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Fan ST, Lo CM, Liu CL. Experience of donor right lobe hepatectomy in adult-to-adult live donor liver transplantation: clinical analysis of 89 cases. Hepatobiliary Pancreat Dis Int 2002; 1: 166. Duffy JP, Hong JC, Farmer DG, et al. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 2009; 208: 896. Millis JM, Seaman DS, Piper JB, et al. Portal vein thrombosis and stenosis in pediatric liver transplantation. Transplantation 1996; 62: 748. Lerut J, Tzakis AG, Bron K, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg 1987; 205: 404. Ueda M, Oike F, Kasahara M, et al. Portal vein complications in pediatric living donor liver transplantation using left-side grafts. Am J Transplant 2008; 8: 2097. Unsinn KM, Freund MC, et al. Spectrum of imaging findings after pediatric liver transplantation: part 2, posttransplantation complications. Am J Roentgenol 2003; 181: 1139. Lo´pez Santamarı´a M, Ga´mez M, Murcia J, et al. Pre-hepatic portal hypertension as a late complication of liver transplantation in children. Cir Pediatr 2001; 14: 135. Chardot C, Herrera JM, Debray D, et al. Portal vein complications after liver transplantation for biliary atresia. Liver Transplant Surg 1997; 3: 351. Lucianetti A, Guizzetti M, Bertani A, et al. Liver transplantation in children weighing less than 6 kg. The Bergamo experience. Transplant Proc 2005; 37: 1143. Huang TL, Cheng YF, Chen TY, et al. Doppler ultrasound evaluation of postoperative portal vein stenosis in adult living donor liver transplantation. Transplant Proc 2010; 42: 879. Ou HY, Concejero AM, Huang TL, et al. Portal vein thrombosis in biliary atresia patients after living donor liver transplantation. Surgery 2011; 149: 40. Cheng YF, Ou HY, Tsang LL, et al. Vascular stents in the management of portal venous complications in living donor liver transplantation. Am J Transplant 2010; 10: 1276. Ko GY, Sung KB, Yoon HK, et al. Early posttransplantation portal vein stenosis following living donor liver transplantation: percutaneous transhepatic primary stent placement. Liver Transpl 2007; 13: 530. Cheng YF, Ou HY, Tsang LL, et al. Interventional percutaneous trans-splenic approach in the management of portal venous occlusion after living donor liver transplantation. Liver Transpl 2009; 15: 1378. Seu P, Shackleton C, Shaked A, et al. Improved results of the liver transplantation in patients with portal vein thrombosis. Arch Surg 1996; 131: 840. Otto G, Richter GM, Theilmann L, et al. [Liver transplantation after trans-jugular intrahepatic portosystemic stent shunt]. Chirurg 1992; 63: 730. Chen CL, Concejero AM, Ou HY, et al. Intraoperative portal vein stent placement in pediatric living donor liver transplantation. J Vasc Interv Radiol 2012; 23: 724.

SECTION 9. TECHNICAL DETAILS OF MICROSURGICAL BILIARY RECONSTRUCTION IN LIVING DONOR LIVER TRANSPLANTATION

Tsan-Shiun Lin,1 Chao-Long Chen,1,3 Allan M Concejero,1 Anthony Q. Yap,1 Yu-Hung Lin,1 Chun-Yi Liu,1 Yuan-Cheng Chiang,1 Chih-Chi Wang,1 Shih-Ho Wang,1 Chih-Che Lin,1 Chee-Chien Yong,1 and Yu-Fan Cheng2

Abstract. Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In ductto-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Ductto-duct anastomosis was performed in 473 (81%) and duct-tojejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome. Keywords: Biliary reconstruction, Microsurgical technique, Living donor liver transplantation, Biliary complications, Biliary outcome.

iliary complications (BC) following LDLT have remained high at a rate of 16% to 67% (1Y10). Small size and multiple ducts, particularly in the right lobe liver grafts are the major factors of such results (4). To overcome these complexities brought by anatomic variations, our institution has routinely used microsurgical biliary reconstruction (MBR) in LDLT since 2006 (11). At the onset of applying the MBR technique, recipient reduction ductoplasty was performed by a liver transplant surgeon without the aid of an operating microscope; then, the anastomosis was performed by the microsurgeon under an operating microscope with a magnification of 5 to 15. This practice resulted in an unacceptably high rate of BC (46.7%) in

