Balakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Viju Kumar Bharathan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Binoj Sivasankara Pillai Thankamony Amma
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Unnikrishnan Gopalakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Ramachandran Narayana Menon
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Puneet Dhar
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Sudheer Othiyil Vayoth
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Surendran Sudhindran
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
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Roos FJM, Poley JW, Polak WG, Metselaar HJ. Biliary complications after liver transplantation; recent developments in etiology, diagnosis and endoscopic treatment. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624111 DOI: 10.1016/j.bpg.2017.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary complications are considered to be the Achilles' heel of liver transplantation. The most common complications are leaks and bile duct strictures. Strictures can arise at the level of the anastomosis (anastomotic strictures; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). Endoscopic treatment via endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the preferred therapy for these complications. This review will focus on the diagnostic modalities, new insights in etiology of biliary complications and outcomes after different endoscopic therapies, in both deceased donor transplantation and living-donor liver transplantations. Advances in recent therapies, such as the use of self-expendable metal stents (SEMS) and endoscopic therapy for patients with a bilio-digestive anastomosis will be discussed.
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Biliary Duct-to-Duct Reconstruction with a Tunneled Retroperitoneal T-Tube During Liver Transplantation: a Novel Approach to Decrease Biliary Leaks After T-Tube Removal. J Gastrointest Surg 2017; 21:723-730. [PMID: 27815760 DOI: 10.1007/s11605-016-3313-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/19/2016] [Indexed: 01/31/2023]
Abstract
The benefit of placing a T-tube for duct-to-duct biliary reconstruction during orthotopic liver transplantation (OLT) remains controversial because it could be associated with specific complications, especially at the time of T-tube removal. While the utility of T-tube during OLT represents an eternal debate, only a few technical refinements of T-tube placement have been described since the report of the original technique by Starzl and colleagues. Herein, we present a novel technique of T-tube placement for duct-to-duct biliary reconstruction during OLT, using a tunneled retroperitoneal route. On the basis of our experience of 305 patients who benefitted from the reported technique, the placement of a tunneled retroperitoneal biliary T-tube appears to be safe and results in a low rate of biliary complications, especially at the time of T-tube removal.
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Teegen EM, Denecke T, Eisele R, Lojewski C, Neuhaus P, Chopra SS. Clinical application of modern ultrasound techniques after liver transplantation. Acta Radiol 2016; 57:1161-70. [PMID: 26924835 DOI: 10.1177/0284185116633910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 01/21/2016] [Indexed: 12/14/2022]
Abstract
Liver transplantation has been established as a first-line therapy for a number of indications. Conventional ultrasound and contrast-enhanced ultrasound (CEUS) are methods of choice during the postoperative period as a safe and fast tool to detect potential complications and to enable early intervention if necessary. CEUS increases diagnostic quality and is an appropriate procedure for the examination of vessels and possibly bile ducts. This article presents the state of the art of ultrasound application during the early period after liver transplantation. It addresses common vascular complications and describes the identification of postoperative abnormal findings using ultrasound and CEUS.
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29
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Schmuck RB, Reutzel-Selke A, Raschzok N, Morgul HM, Struecker B, Lippert S, de Carvalho Fischer C, Schmelzle M, Boas-Knoop S, Bahra M, Pascher A, Pratschke J, Sauer IM. Bile: miRNA pattern and protein-based biomarkers may predict acute cellular rejection after liver transplantation. Biomarkers 2016; 22:19-27. [DOI: 10.1080/1354750x.2016.1201538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Valentino PL, Jonas MM, Lee CK, Kim HB, Vakili K, Elisofon SA. Outcomes after discontinuation of routine use of transanastomotic biliary stents in pediatric liver transplantation at a single site. Pediatr Transplant 2016; 20:647-51. [PMID: 27239056 DOI: 10.1111/petr.12729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 01/24/2023]
Abstract
Routine use of transanastomotic biliary stents (RTBS) for biliary reconstruction in liver transplantation (LT) is controversial, with conflicting outcomes in adult randomized trials. Pediatric literature contains limited data. This study is a retrospective review of 99 patients who underwent first LT (2005-2014). In 2011, RTBS was discontinued at our center. This study describes biliary complications following LT with and without RTBS. 56 (56%) patients had RTBS. Median age at LT was 1.9 yr (IQR 0.7, 8.6); 55% were female. Most common indication for LT was biliary atresia (36%). Most common biliary reconstruction was Roux-en-Y choledochojejunostomy (75% with RTBS, 58% without RTBS, p = 0.09). Biliary complications (strictures, bile leaks, surgical revision) occurred in 23% without significant difference between groups (20% with RTBS, 28% without RTBS, p = 0.33). Patients with RTBS had routine cholangiography via the tube at 6-8 wk; thus, significantly more patients with RTBS had cholangiograms (91% vs. 19%, p < 0.0001). There was no difference in the number of patients who required therapeutic intervention via endoscopic or percutaneous transhepatic cholangiography (11% with RTBS, 19% no RTBS, p = 0.26). Routine use of RTBS for biliary reconstruction in pediatric LT may not be necessary, and possibly associated with need for costlier, invasive imaging without improvement in outcomes.
