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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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Keywords: Biliary complication, Endoscopic management, Endoscopic retrograde cholangiography, Living donor liver transplantation.

ecause of the shortage of deceased donor organs, living donor liver transplantation (LDLT) has become a widely accepted therapeutic option for patients with end-stage liver disease. There have been noticeable improvements in the surgical techniques and immunosuppressive therapies for this procedure; however, biliary complications are still the major cause of morbidity and mortality in LDLT recipients (1Y3). According to recent reports, approximately 15% to 40% of adult recipients will develop biliary complications after an LDLT (3Y8). Biliary complications are more frequent with transplants from living donors compared with transplants from deceased donors (9, 10), and these complications occur with a higher frequency in right liver grafts than in left liver grafts (11). Increased incidences of biliary complications after LDLT are characterized by small diameter of the anastomotic bile duct, biliary anatomic diversity, complex surgical procedures, local ischemia of the peribiliary plexus, and angulated duct anastomosis caused by hypertrophy of the liver graft (3, 4, 8, 12, 13). The process of LDLT itself serves as a risk factor for biliary complications (14). Biliary complications from an LDLT procedure include biliary stricture, bile leakage, and biliary obstruction (with stones, sludge, or casts). Among these, bile leakage and anastomotic stricture are the predominant complications. They can occasionally lead to recurring hospital admissions or to graft failure, which necessitates retransplantation, and both of which increase the costs of treatment (15Y17). Therefore, the management of biliary complications has a significant role in determining the recipient’s quality of life as well as graft survival (17). Although no clear therapeutic algorithm has yet been reported, many approaches to treat biliary complications have been developed, including surgical, endoscopic, or percutaneous transhepatic techniques (18). Recently, nonsurgical approaches have largely replaced reoperation as the initial treatment of biliary complications, although repeated examinations and interventions are required for adequate treatment (7, 19). Endoscopic treatment is the preferable firstline option for patients that have previously undergone ductto-duct biliary reconstruction, as it is less invasive and more convenient for the patient (2, 3, 5, 20Y23). Percutaneous transhepatic therapy is then subsequently considered in incidences where the endoscopic approach has failed (2, 20).

B

This article was presented at the Asian Summit on Living Donor Liver Transplantation held on January 12, 2013 in the Buddha Memorial Center, Kaohsiung, Taiwan. The authors declare no funding or conflicts of interest. 1 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2 Address correspondence to: Jae-Won Joh, M.D., Ph.D., Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. E-mail: [email protected] M.S. participated in the conception, design, content acquisition, interpretation, and article drafting. J.-W.J. participated in critical revision of intellectual content and manuscript supervision.

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

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Surgical revision or conversion is reserved as a rescue therapy when all other modalities have proven unsuccessful (17, 24). The purpose of this article is to give an overview of various aspects of endoscopic procedures and discuss the diagnosis, management, and outcomes of biliary complications that occur after an adult LDLT. General Endoscopic Management Practices Conventional therapeutic endoscopy involves completion of an endoscopic retrograde cholangiography (ERC) and a guide-wire cross through the corresponding lesion. If there is a stricture, balloon dilatation is used as large as the donor duct size, and there can be subsequent insertions of single or multiple endoscopic retrograde biliary drainage (ERBD) stents. The procedure must be repeated every 3 months to evaluate the progression of complicated lesions, to dilate the stricture site, and to prevent stent occlusion or stone formation (25). The total duration of stent deployment averages from 6 to 12 months. Studies indicate that the most common type of late biliary complication (93 months posttransplantation) is biliary stricture (19). Although the stricture can present at any time after transplantation, the median time interval between LDLT and biliary stricture is 5.9 months (26). The strictures occur primarily at the anastomotic site, and treatment in most patients requires balloon dilation of 4 to 10 mm for 30 to 60 seconds and an ERBD stent of 7 to 10 Fr (Fig. 1A). Successful endoscopic management of anastomotic strictures is achieved in 58% to 75% of patients (3, 16, 25). However, nonanastomotic strictures, which account for less than 7% of all strictures, is associated with frequent, rapid stent clogging and a much poorer success rate of 25% (8, 16, 17, 25). Bile leak is a complication that predominates in the early period (G3 months) after LDLT, and in 70% of cases, it is found within 1 month of the LDLT (19). The median time interval between LDLT and bile leak is 0.7 months (26). Bile leak can originate from the anastomotic site, the cystic duct stump, or the cut surface of the liver. ERC is the gold standard for diagnosis of any kind of bile leak (14). Studies indicate that ERBD stent placement for about 2 to 3 months results in resolution of 88% to 100% of bile leaks (Fig. 1B) (22, 27). Occasionally, instead of the ERBD stent, an endoscopic naso-iliary drainage (ENBD) tube can be inserted proximal to the bile leakage (5, 22, 26). Biliary obstruction can also be caused by stones, sludge, debris, or casts after an LDLT. Similar endoscopic management was applied in these incidences, and the obstructions were treated with sphincterotomy and balloon retrieval or trapezoid basket extraction. In some cases, reduction of intraductal pressure by endoscopic sphincterotomy was sufficient to achieve a favorable therapeutic outcome (Fig. 1C). Types of Biliary Anastomotic Strictures Several reports have proposed various classifications for dividing the types of biliary anastomotic strictures which occur after an LDLT (Fig. 2). There is a general consensus that the clinical outcomes and prognoses of the different types of strictures are markedly distinct. Lee et al. (21) classified biliary anastomotic strictures by stricture morphology and divided them into nonvisualization type, separate type, narrow type, and wide type categories. Lee and colleagues also

