A simple modification in operative technique can reduce the incidence of nonanastomotic biliary strictures after orthotopic liver transplantation

Abstract

Nonanastomotic strictures after liver transplantations are a source of significant morbidity, often necessitating retransplantation. The purpose of this study was twofold: first to identify features associated with the development of this lesion; second, to make technical modifications that will decrease the incidence of this problem. In the first part of this study, 15 of 131 patients were diagnosed with nonanastomotic biliary stricture. A stepwise logistic-regression analysis associated donor cold ischemic time and dopamine dose with the development of nonanastomotic biliary strictures. All these patients had arterial reconstruction after partial revascularization of the liver with portal venous blood. Because the bile duct receives its blood supply from only the hepatic artery, we hypothesized that the prolonged period of warm ischemia from staged reconstruction of the vascular supply would promote the development of this lesion. In a second part of this study, the stricture rate in 45 patients with simultaneous revascularization using both the hepatic artery and portal vein was compared with that in 83 patients from the first part of this study initially revascularized with portal venous blood. All patients in the second study had grafts preserved using UW solution. Only 1 patient with simultaneous revascularization developed a nonanastomotic biliary stricture. Because we were unable to identify any significant complications related to this method of revascularization, we propose that the hepatic artery and portal vein should be released simultaneously, especially in patients receiving a graft with prolonged storage time.

Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis

“…These are important aspects for the viability of the BD of the graft and for the subsequent danger of anastomotic insufficiency or stricture formation [30,31,32,33].…”

A single-center experience with retrograde-reperfusion in liver transplantation

“…No clinically significant differences in early graft function between hepatic artery and portal vein reperfusion during LTX have been found [3]. Two recent human studies suggest that simultaneous portal vein and hepatic artery reperfusion may reduce biliary complications [4,23], and animal studies indicate that simultaneous [24] or primary hepatic artery [25] reperfusion may reduce ischemia reperfusion injury. We present a new method of reperfusion in LTX leading to reduction of reperfusion injury.…”

Biliary Tract Complications after Liver Transplantation: A Review

“…The pathogenesis of ischemic-type biliary lesions remains unclear; however, an increased frequency of such lesions in patients with prolonged cold ischemia time [54,66,67,68,69], delayed rearterialization of the graft [70] or transplants from non-heart-beating donors [71] suggests ischemia-reperfusion injury as a causative factor. Immunologically related ischemic-type biliary lesions comprise injury to the biliary epithelium and/or vascular endothelium in the course of chronic rejection, cytomegaloviral infection, recurrent sclerosing cholangitis and ABO incompatible transplantation [54,55,56,57,58,59,60,61].…”

“…Ischemic-type biliary lesions occur in 2–20% of patients, are localized proximal to the anastomotic site, and on cholangiogram are indistinguishable from strictures caused by hepatic artery thrombosis [66, 68, 69]. They usually manifest themselves 1–6 months after OLT with most patients showing destroyed intrahepatic as well as extrahepatic bile ducts, while a few develop only extrahepatic or intrahepatic lesions [54, 66,68,69,70]. In patients with changes located primarily in the extrahepatic bile duct and the duct bifurcation, complex surgical reconstruction with resection of the bifurcation and Roux-en-Y hepaticojejunostomy can be a successful treatment [125].…”