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Affiliation(s)
- Pamela L Valentino
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine K Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Heung B Kim
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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31
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Wang SH, Lin PY, Wang JY, Lin HC, Hsieh CE, Chen YL. Predictors of Biliary Leakage After T-Tube Removal in Living Donor Liver Transplantation Recipients. Transplant Proc 2016; 47:2488-92. [PMID: 26518957 DOI: 10.1016/j.transproceed.2015.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/07/2015] [Accepted: 09/02/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Biliary leakage after T-tube removal is a frequent cause of morbidity in liver transplant recipients. The aim of this study was to determine the factors that predict the development of biliary leakage after T-tube removal in living donor liver transplantation (LDLT) recipients. METHODS Of the 144 patients who underwent LDLT with right-lobe liver grafts during the period January 2007 to May 2013 at a single medical center, 40 received biliary anastomosis with T-tube placement. Subjects were grouped into either a biliary leakage or non-biliary leakage group on the basis of the presence or absence of abdominal symptoms associated with signs of peritoneal irritation after T-tube removal. Recipient, graft, operative, and postoperative factors were included in a forward, stepwise multiple logistic regression model to identify the most important risk factors for biliary leakage after T-tube removal. RESULTS Biliary leakage developed in 9 (22.5%) patients after T-tube removal. Risk factors associated with biliary leakage included the number of abdominal surgeries performed [odds ratio (OR) = 12.6, 95% confidence interval (CI): 2.1-20.4] and duration of T-tube placement (OR = 6.9, 95% CI: 1.2-10.7). CONCLUSIONS Biliary leakage after T-tube removal is associated with significant morbidity in LDLT recipients. We suggest that T-tube placement be used sparingly in LDLT biliary reconstruction. When used, a T-tube should not be removed earlier than 8 months after placement, especially in recipients who have received primary abdominal surgery.
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Affiliation(s)
- S-H Wang
- Organ Transplant Center, Changhua Christian Hospital, Changhua, Taiwan
| | - P-Y Lin
- Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan
| | - J-Y Wang
- Department of Health Care Administration, Asia University, Taichung, Taiwan
| | - H-C Lin
- Department of Senior Citizen Welfare and Business, Hung Kuang University, Taichung, Taiwan
| | - C-E Hsieh
- Organ Transplant Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Y-L Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan, and School of Medicine, Chung Shan Medical University, Taichung, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Andreou A, Bahra M, Schmelzle M, Öllinger R, Sucher R, Sauer IM, Guel-Klein S, Struecker B, Eurich D, Klein F, Pascher A, Pratschke J, Seehofer D. Predictive factors for extrahepatic recurrence of hepatocellular carcinoma following liver transplantation. Clin Transplant 2016; 30:819-27. [PMID: 27107252 DOI: 10.1111/ctr.12755] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recurrence of hepatocellular carcinoma (HCC) in patients treated with liver transplantation (LT) is associated with diminished survival. Particularly, extrahepatic localization of HCC recurrence contributes to poor prognosis. PATIENTS AND METHODS Clinicopathological data of patients who underwent LT for HCC between 1989 and 2010 in a high-volume transplant center were retrospectively evaluated, and predictors of extrahepatic recurrence were identified. RESULTS Three hundred and sixty-four patients underwent LT for HCC. After a median follow-up time of 78 months, 93 patients (25%) were diagnosed with a recurrence. Median time to recurrence was 19 months. Recurrence was located exclusively in the liver in 19 cases (20%), and 74 patients (80%) had extrahepatic recurrence. Factors associated with extrahepatic recurrence in multivariate analysis included HCC beyond the Milan criteria (p < 0.0001) and the presence of macrovascular tumor invasion (p = 0.035). In patients with HCC beyond the Milan criteria who developed a recurrence (N = 73), macrovascular invasion was the only positive predictor of extrahepatic recurrence in multivariate analysis (p < 0.0001). In patients with HCC within the Milan criteria who recurred after LT (N = 20), DNA-index >1.5 (p = 0.013) was the only predictive factor for extrahepatic recurrence in multivariate analysis. CONCLUSIONS Advanced HCC beyond the Milan criteria and the presence of macrovascular invasion are associated with an increased risk for extrahepatic recurrence and are currently considered as relative contraindications to LT. In patients with HCC within the Milan criteria, the DNA-index represents a valuable prognostic marker for the development of extrahepatic recurrence and may support the selection of patients for intensified postoperative tumor surveillance.