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FIGURE 1. General practice of endoscopic management of biliary complications after an adult LDLT (ERC, endoscopic retrograde cholangiography; ERBD, endoscopic retrograde biliary drainage; ENBD, endoscopic naso-biliary drainage; LDLT, living donor liver transplantation). A, A 57-year-old man with right lobe LDLT developed a biliary anastomotic stricture (orange arrow) 1 month posttransplant. After dilatation using a high-pressure pneumatic balloon for 30 seconds, a 7-Fr straight plastic stent was inserted. B, A 44-year-old man with right lobe LDLT developed a bile leak (orange arrow) at the duct-to-duct anastomosis. An ERBD stent was inserted proximal to the site of anastomosis. C, A 30-year-old man with right lobe LDLT developed a 2-cm biliary stone and severe dilatation of the common bile duct due to papillary stenosis (orange arrows). Biliary anastomotic stricture was not proven. His problemwas relieved by endoscopic sphincterotomy only.

classified the strictures by the angle between the proximal and distal ducts: 0 to 30, 30 to 60, 60 to 90, and larger than 90 degrees (S-shaped stricture) (21). In comparison, Kim et al. (28) divided strictures into three types (pouched, intermediate, or triangular) based on the shape of the distal-side (donor) duct of the biliary anastomosis. Additionally, Yazumi et al. (8, 23) divided the strictures into four types, unbranched, forkshaped, trident-shaped, and multibranched (more than three strictures) based on the number of biliary strictures at the proximal side of the biliary anastomosis. Special Techniques and Pitfall of Endoscopic Management Occasionally, there are cases where conventional endoscopic access is unsuccessful. In these situations, another alternative treatment option can be considered to facilitate

cannulation of the bile duct. Biliary stricture recannulation is performed using the rendezvous technique, which combines percutaneous transhepatic and endoscopic approaches (29Y32). This procedure is performed by introducing a snare through a percutaneous transhepatic biliary drainage (PTBD) catheter and inserting a guide wire into the stricture through ERC. The snare is then used to capture the guide wire and pull it through the stricture to completely cannulate the stricture. This technique is recommended in patients with angulated or twisted strictures (29). Some reports support the application of the rendezvous technique for bile leak and biliary anastomotic disruption treatment (33, 34). Magnetic compression anastomosis is another hybrid technique, which is used to canalize biliary anastomotic stricture after an LDLT (35Y38). For this procedure, two magnets are introduced on each side of the obstructed bile tract: the

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FIGURE 2. Example of biliary anastomotic stricture after adult living donor liver transplantation.

