Targeting the Achilles' heel of adult living donor liver transplant: Corner‐sparing sutures with mucosal eversion technique of biliary anastomosis

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. Liver Transpl 22:14‐23, 2016. © 2015 AASLD.

Endoscopic management of biliary strictures after living donor liver transplantation

“…While identification of the causative factors of biliary complications and subsequent refinements in reconstruction techniques might reduce the incidence of these complications in some institutions [20][21][22], the rate of biliary complications, particularly biliary strictures, does not seem to significantly decrease with experience [7,8,19,23]. Kyoto University divided LDLT recipients into three groups according to case experience (Group 1, cases 1-100; Group 2, cases 101-200; and Group 3, cases 201-335), and found that while the rate of bile leakage significantly decreased with experience (25% in Group 1, 14% in Group 2, and 13% in Group 3, p = 0.021), there were no differences in the development of biliary strictures among the three groups (19,28, 26%, respectively, p = 0.290) [7].…”

Management issues in post living donor liver transplant biliary strictures

“…The incidence is higher after LDLT compared to deceased donor liver transplant (DDLT) [3] . Over last 3 decades the reported incidence of bile leaks as well strictures is decreasing (Table 1) [4][5][6][7][8][9][10][11][12][13][14][15] . This can be ascribed to better understanding of the technical causes leading to biliary complications.…”

“…Overview of the possible contributory factors and role of each has been listed in Table 2 [12, [14][15][16][17][18][19][20][21][22] . In LDLT the anastomosis is made between right anterior and posterior ducts of the donor with the common hepatic duct of the recipient.…”

“…Wadhawan et al [14] 2013 India 65 28 8.8% 10.3% Mizuno et al [13] 2014 Japan 108 58.4 5.6% 13.9% Vij et al [15] 2015 India 127 9.32 0.7% 0%…”

Reply

“…(5) The incidence of biliary complications at these centers is similar. (1) All the points raised in the letter might be theoretically relevant but probably have no practical implication. …”