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Affiliation(s)
- Andreas Andreou
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Bahra
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Sucher
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Igor M Sauer
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Safak Guel-Klein
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Fritz Klein
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Seehofer
- Department of General, Visceral and Transplantation Surgery, Campus Virchow-Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Vij V, Makki K, Chorasiya VK, Sood G, Singhal A, Dargan P. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:14-23. [PMID: 26390361 DOI: 10.1002/lt.24343] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/19/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.
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Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Kausar Makki
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Vishal Kumar Chorasiya
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Gaurav Sood
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Puneet Dargan
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
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Goumard C, Cachanado M, Herrero A, Rousseau G, Dondero F, Compagnon P, Boleslawski E, Mabrut JY, Salamé E, Soubrane O, Simon T, Scatton O. Biliary reconstruction with or without an intraductal removable stent in liver transplantation: study protocol for a randomized controlled trial. Trials 2015; 16:598. [PMID: 26719017 PMCID: PMC4696210 DOI: 10.1186/s13063-015-1139-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of biliary complications following liver transplantation (LT) remains high, ranging from 10 to 50 % of patients, especially when the diameter of the bile duct is smaller than 7 mm. Biliary reconstruction is most often performed by duct-to-duct anastomosis. In a preliminary study (n = 20), we previously reported a technique of biliary reconstruction using an intraductal stent tube followed by its endoscopic removal and showed both the feasibility and safety of this innovative procedure. The next step is to validate the potential benefit of this procedure in a randomized controlled trial. Design This is a multicenter randomized controlled trial in France comparing the efficacy of biliary reconstruction with or without a removable intraductal stent on reducing biliary complications. Inclusion and randomization are performed during LT when a duct-to-duct biliary anastomosis smaller than 7 mm in diameter is envisioned. In the intraductal stent group, a custom-made segment of a T-tube is placed into the bile duct and removed endoscopically 4 to 6 months later. The surgical technique is described in a video during randomization and is available on the secure website used for inclusion and randomization. The primary endpoint is the occurrence of biliary complications, including biliary fistulae and strictures, during the 6 months of follow-up. Secondary evaluation criteria are the incidence of complications related to the stent placement and its extraction by endoscopy. The inclusion of 248 patients in total has been determined based on an expected incidence of biliary complications of 25 % in the non-IST group and a 60 % reduction of biliary complications (10 %) in the IST group. Discussion Biliary complications following LT are significant causes of morbidity, retransplantation, and mortality. Although controversial, the use of a T-tube has been proven to be useless and even responsible for specific complications related to the external part of the tube in many studies, including several randomized trials. However, several studies have identified a small bile duct diameter as a risk factor for biliary stenosis. A threshold of 7 mm was found to be significantly associated with biliary stenosis. Our team published a preliminary study that included 20 patients using a new technique of intraductal stenting. Only four complications were reported in the overall study population, whereas no biliary complication occurred in the subgroup of patients who received a whole graft LT. Moreover, no technical failures and no procedure-related complications were noted before and during the drain removal. Although an intraductal stent tube in duct-to duct biliary anastomosis seems feasible and safe, a multicenter randomized controlled trial is needed to validate its benefit as a protective tool against the occurrence of biliary complications. One original aspect of this protocol is the video demonstration of the surgical procedure, which is available on the web to standardize and homogenize the technique. The surgical community may be inspired by this type of tool in the future to minimize technical bias related to technical issues. Trial registration NCT02356939, date of registration 2 February 2015.
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Affiliation(s)
- Claire Goumard
- Hepatobiliary surgery and liver transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpétrière, UPMC-Paris 06, Paris, France.
| | - Marine Cachanado
- Department of Clinical Pharmacoloy, APHP, Hôpital St Antoine, Unité de Recherche Clinique de l'Est Parisien (URCEST), UPMC-Paris 06, Paris, France.
| | - Astrid Herrero
- Hepatobiliary surgery and liver transplantation, CHR Montpellier, Montpellier, France.
| | - Géraldine Rousseau
- Hepatobiliary surgery and liver transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpétrière, UPMC-Paris 06, Paris, France
| | - Federica Dondero
- Hepatobiliary surgery and liver transplantation, APHP, Hôpital Beaujon, Clichy, France.
| | - Philippe Compagnon
- Hepatobiliary surgery and liver transplantation, APHP, Hôpital Henri Mondor, Creteil, France.