first magnet is inserted via ERC and then the second is introduced via PTBD. The transmural compression of the two magnets causes gradual ischemic necrosis and creates a new anastomosis between the bile duct. This technique can prevent the need for a lifelong external drainage bag and reduce the chance of requiring reoperation for anastomotic stricture after an LDLT (39). The research indicates that most of the technical failures of conventional endoscopy can be overcome with the rendezvous procedure or by using the magnetic compression anastomosis technique. Advancements in endoscopic biliary complication management have resulted in the widespread use of ERBD deployment, and several studies have reported successful applications of this treatment. However, there are a few limitations to the broad applications of clinical endoscopic therapy. One example of these limitations is the occurrence of a missing duct, an unidentified separated bile duct branch. These separated bile duct branches can be overlooked because ERC is performed with two-dimensional imaging. This issue is described in further detail in Figure 3. Technical Success Rate and Outcome Predictors Therapeutic endoscopy plays an important role in the treatment of posttransplant biliary complications. Currently, the preferred endoscopy method is to aggressively dilate the stricture and repeatedly insert multiple plastic stents with the intent of improving anastomotic stricture (17). Several studies have recently reported high success rates and factors associated with the outcomes in endoscopic management of biliary complications. Table 1 summarizes the results of endoscopic therapeutic treatment of these biliary complications following adult LDLT with duct-to-duct anastomosis. ERBD Stent Selection There is still debate regarding which endoscopic devices should be used in LDLT recipients with biliary complications. Endoscopic methods include procedures such as balloon dilatation, ERBD stent, ENBD tube, or sphincterotomy, and the

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selection of a method depends on the characteristics of the lesion, including its etiology, location, severity, and findings from ERC imaging. The number, size, and form of the endoscopic devices were determined based on the various treatment method options. The current data suggest that, in cases of biliary stricture, using balloon dilatation with multiple ERBD stents is better for long-term recovery than using balloon dilatation without stenting or using just a single stent. The most commonly used ERBD stent is a plastic (polyethylene) stent. Plastic stents are easy to insert and more cost effective but have a small diameter and can become clogged over time. Because of this, there is often a need for frequent ERC to replace the clogged ERBD stent. In an effort to reduce the recurrence of biliary stricture and to maintain a longer patent duration, a metal stent with a larger diameter has been developed (17). However, metal stents are expensive and have a tendency to migrate out of the ducts. Traditional uncovered metal stents are associated with frequent stent occlusion due to epithelial hyperplasia and stone formation. These disadvantages limit the use of a metal stent for benign biliary diseases such as posttransplant biliary stricture (40, 41). A recently developed fully covered selfexpandable metal stent has emerged as a good alternative to the traditional metal stent in select cases (42, 43). Some of the advantages of this metal stent include small predeployment and large postexpansion diameters. The lack of imbedding of the metal into the bile duct wall also allows for easier removability overall (42). Comparison With Percutaneous Transhepatic Approach Endoscopic techniques and percutaneous transhepatic radiologic procedures have traditionally been used to treat biliary complication after an LDLT. However, recent reports have recommended performing ERC as a first approach for treatment and reserving percutaneous transhepatic biliary

FIGURE 3. Missing duct: A 60-year-old man with right lobe LDLT developed jaundice 6 months posttransplant. ERC imaging showed a biliary anastomotic stricture, which was treated with an ERBD insertion. After intervention, his bilirubin level decreased but did not return to normal range. A follow-up CT scan identified a dilated and separated posterior bile duct, and a PTBD was performed via the posterior bile duct branch. Following these procedures the patient’s bilirubin level returned to normal.

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TABLE 1. Results of endoscopic management of biliary complications after adult living donor liver transplantation: a review of the literature Authors

Factors affecting endoscopic treatment outcomes

Technical success rate

Chang et al. (2010) (51)

90/113 (79.6%) for stricture

Kato et al. (2009) (16) Lee et al. (2011) (21)

31/41 (75.6%) for stricture 68/137 (49.6%) for stricture

Yazumi et al. (2006) (8) Tsujino et al. (2006) (7)

Kim et al. (2009) (28) Tashiro et al. (2007) (12)

52/80 (65.0%) 8/16 (50.0%) 12/17 (70.6%) 2/3 (66.7%) 8/9 (88.9%) 38/60 (63.3%)

for stricture* for bile leak for stricture for bile leak for biliary casts for stricture

Lee et al. (2008) (52)

10/20 (50.0%) for stricture 5/12 (41.7%) for bile leak 12/17 (70.6%) for stricture

