Protection of the intrahepatic biliary tree by contemporaneous portal and arterial reperfusion: results of a prospective randomized pilot study

Abstract

Sequential portal and arterial revascularization (SPAr) is the most common method of graft reperfusion at liver transplantation (LT), contemporaneous portal and arterial revascularization (CPAr) was used to reduce arterial ischemia to the bile ducts. Aim of this pilot study is to prospectively compare SPAr (group 1 #38) versus CPAr (group 2 #42) in 80 consecutive LTs. Biliary anastomosis was always duct to duct [T-tube in 21 % of cases (p = 0.83) in both groups]. CPAr had longer warm ischemia 61 ± 10 versus 39 ± 13 min, p < 0.0001, while SPAr had longer arterial ischemia 96 ± 39 min (p = 0.0001). No PNF while DGF was encountered in 10 versus 5 % (p = 0.32). One-year graft and patient's survival were respectively 87 versus 93 % and 83 versus 88 % in groups 1 and 2 (p = 0.31 and p = 0.39). At a median follow-up of 19 ± 8 versus 17 ± 8 months (p = 0.24), biliary complications were 28 %, being 39 % in group 1 and 19 % in group 2 (p = 0.04). Anastomotic stenoses were present in 11 versus 12 % (p = 0.84), biliary leakage in 5 versus 5 % (p = 0.72) and intrahepatic non-anastomotic biliary strictures in 23 versus 0 % (p = 0.0008) in groups 1 and 2. CPAr is safe and feasible and reduces the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia to the intrahepatic bile ducts.

Variation in Biliary Complication Rates Following Liver Transplantation: Implications for Cost and Outcome

“…Surgical technique may also contribute; however, improved results have not been consistently demonstrated when comparing end-to-end with side-to-side orientation nor interrupted with continuous sutures (15). The use of contemporaneous release of both arterial and portal inflow has also been suggested as a means to reduce ischemic injury to the biliary system, with a reduction in incidence from 23% to 0% reported by Baccarani et al (27). In addition, surgical experience and technical judgment, which are hard to quantify, may contribute to outcomes in whole organ transplantation as has been shown in living donor LT (12).…”

National assessment of early biliary complications following liver transplantation: Incidence and outcomes

“…However, despite positive results in small series, neither a side‐to‐side orientation nor the use of interrupted sutures rather than continuous sutures has been consistently associated with improved outcomes . The use of the contemporaneous release of both arterial and portal inflows has also been suggested as a means of reducing ischemic injury to the biliary system . Baccarani et al reported a substantial reduction (0% versus 23%) in intrahepatic strictures for patients who had contemporaneous revascularization (n = 42) versus patients who had sequential revascularization (n = 38).…”

“…The use of the contemporaneous release of both arterial and portal inflows has also been suggested as a means of reducing ischemic injury to the biliary system . Baccarani et al reported a substantial reduction (0% versus 23%) in intrahepatic strictures for patients who had contemporaneous revascularization (n = 42) versus patients who had sequential revascularization (n = 38). Other centers have recommended the use of thrombolytic injections into the hepatic artery before perfusion and achieved a 0% rate of NASs in 12 patients, but the rate of significant hemorrhage increased .…”

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“…Therefore at the stage of conditioning and during postoperative period a number of measures should be undertaken aimed at prophylaxis of ITBL development. Since 2013 year for prophylaxis of development of ischemic non-anastomotic biliary structures we have been using complex of treatment measures consisting of streptokinase injection during donor operation, washing biliary duct with saline (at room temperature) prior to flushing to prevent formation of bile casts and their toxic impact on the bile pathway epithelium and washing transplant liver artery under pressure 40-50 mm Hg during back-table surgery [3,5]. Within a period from 01.01.2013 to 01.07.2014 years (99 transplantations) there was not a single case of this complication (p = 0.0003) after application of this prophylactic method.…”