| | | | - Jean Yves Mabrut
- Hepatobiliary surgery and liver transplantation, Hopital Edouard Herriot, Lyon, France.
| | - Ephrem Salamé
- Hepatobiliary surgery and liver transplantation, CHR Tours, Tours, France.
| | - Olivier Soubrane
- Hepatobiliary surgery and liver transplantation, APHP, Hôpital Beaujon, Clichy, France
| | - Tabassome Simon
- Department of Clinical Pharmacoloy, APHP, Hôpital St Antoine, Unité de Recherche Clinique de l'Est Parisien (URCEST), UPMC-Paris 06, Paris, France
| | - Olivier Scatton
- Hepatobiliary surgery and liver transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpétrière, UPMC-Paris 06, Paris, France.
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Kienlein S, Schoening W, Andert A, Kroy D, Neumann UP, Schmeding M. Biliary complications in liver transplantation: Impact of anastomotic technique and ischemic time on short- and long-term outcome. World J Transplant 2015; 5:300-309. [PMID: 26722658 PMCID: PMC4689941 DOI: 10.5500/wjt.v5.i4.300] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/29/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.
METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation (LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side (SS), end-to-end (EE) anastomosis or hepeaticojejunostomy (HJ). Biliary complications (BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion (ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography (ERCP)]. Laboratory results included alanine aminotransferase (ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional (e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.
RESULTS: A total of 200 patients [age: 56 (19-72), alcoholic cirrhosis: n = 64 (32%), hepatocellular carcinoma: n = 40 (20%), acute liver failure: n = 23 (11.5%), cryptogenic cirrhosis: n = 22 (11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13 (6.5%), primary sclerosing cholangitis: n = 13 (6.5%), others: n = 25 (12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5% (n = 75) with anastomotic strictures (AS): n = 38 (19%), bile leak (BL): n = 12 (6%), biliary drain complication: n = 12 (6%); papillary stenosis (PS): n = 7 (3.5%), ITBL: n = 6 (3%). Clinically relevant were only 19% (n = 38). We established a comprehensive classification for AS with four grades according to clinical relevance. The reconstruction techniques [SS: n = 164, EE: n = 18, HJ: n = 18] showed no significant impact on the development of BCs in general (all n < 0.05), whereas in the HJ group significantly less AS were found (P = 0.031). The length of donor intensive care unit stay over 6 d had a significant influence on BC development (P = 0.007, HR = 2.85; 95%CI: 1.33-6.08) in the binary logistic regression model, whereas other reviewed variables had not [warm ischemic time > 45 min (P = 0.543), cold ischemic time > 10 h (P = 0.114), ALT init > 1500 U/L (P = 0.631), bilirubin init > 5 mg/dL (P = 0.595), donor age > 65 (P = 0.244), donor sex (P = 0.068), rescue organ (P = 0.971)]. 13% (n = 10) of BCs had no therapeutic consequences, 36% (n = 27) resulted in repeated lab control, 40% (n = 30) received ERCP and 11% (n = 8) surgical therapy. Fifteen (7.5%) patients developed cholangitis [AS (n = 6), ITBL (n = 5), PS (n = 3), biliary lesion BL (n = 1)]. One patient developed ITBL twelve months after LT and subsequently needed retransplantation. Rehospitalisation rate was 10.5 % (n= 21) [AS (n = 11), ITBL (n = 5), PS (n = 3), BL (n = 1)] with intervention or reinterventional therapy as main reasons. Retransplantation was performed in 5 (2.5%) patients [ITBL (n = 1), acute liver injury (ALI) by organ rejection (n = 3), ALI by occlusion of hepatic artery (n = 1)]. In total 21 (10.5%) patients died within the follow-up period. Out of these, one patient with AS developed severe fatal chologenic sepsis after ERCP.
CONCLUSION: In our data biliary reconstruction technique and ischemic times seem to have little impact on the development of BCs.