Seo et al. (2009) (53)

9/13 (69.2%) for bile leak 15/26 (57.7%) for stricture

Morelli et al. (2008) (50)

33/38 (86.8%) for stricture

Nonanastomotic stricture Hepatic artery stenosis Concomitant bile leak Stricture-to-ERC interval Cholangiographic stricture morphology Shape of the distal side of biliary Anastomosis Anastomotic stricture with crane-neck deformity Nonanastomotic stricture V

Shape of the distal side of the biliary Anastomosis V Sharp angle (between right anterior bile duct and common bile duct) Concomitant bile leak Late onset (over 24 weeks) of biliary Stricture Rapid-sequence balloon dilation Shorter total length of multiple stenting

*51/75 (68.0%) for anastomotic stricture.

drainage (PTBD) for rescue therapy (20, 28, 44). A summary of these two techniques is presented in Table 2. One consideration between these two techniques is the issue of safety. Complications from a PTBD procedure can include cholangitis, bile peritonitis due to bile leakage, bleeding, hemobilia, pancreatitis, pain at the insertion site, tube malfunction, hepatic vascular injury, hemothorax, and body fluid loss with an imbalance of electrolytes (26, 45). The possible complications from an ERC, such as bleeding, pancreatitis, cholangitis due to duodenal content reflux, and stent migration into the intestine, are common, although duodenal or bile duct perforation occur rarely (46, 47). In general, it is believed that ERC is safer because it is minimally invasive and has fewer procedure-related complications, with the exception of higher pancreatitis immediately following the ERC (28). Despite the limited data, some studies have compared the efficacy of ERBD and PTBD. Park et al. (26) reported that both procedures were effective therapies for LDLT-associated biliary complications. Lee et al. (20) also demonstrated that the rate of successful intervention and stent patency do not differ for ERBD or PTBD. In consideration of cost effectiveness, the expense of the PTBD procedure is lower than the ERBD treatment ($390,000 versus $729,000 USD, respectively). However, these numbers represent the overall medical care cost, which is the sum of the total hospital cost, the

cost of admission, and the duration of the patient’s stay in the hospital. It is also known that the number of reinterventions is an important factor that influences the final costs of treatment (48). Both diagnosis of biliary complications and therapeutic intervention are possible when using endoscopic and percutaneous transhepatic approaches. These techniques can make complete cholangiography possible. Although ERC allows much easier to access the lesion, ERC is nearly impossible to perform in patients who have previously undergone Roux-en-Y hepaticojejunostomy biliary reconstruction. Percutaneous transhepatic access may be easier for the treatment of nonanastomotic intrahepatic strictures (32). Endoscopic retrograde biliary drainage is internal drainage and more physiological, which helps maintain the enterohepatic circulation of bile salts. Another reason for selecting endoscopic treatment as the preferred drainage method is cosmetic appeal because there is no need for catheter exposure. In addition, patients have reported the highest satisfaction with ERC treatment and that discomforts caused by PTBD can disturb daily living activities and decrease quality of life. Another advantage of ERC is that it allows easy placement of multiple, simultaneous ERBD stents during a single intervention in the occurrence of a multi-branched biliary stricture. Yazumi et al. (8) and Kim et al. (28) used interventional ERC methods and reported a recurrence of biliary

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TABLE 2. Comparison of endoscopic retrograde biliary drainage (ERBD) and percutaneous transhepatic biliary drainage (PTBD) procedures

Safety (procedure-related complication)

Effectiveness of bile drainage Cost Effectiveness

:Procedure charge : Final costs

Diagnostic usefulness

ERBD

PTBD

Bleeding (sphincterotomy site) Pancreatitis Cholangitis Stent migration Duodenal perforation Bile duct perforation High efficacy Acceptable stent patency $729,000 USD (Dependent on the number of reinterventions) Complete cholangiography

Bleeding (hemobilia) Pancreatitis Cholangitis Tube dislocation Bile leak, bile peritonitis Portal vein injury High efficacy Acceptable stent patency $390,000 USD

Compliance

More physiologic Cosmetic appeal Comfortable Normal daily living activity

Long-term treatment Accessibility Recurrence rate of biliary stricture after successful interventions*