B

This work was presented in the video session during the 2013 Asian summit on living donor liver transplantation held in Kaohsiung, Taiwan, January 12, 2013. The authors declare no funding or conflicts of interest. 1 Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 2 Liver Transplantation Program and Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 3 Address correspondence to: Chao-Long Chen, M.D., Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305 Taiwan. E-mail: [email protected]

Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9708-00 DOI: 10.1097/TP.0000000000000060

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

* 2014 Lippincott Williams & Wilkins

the first 15 cases. After reviewing the technique, we found that despite the recipient reduction ductoplasty, there remained a significant degree of discrepancy between the recipient and graft ducts. It is difficult to fix such incongruence after the completion of the anastomosis. We believe that the majority of our initial anastomotic BC especially bile leak was largely attributed to this factor. In this report, we aim to highlight the technical refinements and details of MBR in LDLT.

MATERIALS AND METHODS From March 22, 2006, to June 30, 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants) at Kaohsiung Chang Gung Memorial Hospital, Taiwan. All biliary reconstructions were performed using microsurgical technique by a single microsurgeon (1). The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. All biliary reconstructions were performed under an operating microscope (Carl Zeiss, Jena, Germany) with a magnification of 5 to 15. The anastomosis was performed with 6-0 Prolene sutures (Johnson and Johnson, Somerville, NJ) on a 6-0 gauge cardiovascular point needle. The interrupted suturing technique was used for the posterior wall anastomosis first, and then, the continuous suture and interrupted tie technique (combined method) was used for the anterior wall (12).

Surgical Techniques Duct-to-Duct Biliary Reconstruction and Reduction Ductoplasty Interrupted suture technique was performed for the posterior wall first. The knots were placed extraluminally. The anterior wall was reconstructed using the combined method. Continuous running suture was initially done, and chain loops were formed. Recipient reduction ductoplasty, if required, because of discrepancy in the graft and recipient ducts, was performed by the microsurgeon under an operating microscope. The running sutures coursed through the anterior and posterior walls of the remaining length of the recipient duct. The reconstruction was completed by interrupted ties.

Duct-to-Jejunum Biliary Reconstruction Enterotomy was done under microscope. The serosal and mucosal layers were sutured together using 8-0 prolene. Eight sutures were required in this procedure. Interrupted suture technique was performed for the posterior wall first. The knots were placed extraluminally. The anterior wall was reconstructed using the combined method. Continuous running was done, and chain loops were formed. The reconstruction was completed by interrupted ties.

RESULTS There were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135 (23.12%), and three duct openings in 9 (1.54%) grafts. Duct-to-duct anastomosis was performed in 473 (81%) and duct-to-jejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. A 1-to-1 reconstruction was performed in 440 (75.34%) [353 (60.44%) with the recipient duct and 87 (14.90%) with the jejunum]. A 2-in-1 reconstruction was performed in 50 (8.56%). This group consisted of 43 (7.36%) 2-in-1 duct-to-duct and 7 (1.20 %) 2-in-1 duct-to-jejunum reconstructions. A 2-to-2 unmixed reconstruction was performed in 74 (12.67%).

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This group consisted of 66 (11.30%) 2-to-2 duct-to-duct and 8 (1.37%) 2-to-2 duct-to-jejunum reconstructions. A 2-to-2 mixed reconstruction was performed in 4 (0.68%). A 3-in-1 reconstruction was used in 2 (0.34%) where recipient duct was utilized as conduit. A 3-to-3 unmixed reconstruction was performed in 2 (0.34%) where all utilized the recipient duct as conduit. A 2-in-1 duct-toduct and 1-to-1 duct-to-duct unmixed reconstruction was performed in 5 (0.86%). The overall BC was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. Only 5.6% of the complications needed interventions. The complications were not significantly related to right or left lobe used, size and number of ducts, discrepancy between recipient and donor ducts, recipient age, ischemia time, and type of graft used.