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T-tube or No T-tube in Cadaveric Orthotopic Liver Transplantation: The Type of Tube Really Matters. Ann Surg 2015; 261:e172. [PMID: 23799419 DOI: 10.1097/sla.0b013e31829d56c0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Andreou A, Bahra M, Guel S, Struecker B, Sauer IM, Klein F, Pascher A, Pratschke J, Seehofer D. Tumor DNA Index and α-Fetoprotein Level Define Outcome following Liver Transplantation for Advanced Hepatocellular Carcinoma. Eur Surg Res 2015; 55:302-318. [PMID: 26440793 DOI: 10.1159/000439565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 08/20/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) beyond the Milan criteria are expected to have inferior outcome after liver transplantation (LT) and are therefore currently not considered for LT in many countries. The purpose of this study was to identify predictive factors for overall survival following LT for HCC that may support the Milan criteria in the selection of appropriate transplant candidates. METHODS Clinicopathological data on 364 patients with HCC who underwent LT between 1989 and 2010 were retrospectively evaluated. Predictors of overall survival in the entire cohort as well as in subsets of patients within (n = 214) and beyond (n = 150) the Milan criteria were analyzed. RESULTS Multivariate analysis in the entire cohort identified DNA index >1.5 (p < 0.0001), α-fetoprotein level (AFP) >200 ng/ml (p = 0.005), and HCC beyond the Milan criteria (p = 0.002) to be associated with worse overall survival. In patients within the Milan criteria (median survival: 170 months), DNA index >1.5 (p < 0.0001) was the only predictor of worse overall survival in multivariate analysis. In patients beyond the Milan criteria (median survival: 44 months), DNA index >1.5, AFP >200 ng/ml, microvascular invasion, patient age >60 years, and DNA index >1.5 concomitant with AFP >200 ng/ml were associated with worse overall survival in univariate analysis. Multivariate analysis identified DNA index >1.5 concomitant with AFP >200 ng/ml (p < 0.0001) as the only independent predictor of worse overall survival. Consequently, patients beyond the Milan criteria with a combined favorable DNA index ≤1.5 and AFP ≤200 ng/ml had a median survival (147 months) comparable to that of patients within the Milan criteria. CONCLUSIONS DNA index and AFP level predict overall survival following LT in patients with advanced HCC beyond the Milan criteria. A combined assessment of these markers during the evaluation of transplant candidates can contribute to the selection of patients with HCC who may benefit from LT independently of their tumor burden.
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Affiliation(s)
- Andreas Andreou
- Department of General, Visceral and Transplant Surgery, Charitx00E9; - Universitx00E4;tsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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Weiss S, Messner F, Huth M, Weissenbacher A, Denecke C, Aigner F, Brandl A, Dziodzio T, Sucher R, Boesmueller C, Oellinger R, Schneeberger S, Oefner D, Pratschke J, Biebl M. Impact of abdominal drainage systems on postoperative complication rates following liver transplantation. Eur J Med Res 2015; 20:66. [PMID: 26293656 PMCID: PMC4546128 DOI: 10.1186/s40001-015-0163-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/11/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Depending on the extent of surgery, coagulation status and the number of anastomoses, drains are routinely used during liver transplantation. The aim of this study was to compare different drain types with regard to abdominal complication rates. METHODS All consecutive full-size orthotopic liver transplantations (LTX) performed over a 7-year period were included in this retrospective analysis. Abdominal drain groups were divided into open-circuit drains and closed-circuit drains. Data are reported as total number (%) or median (range); for all comparisons a p value <0.05 was considered statistically significant. RESULTS A total of 256 LTX [age 56.89 (0.30-75.21) years; MELD 14.5 (7-40)] was included; 56 (21.8 %) patients received an open-circuit Easy Flow Drain (Group 1) and 200 (78.2 %) a closed-circuit Robinson Drainage System (Group 2). For Groups 1 and 2, overall infection rates were 78.6 and 56 % (p = 0.001), abdominal infection rates 50.82 and 21.92 % (p = 0.001), yeast infection rates 37 and 23 % (p = 0.02), abdominal bleeding rates 26.78 and 17 % (p = 0.07), biliary complication rates 14.28 and 13.5 % (p = 0.51), respectively. CONCLUSIONS In this retrospective series, open-circuit drains were associated with more abdominal complications, mainly due to intraabdominal infections, than were closed-circuit drains.
