Accepted Manuscript The influence of contemporaneous revascularization on biliary complications after liver transplantation Mikel Gastaca, MD PII:
To appear in:
Received Date: 3 February 2014 Accepted Date: 24 February 2014
Please cite this article as: Gastaca M, The influence of contemporaneous revascularization on biliary complications after liver transplantation, Surgery (2014), doi: 10.1016/j.surg.2014.02.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
TITLE OF THE MANUSCRIPT: The influence of contemporaneous
revascularization on biliary complications after liver transplantation
DEPARTMENT AND INSTITUTION
Cruces University Hospital University of the Basque Country
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Hepatobiliary Surgery and Liver Transplantation Unit
Mikel Gastaca MD
Address: Plaza de Cruces s/n. 48903 Baracaldo. Vizcaya. Spain
AUTHOR CONTACT INFORMATION Mikel Gastaca
Unidad de Cirugía Hepato-biliar y Trasplante Hepático Hospital Universitario de Cruces
Plaza de Cruces s/n. 48903. Baracaldo. Vizcaya. Spain Tel: +34946006372
E-mail: [email protected] [email protected]
ACCEPTED MANUSCRIPT No external funding was received to support this work.
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Authors have no commercial associations or conflicts of interest to declare.
TEXT I read with great interest the study by Lu et al. (1) recently published in Surgery. In the article, the authors retrospectively compare contemporaneous portal and hepatic artery
revascularization (CPA) with sequential revascularization (SPA) with an interval >10 minutes in liver transplantation (LT). In the study, SPA was followed by a significant increase in biliary complications (BCs) (25% vs 9%; p=.005) mainly due to
nonanastomotic strictures (9% vs 2%; p=.03). BCs in the SPA group tended to be more severe by the Clavien-Dindo Classification. The authors conclude that the CPA protocol
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should be regarded as the priority for revascularization in LT.
The delay in reestablishing arterial inflow in a liver perfused only by portal flow may prolong the warm ischemia time to the bile ducts and contribute to the development of complications (2). Based on this, a progressive effect should be expected with more
serious damage associated with a longer interval. We have recently published our experience with a very homogenous cohort of 743 LTs performed using choledochocholedochostomy with T-tube, sequential reperfusion, a median cold
ischemia time of 293 minutes (range 137-887) and a median arterial ischemia time of 29
minutes (range 9-135) (3). In the study, we observed a low rate of BCs (9%) including a 2.5% rate of stenosis, with only a 0.2% rate of nonanastomotic stenosis. Median arterial ischemia time was higher in patients with BCs 35 min (13-110) vs 29 min (9-35); p30 minutes were factors related to the development of BCs. Nevertheless, the area under the ROC curve of our model was 0.637; CI 0.564-0.710 suggesting other factors not included in our model could influence the development of BCs after LT.
ACCEPTED MANUSCRIPT Of note, the study by Lu et al. (1) is retrospective and based on two sequential nonsimultaneous cohorts what might presume a significant bias. Surprisingly, only a >10 minutes sequential revascularization time (the definition for the SPA group) was related with BCs, as no difference was found for the portal vein-hepatic artery interval between
cases with and without BCs within the SPA group (36±10 vs 36±7 minutes; p=.83). This finding of a cutoff point of 10 minutes for the development of BCs warrants further explanation. Moreover, the incidence of vascular complications including
hepatic artery thrombosis was higher in the SPA group (7% vs 3%; p=.21) and it is well known that vascular complications are closely related with BCs (4). Although the
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difference did not achieve significance, it could have influenced the development of BCs in the SPA group and explain the high incidence of nonanastomotic strictures in this group (9%). In summary, although simultaneous revascularization could be of help in reducing the incidence of BCs, it has not been demonstrated that it should be
regarded as a priority. Reducing cold, warm and arterial ischemia time or modifying technical aspects with the use of a rubber T-tube in biliary reconstruction should also be
considered to achieve this goal (5).
ACCEPTED MANUSCRIPT REFERENCES 1.- Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, et al. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary
complications after liver transplantation. Surgery 2014;155:190-5
2.- Adani GL, Rossetto A, Lorenzin D, Lugano M, De Anna D, Della Rocca G, et al. Sequential versus contemporaneous portal and arterial reperfusion during liver
transplantation. Transplant Proc 2011;43:1107-9
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3.- Gastaca M, Matarranz A, Martinez L, Muñoz F, Valdivieso A, Bustamante J, et al. Incidence of and Risk Factors for Biliary Complications after CholedochoCholedochostomy with T-tube in Orthotopic Liver Transplantation. A Single Center
Cohort of 743 Transplants. Am J Transplant 2012; 12 Suppl3:256
4.- Dacha S, Barad A, Martin J, Levitsky J. Association of hepatic artery stenosis and biliary strictures in liver transplant recipients.
Liver Transpl. 2011;17(7):849-54
5.- Gastaca M, Valdivieso A, Ruiz P, Ventoso A, Ortiz de Urbina J. T-tube or no T-tube in cadaveric orthotopic liver transplantation: The type of tube really matters. Ann Surg Doi:10.1097/SLA.0b013e31829d56c0. In press