DISCUSSION Biliary complications may due to many factors such as rejection, ischemia, hepatic artery complications, cytomegalovirus infections, and blood type incompatibility. Complications related to BC have resulted in considerable number of graft failures and death among liver transplant recipients (6, 9). Hence, investigators have relentlessly delved into understanding its causes, and created several innovations to overcome BC. Some of these advances included the acquisition of a comprehensive understanding of the liver, biliary tree and its blood supply (13Y17), conception of novel techniques in hepatic dissection and biliary reconstructions (3, 4, 6, 7, 18Y20), use of T-tubes and stents (4, 21Y24), and the application of microsurgical technique in biliary reconstruction (11). The high BC has often been attributed to the disparity in bile duct anatomy in partial liver grafts. In contrast to whole organ liver transplant, the bile duct in reduced size grafts, particularly in right lobe grafts, is conspicuously small and at times, multiple (7, 25). Furthermore, the sizes of duct opening in reduced grafts are often divergent (frequently smaller) from that of the recipient duct. These predicaments add up to the difficulty in biliary reconstruction and pose a greater risk of developing BC in LDLT (1, 4, 7). On this basis, some surgeons have performed duct-to-duct reconstruction in selected grafts that would secure a single bile duct anastomosis (8, 26). Such impasse could have resulted in the exclusion of what could have been otherwise a suitable living liver donor. Microsurgical biliary reconstruction has the technical advantages of enhanced visualization of the operative field under magnification to avoid physical trauma to the bile duct epithelium, effectively approach multiple ducts and allow more precise placement of stitches during anastomosis. Our team has adopted routine MBR since March 2006. Our report comparing this technique with the conventional method showed that the risk of developing BC in MBR was reduced to 4.6% after gaining an ample experience and refinements of the recipient reduction ductoplasty. Bile leak remains a serious problem (4.7%Y18.2%) in LDLT especially in right lobe graft. The presence of bile leaks has emerged as one of the most important factors in addition to technical factors in the causation of biliary stricture (27). In our series, size discrepancy in the graft and recipient

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ducts was noted in 83.3% duct-to-duct reconstructions. It is the major course of bile leak. This obstacle could be overcome by the combined method, which precisely approximated the quantity of sutures to securely close the remaining length of the recipient duct and effectively reduced the complication of bile leak to 3.3%. Biliary complications are difficult to solve in duct-tojejunum biliary reconstruction once it has been adopted for diseased extra-hepatic bile ducts or duct that was unfit for reconstruction. Size incongruence of intestinal opening and donor bile duct and mistake in suturing due to difficult identification of the intestinal lumen opening are some of the most risk factors causing bile leak and biliary stricture, respectively. Enterotomy under microscope provides delicate creation of intestinal opening and hemostasis. Suturing of the serosal and mucosal layers together using 8-0 Prolene facilitated the duct-to jejunum biliary anastomosis. Our technical experience showed that BC in LDLT can be reduced remarkably not only by way of preserving the blood supply of the biliary tree but also by appropriately planning the type of biliary reconstruction and properly aligning the anastomosis of the graft and recipient hepatic ducts. The latter objective is achieved by applying the modifications that were instituted in our techniques (28). In summary, the routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome. The routine use of MBR can decrease early and long-term biliary anastomotic complications in LDLT.