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Affiliation(s)
- Sascha Weiss
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Marcus Huth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Christian Denecke
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Felix Aigner
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Tomasz Dziodzio
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Robert Sucher
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Claudia Boesmueller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Robert Oellinger
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Dietmar Oefner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Johann Pratschke
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Matthias Biebl
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Sun N, Zhang J, Li X, Zhang C, Zhou X, Zhang C. Biliary tract reconstruction with or without T-tube in orthotopic liver transplantation: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2015; 9:529-38. [PMID: 25583036 DOI: 10.1586/17474124.2015.1002084] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION At present whether to use T-tube or not during orthotopic liver transplantation (OLT) in biliary tract reconstruction still remains controversial. Most transplant centers choose not to use T-tube because the T-tube can increase the incidence of cholangitis, but some centers still use T-tube because the T-tube can decrease the incidence of anastomotic strictures. AIM The purpose of this study is to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. METHODS systematic review and meta-analysis of a collection of 15 studies (six randomized control trails (RCTs) and nine comparative studies) to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. RESULTS The data showed that the biliary tract reconstruction with T-tube and without T-tube had equivalent outcomes for overall biliary complications (six RCTs p = 0.76; odd ratio [OR] = 1.19; 95% CI: 0.40, 3.58; all studies p = 0.14; OR = 1.50; 95% CI: 0.88, 2.57), bile leaks (six RCTs p = 0.61; OR = 0.86; 95% CI: 0.49, 1.52; all studies p = 0.09; OR = 1.39; 95% CI: 0.95, 2.02), cholangitis (six RCTs p = 0.13; OR = 5.54; 95% CI: 0.62, 49.79; all studies p = 0.08; OR = 4.27; 95% CI: 0.86, 21.16), hepatic artery thrombosis (two RCTs p = 1.00; OR = 1.00; 95% CI: 0.22, 4.49; all studies p = 0.75; OR = 1.19; 95% CI: 0.41, 3.44). However, in the group with T-tube there were better outcomes for biliary strictures (six RCTs p = 0.0003; OR = 0.34; 95% CI: 0.19, 0.61; all studies p < 0.0001; OR = 0.49; 95% CI: 0.34, 0.69). DISCUSSION Although most organizations choose not to use T-tube in OLT, we suggest that use of T-tube in biliary tract reconstruction during OLT for the recipients who possibly have high risks of biliary stricture is useful and necessary.
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Affiliation(s)
- Ning Sun
- Department of Hepatobiliary and Transplantation Surgery, the First Affiliated Hospital of China Medical University, Shenyang, P.R. China
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Abstract
UNLABELLED Biliary complications (BCs) remain one of the most outstanding factors influencing long-term results after orthotopic liver transplantation. The authors carried out a systematic overview of 1720 papers since 2008, and focused on 45 relevant ones. Among 14,411 transplanted patients the incidence of BCs was 23%. Biliary leakage occurred in 8.5%, biliary stricture in 14.7%, mortality rate was 1-3%. RISK FACTORS preoperative sodium level; p = 0.037, model of end-stage liver disease score >25; p = 0.048, primary sclerosing cholangitis; p = 0.001, malignancy; p = 0.026, donor age >60, macrovesicular graft steatosis; p = 0.001, duct-to-duct anastomosis; p = 0.004, long anhepatic phase; p = 0.04, cold ischemic time >12 h; p = 0.043, use of T-tube; p = 0.032, insufficient flush of bile ducts; p = 0.001, acute rejection; p = 0.003, cytomegalovirus infection; p = 0.004 and hepatic artery thrombosis; p = 0.001. The management was surgical in case of biliary leakage, and interventional radiology or endoscopic retrograde cholangiopancreatography in case of biliary stricture. Mapping of miRNA profile is a new field of research. Nemes-Doros score is a useful tool in the estimation of hepatic artery thrombosis. Management of BCs requires a multidisciplinary expert team.
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Affiliation(s)
- Balázs Nemes
- Division of Transplantation, Institute of Surgery, Clinical Centre, University of Debrecen, Moricz Zs. krt. 22, Debrecen, H-4032, Hungary
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Andreou A, Gül S, Pascher A, Schöning W, Al-Abadi H, Bahra M, Klein F, Denecke T, Strücker B, Puhl G, Pratschke J, Seehofer D. Patient and tumour biology predict survival beyond the Milan criteria in liver transplantation for hepatocellular carcinoma. HPB (Oxford) 2015; 17:168-75. [PMID: 25263399 PMCID: PMC4299391 DOI: 10.1111/hpb.12345] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) beyond the Milan criteria are not considered for liver transplantation (LT) in many centres; however, LT may be the only treatment able to achieve long-term survival in patients with unresectable HCC. The aim of this study was to assess the role of recipient age and tumour biology expressed by the DNA index in the selection of HCC patients for LT. PATIENTS Clinicopathological data of 364 patients with HCC who underwent LT between 1989 and 2010 were evaluated. Overall survival (OS) was analysed by patient age, tumour burden based on Milan criteria and the DNA index. RESULTS After a median follow-up time of 78 months, the median survival was 100 months. Factors associated with OS on univariate analysis included Milan criteria, patient age, hepatitis C infection, alpha-fetoprotein (AFP) level, the DNA index, number of HCC, diameter of HCC, bilobar HCC, microvascular tumour invasion and tumour grading. On multivariate analysis, HCC beyond Milan criteria and the DNA index >1.5 independently predicted a worse OS. When stratifying patients by both age and Milan criteria, patients ≤ 60 years with HCC beyond Milan criteria had an OS comparable to that of patients >60 years within Milan criteria (10-year OS: 33% versus 37%, P = 0.08). Patients ≤ 60 years with HCC beyond Milan criteria but a favourable DNA index ≤ 1.5 achieved excellent long-term outcomes, comparable with those of patients within Milan criteria. CONCLUSIONS Patients ≤ 60 years may undergo LT for HCC with favourable outcomes independently of their tumour burden. Additional assessment of tumour biology, e.g. using the DNA index, especially in this subgroup of patients can support the selection of LT candidates who may derive the most long-term survival benefit, even if Milan criteria are not fulfilled.