Easy to insert multiple Stents 11.1% to 13.2% at 6 months 22.6% at 9 months

Complete cholangiography Able to diagnose Roux-en-Y hepaticojejunostomy stricture Body fluid (electrolyte) loss Pain at insertion site Uncomfortable Limited daily living activity One stent at one duct Branch 16.7% at 8 months

*[7, 16, 28, 45]

strictures in 10.7% (3/28) of patients at a mean of 1.8 months, and in 13.2% (5/38) of patients at a mean of 6 months, respectively. Tsujino et al. (7) demonstrated a cumulative recurrence rate of 11.1% at 6 months. In a study by Kato et al. (16), 7 of 31 (22.6%) patients experienced restenosis at a median of 9 months after ERBD removal. Choo et al. (45) used a PTBD catheter and reported a recurrence rate of 16.7% (2 of 12 patients between 6 to 8 months after the most recent procedure). Recently, Gwon et al. (49) developed a technique using percutaneous balloon dilation and dual-catheter placement (up to 22.5 Fr) and achieved a 3-year patency rate of 91% and a recurrence rate of 9% (7/78) with a mean follow-up period of 15.4 months. Based on these studies and with continued development of endoscopic interventional techniques, ERC has an acceptable long-term outcome for the management of biliary strictures resulting from adult LDLT with duct-to-duct biliary anastomosis.

superior long-term outcomes from using multiple plastic stents with or without repeated aggressive dilation. According to recently published studies, the overall success rates of endoscopic approaches for LDLT recipients has ranged from 49.6% (21) to 86.8% (50). Based on these results, therapeutic endoscopy is recommended as a first-line approach, and percutaneous transhepatic and surgical modalities may serve as subsequent rescue procedures in failed or resistant cases of endoscopic therapy. In the future, more effective procedures with refined devices need to be established to increase optimal results.

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SUMMARY Biliary complications after an adult LDLT are common and can lead to significant morbidity and mortality. These complications can be optimally managed through various endoscopic procedures, including internal drainage, which has been proven to be safe and effective. Although the outcome of endoscopic management depends on both the etiology and location of the complication, several reports suggest

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Chen et al.

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Seo JK, Ryu JK, Lee SH, et al. Endoscopic treatment for biliary stricture after adult living donor liver transplantation. Liver Transpl 2009; 15: 369.

SECTION 11. RADIOLOGICAL INTERVENTION APPROACHES TO BILIARY COMPLICATIONS AFTER LIVING DONOR LIVER TRANSPLANTATION

Gi-Young Ko,1,2 and Kyu-Bo Sung1 Abstract. Although endoscopic treatment has become the first choice to treat biliary complications, percutaneous transhepatic treatment still has important roles to treat biliary stricture or leak after living donor liver transplantation. This study reviewed a total of 527 recipients who had undergone percutaneous transhepatic treatment to treat biliary stricture (n=498) and leaks (n=29). Percutaneous transhepatic treatment included percutaneous transhepatic biliary drainage, perihepatic biloma drainage, balloon dilation of biliary stricture, and drainage catheter interposition or retrievable covered stent placement across a stricture or leak segment. Clinical success was achieved in 440 (88.4%) recipients with biliary stricture and 19 (65.5%) recipients with bile leaks. Percutaneous transhepatic treatment seems to be an effective alternative for treating biliary complications resistant to or inaccessible by endoscopic treatment. Keywords: Liver transplantation, Biliary complications, PTBD, Stent.

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Korea. The initial diagnosis of biliary complications was based on a combination of clinical symptoms, biochemical data, and the results of imaging studies using ultrasonography, computed tomography, and diisopropyl iminodiacetic acid scanning.