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Ishiko T, Egawa H, Kasahara M, et al. Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft. Ann Surg 2002; 236: 235. Liu CL, Lo CM, Chan SC, et al. Safety of duct-to-duct biliary reconstruction in right lobe live donor liver transplantation without biliary drainage. Transplantation 2004; 77: 726. Fan ST, Lo CM, Liu CL, et al. Biliary reconstruction and complications of right lobe live donor liver transplantation. Ann Surg 2002; 236: 676. Kasahara M, Egawa H, Takada Y, et al. Biliary reconstruction in right lobe living donor liver transplantation. Comparison of different techniques in 321 recipients. Ann Surg 2006; 243: 559. Scatton O, Meunier B, Cherqui D, et al. Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 2001; 233: 432. Icoz G, Kilic M, Zeytunlu M, et al. Biliary reconstructions and complications encountered in 50 consecutive right- lobe living donor liver transplantations. Liver Transpl 2003; 9: 575. Dulundu E, Sugawara Y, Sano K, et al. Duct-to-duct biliary reconstruction in adult living-donor liver transplantation. Transplantation 2004; 78: 574. Kawachi S, Shimazu M, Wakabayashi G, et al. Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction. Surgery 2002; 132: 48. Gondolesi GE, Varotti G, Florman SS, et al. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 2004; 77: 1842. Lee KW, Joh JW, Kim SJ, et al. High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation. Liver Transpl 2004; 10: 1158.

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Lin TS, Concejero AM, Chen CL, et al. Routine microsurgical biliary reconstruction decreases early anastomotic complications in living donor liver transplantation. Liver Transp 2009; 15: 1766. Lin TS, Chiang YC. Combined microvascular anastomosis: experimental and clinical experience. Ann Plast Surg 2000; 45: 280. Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical complications. Br J Surg 1979; 66: 379. Northover JM, Terblanche J. Bile duct blood supply: Its importance in human liver transplantation. Transplantation 1978; 26: 67. Terblanche J, Allison HF, Northover JM. An ischemic basis for biliary strictures. Surgery 1983; 94: 52. Stapleton GN, Hickman R, Terblanche J. Blood supply of the right and left hepatic ducts. Br J Surg 1998; 85: 202. Shokouh-Amiri MH, Grewal HP, Vera SR, et al. Duct-to duct biliary reconstruction in right lobe adult living donor liver transplantation. Am Coll Surg 2001; 192: 798. Sugawara Y, Makuuchi M, Sano K, et al. Duct-to-duct biliary reconstruction in living related liver transplantation. Transplantation 2002; 73: 348. Sugawara Y, Makuuchi M, Takayama T, et al. Safe donor hepatectomy for living related liver transplantation. Liver transpl 2002; 8: 58. Grewal HP, Shokouh-Amiri MH, Vera S, et al. Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction. Ann Surg 2001; 233: 502. Marcos A, Fisher RA, Ham JM, et al. Right lobe living donor liver transplantation. Transplantation 1999; 68: 798. Shaked A. Use of T-tube in liver transplantation. Liver Transpl Surg 1997; 3(5 suppl 1): 22. Roberts JP. T tube or not T tube? Liver Transpl Surg 1997; 3: S20. Egawa H, Inomata Y, Uemoto S, et al. Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 2001; 25: 1300. Heffron TG, Emond JC, Whitington PF, et al. Biliary complications in pediatric liver transplantation: A comparison of reduced-size and whole grafts. Transplantation 1992; 53: 391. Malago´ M, Testa G, Hertl M, et al. Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis. Langenbecks Arch Surg 2002; 387: 37. Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: Past, present and preventive strategies. Liver Transpl 2008; 14: 759. Lin TS, Chen CL, Concejero AM, et al. Early and Long-term results of routine microsurgical reconstruction in living donor liver transplantation. Liver Transp 2013; 19: 207.

SECTION 10. ENDOSCOPIC MANAGEMENT OF BILIARY COMPLICATIONS IN ADULT LIVING DONOR LIVER TRANSPLANTATION

Milljae Shin,1 and Jae-Won Joh1,2 Abstract. Living donor liver transplantation (LDLT) has become an accepted therapeutic option for patients with end-stage liver disease. However, biliary complications remain the major causes of morbidity and mortality for LDLT recipients. Although there are currently no reports of a clear therapeutic algorithm, many approaches have been developed to treat biliary complications, including surgical, endoscopic, and percutaneous transhepatic techniques. Endoscopic treatment is currently the preferred initial treatment for patients that have previously undergone duct-to-duct biliary reconstruction. This article discusses aspects of endoscopic management of biliary complications that occur in adult LDLT.

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Section 9. Technical details of microsurgical biliary reconstruction in living donor liver transplantation.

Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liv...
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