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Affiliation(s)
- Andreas Andreou
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany,Correspondence, Andreas Andreou, Department of General, Visceral and Transplant Surgery, Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany. Tel: 30 450 652274. Fax: 450 552900. E-mail:
| | - Safak Gül
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Wenzel Schöning
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Hussein Al-Abadi
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Marcus Bahra
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Fritz Klein
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, CharitéBerlin, Germany
| | - Benjamin Strücker
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Gero Puhl
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
| | - Daniel Seehofer
- Department of General, Visceral and Transplant Surgery, CharitéBerlin, Germany
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Intraoperative placement of external biliary drains for prevention and treatment of bile leaks after extended liver resection without bilioenteric anastomosis. World J Surg 2014; 37:2629-34. [PMID: 23892726 DOI: 10.1007/s00268-013-2161-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage. METHODS We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external-internal or internal-external drain into long-segment exposed bile ducts. For internal-external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel's channel. RESULTS Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external-internal drainage, bile leakage stopped immediately. The patient's course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external-internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up. CONCLUSIONS The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal-external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.
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Reply to Letter: "A Question Seeking for an Answer: Use of T-tube in the Era of Liver Transplantation With Grafts From Extended Criteria Donors and Donors After Cardiac Death". Ann Surg 2014; 261:e174-5. [PMID: 24836150 DOI: 10.1097/sla.0000000000000722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Biliary complications account for relevant morbidity and mortality after liver transplantation. Advances have taken place in understanding their aetiology, in preventive operative techniques, imaging procedures, as well as interventional and endoscopic management. However, progress in living donation, donation after cardiac death as well as paediatric transplant procedures have changed the incidence and causes of biliary complications. This review summarizes recent progress in the field, particularly related to biliary strictures after liver transplantation. RECENT FINDINGS Significant findings in the period of interest for this review focussed on improvements of endoscopic treatment of postliver transplant biliary complications, including novel stenting devices, the routine analysis of bacterial and fungal flora, and the use of steroids to prevent postendoscopic retrograde cholangiopancreaticography pancreatitis. The importance of cytomegalovirus and hepatitis C in the aetiology of biliary complications was highlighted. Under certain circumstances, biliary complications after liver transplantation of organs secondary to donation after cardiac death may be reduced to a level known from liver transplantation after brain death. Further evidence was added to support the risk-adapted use of biliary drainage during liver transplantation. SUMMARY The ongoing research in the aetiology, prevention, and treatment of biliary strictures after liver transplantation highlights the significance of biliary complications for patient and graft outcome.
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45
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Clinical Outcome of Internal Stent for Biliary Anastomosis in Liver Transplantation. Transplant Proc 2014; 46:856-60. [DOI: 10.1016/j.transproceed.2013.12.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/01/2013] [Accepted: 12/11/2013] [Indexed: 11/22/2022]
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Yamamoto H, Hayashida S, Asonuma K, Honda M, Suda H, Murokawa T, Ohya Y, Lee KJ, Takeichi T, Inomata Y. Single-center experience and long-term outcomes of duct-to-duct biliary reconstruction in infantile living donor liver transplantation. Liver Transpl 2014; 20:347-54. [PMID: 24415519 DOI: 10.1002/lt.23819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/04/2013] [Indexed: 02/07/2023]
Abstract
The indications for duct-to-duct (DD) biliary reconstruction in living donor liver transplantation (LDLT) for small children are still controversial. In this study, the feasibility of DD biliary reconstruction versus Roux-en-Y (RY) biliary reconstruction was investigated in terms of long-term outcomes. Fifty-six children who consecutively underwent LDLT with a weight less than or equal to 10.0 kg were enrolled. Biliary reconstruction was performed in a DD fashion for 20 patients and in an RY fashion for 36 patients. During a minimum follow-up of 2 years, the incidence of biliary strictures was 5.0% in the DD group and 11.1% in the RY group. Cholangitis during the posttransplant period was observed in the RY group only. There were no deaths related to biliary problems. This study shows that DD reconstruction in LDLT for small children (weighing 10.0 kg or less) is a feasible option for biliary reconstruction.