Stricture Four hundred ninety-eight of the 527 recipients underwent percutaneous transhepatic treatment to treat biliary stricture. The routine protocol of percutaneous transhepatic treatment included percutaneous transhepatic biliary drainage (PTBD), repeated balloon dilation of biliary stricture, and serial exchanges of biliary drainage catheters (Cook, Bloomington, IN) up to 14 Fr (Group 1). Stone removal using a stone basket was also performed if there were filling defects in the intrahepatic or common bile ducts. Since 2006, dual catheter placement technique, in which insertion of two drainage catheters (14 and 8.5 Fr) via a single percutaneous tract, was also adopted to achieve sufficient dilation of the stricture (Group 2). After at least 3 months of 14 Fr or dual catheter interposition across the stricture, the catheter was repositioned above the stricture, with the tip clamped for 4 weeks to assess the presence of elastic restenosis of the treated stricture. Drainage catheters were removed when the 4-week follow-up cholangiogram revealed fluent internal drainage with stable biochemical data. Retrievable covered stent placement after initial PTBD and balloon dilation was also tried to achieve sufficient dilation of the anastomotic stricture with reduced treatment duration (Group 3). Covered stent (TaeWoong Medical, Seoul, Korea) with 8 to 10 mm in diameter was deployed across the stricture, and it was removed using a 9-Fr braded sheath and a retrieval hook wire (TaeWoong) at least 8 weeks after placement. Detailed procedural technique of each percutaneous transhepatic treatment was described elsewhere (3Y5). Three hundred twenty-two of the 498 recipients had DD anastomotic stricture, 165 had HJ anastomotic stricture, and the remaining 11 had both DD and HJ anastomotic strictures. The initial endoscopic cannulation of the intrahepatic or common bile ducts failed in 199 recipients who had DD anastomosis.

iliary complications, including biliary stricture, leaks, stone or biliary cast syndrome, still remain as common causes of morbidity following living donor liver transplantation (LDLT). Endoscopic treatment is generally accepted as the best initial method for treating biliary complications with low morbidity and mortality (1, 2). However, endoscopic treatment is not easy in patients who have complete duct-to-duct (DD) anastomotic occlusion. In addition, endoscopic treatment is nearly impossible in patients who have hepaticojejunostomy (HJ). In such situations, percutaneous trans-hepatic treatment may be a good alternative. The aim of this current study is to retrospectively review the efficacy of various percutaneous trans-hepatic treatments for treating biliary complications following LDLT at a single institution.

Twenty-nine recipients underwent percutaneous transhepatic treatment to treat bile leaks. Sixteen of them had DD anastomosis, six had HJ anastomosis, and seven had both DD and HJ anastomoses. The indications for PTBD in patients who had DD anastomosis were bile leaks refractory to endoscopic management for 1 week, failed endoscopic cannulation of the intrahepatic bile duct across anastomosis, and a poor general condition for endoscopy. Percutaneous transhepatic treatment included percutaneous drainage of perihepatic biloma under ultrasonographic or fluoroscopic guidance, PTBD, and interposition of a drainage catheter across the leakage site. In patients who had bile leaks with anastomotic biliary stricture, balloon dilation of the biliary stricture was also performed. Serial exchanges of the bile drainage catheter up to 14 Fr were routinely performed at 4-week intervals to avoid postinflammatory stricture or restenosis. Detailed procedural technique was described elsewhere (6).

MATERIALS AND METHODS

The primary patency of clinical success was analyzed with the KaplanMeier method. The analysis was performed with SPSS software, version 19.0 (SPSS, Chicago, IL).

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During the last 15 years, 527 (18.8%) of 2798 LDLT recipients including 10 pediatric patients (G15 years) underwent percutaneous transhepatic treatment to manage biliary complications at the Asan Medical Center, Seoul, The authors declare no funding or conflicts of interest. 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea. 2 Address correspondence to: Gi-Young Ko, M.D., Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. E-mail: [email protected] G.-Y.K. participated in research design, manuscript writing, performance of the research, and data analysis. K.-B.S. participated in research design, performance of the research, and data analysis.

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

Leak

Statistical Analyses

RESULTS Stricture Percutaneous transhepatic biliary drainage was successfully performed in all 498 recipients. Fifteen recipients had anastomotic as well as nonanastomotic biliary strictures. One hundred twenty-eight recipients required 2 or more PTBD sessions to treat complex anastomotic strictures. Cannulation of the biliary strictures or occlusion and subsequent balloon dilation were technically successful in 488 (98.0%) of 498recipients. In the remaining 10 recipients, cannulation of the biliary stricture failed despite

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

Section 10. Endoscopic management of biliary complications in adult living donor liver transplantation.

Living donor liver transplantation (LDLT) has become an accepted therapeutic option for patients with end-stage liver disease. However, biliary compli...
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