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Affiliation(s)
- Hidekazu Yamamoto
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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Sankarankutty AK, Mente ED, Cardoso NM, Castro-E-Silva O. T-tube or no T-tube for bile duct anastomosis in orthotopic liver transplantation. Hepatobiliary Surg Nutr 2014; 2:171-3. [PMID: 24570938 DOI: 10.3978/j.issn.2304-3881.2013.05.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 05/15/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Ajith K Sankarankutty
- Integrated Liver Transplant Unit, Division of Digestive Tract Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brazil
| | - Enio D Mente
- Integrated Liver Transplant Unit, Division of Digestive Tract Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brazil
| | - Nathalia M Cardoso
- Integrated Liver Transplant Unit, Division of Digestive Tract Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brazil
| | - Orlando Castro-E-Silva
- Integrated Liver Transplant Unit, Division of Digestive Tract Surgery, Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brazil
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Kalmuk S, Neuhaus P, Pascher A. [Surgery and organ transplantation]. Chirurg 2013; 84:937-44. [PMID: 24071973 DOI: 10.1007/s00104-013-2514-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Liver and kidney transplantations have been performed for almost 50 years and is nowadays a routine procedure for the treatment of terminal liver failure and terminal-stage renal failure. Under given optimal conditions and increasing experience good results can be achieved. Improvements in surgical techniques have led to a decrease in the incidence of surgical complications after transplantation. Nevertheless after liver and kidney transplantation complications can occur and increase the morbidity and mortality. There are a number of possible complications which range from harmless wound healing disorders to severe vascular, biliary or urinary complications that can be associated with graft dysfunction and lead to graft loss. In order to identify risk factors preoperatively and achieve good outcome after transplantation a good preparation of the recipients is necessary. Furthermore, a good interdisciplinary cooperation is necessary both to recognize complications early and to treat these adequately.
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Affiliation(s)
- S Kalmuk
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Charite - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland,
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Enestvedt CK, Malik S, Reese PP, Maskin A, Yoo PS, Fayek SA, Abt P, Olthoff KM, Shaked A. Biliary complications adversely affect patient and graft survival after liver retransplantation. Liver Transpl 2013; 19:965-72. [PMID: 23818332 DOI: 10.1002/lt.23696] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 06/01/2013] [Indexed: 02/07/2023]
Abstract
Inferior outcomes are consistently observed for recipients of liver retransplantation (re-LT) versus recipients of primary transplants. Few studies have examined the incidence and impact of biliary complications (BCs) on outcomes after re-LT. The aim of this study was to compare patient and graft survival for re-LT recipients with BCs (BC(+) ) and re-LT recipients without BCs (BC(-) ). Additional aims were to determine the impact of biliary reconstruction on the incidence of BCs and to identify risk factors for BCs after re-LT. A single-center, retrospective analysis of all re-LT recipients over a decade was performed. Univariate analyses were performed, and survival was compared with the log-rank method. A multivariate Cox regression analysis was performed to determine independent predictors of death and graft failure. The BC rate was 20.9% (n = 23) for 110 re-LT cases. The average follow-up was 55 months. The survival rates for BC(-) recipients at 3 months and 1, 3, and 5 years were 95.3%, 91.7%, 85.4%, and 80.9%, respectively, whereas BC(+) patients had survival rates of 64.3%, 49.7%, 34.8%, and 29.8%, respectively (P < 0.001, log-rank). The graft survival rates at 3 months and 1, 3, and 5 years were 92.0%, 88.5%, 82.4%, and 78.0%, respectively, for the BC(-) group and 60.9%, 43.5%, 30.4%, and 26.1%, respectively, for the BC(+) group (P < 0.001, log-rank). BCs, a length of stay ≥ 12 days, and donor age were strongly associated with death and graft failure in a regression analysis, whereas retransplant indications other than chronic rejection and recurrent disease also affected graft failure. In conclusion, BCs significantly affected both patient and graft survival, with an increased risk of death and graft loss among BC(+) recipients. Early recognition, appropriate interventions, and preventative measures for BCs are critical in the clinical management of re-LT recipients.
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Affiliation(s)
- C Kristian Enestvedt
- Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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Herzog T, Belyaev O, Bakowski P, Chromik AM, Janot M, Suelberg D, Uhl W, Seelig MH. The difficult hepaticojejunostomy after pancreatic head resection: reconstruction with a T tube. Am J Surg 2013; 206:578-85. [PMID: 23906984 DOI: 10.1016/j.amjsurg.2013.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/11/2013] [Accepted: 01/24/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS In 48% (55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9% [5/55] in patients with a T tube vs 15% [9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations.
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Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital Bochum, University Hospital, Gudrunstr. 56, D-44791 Bochum, Germany
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