Bile duct anastomotic stricture after right lobe adult-to-adult living donor liver transplantation

Abstract

BACKGROUND: Duct-to-duct anastomosis and hepaticojejunostomy (HJ) are both the accepted options for bile duct reconstruction in right lobe adult-to-adult living donor liver transplantation (RLDLT) in recent years. Postoperative bile duct anastomotic stricture is common and the associated risk factor is not clearly defined. The aim of the present study is to determine the rate of bile duct anastomotic stricture after RLDLT and the associated risk factors. PATIENTS AND METHODS: A total of 315 adult patients who underwent RLDLT from July 1994 to December 2008 were included in the present study. First 50 cases were excluded because of the learning curve effect. RESULTS: A total of 265 patients were included, in which 55 patients (20.8%) developed bile duct anastomotic stricture after RLDLT. 43 out of 201 patients (21.4%) undergone duct-to-duct anastomosis, 10 out of 53 patients (18.9%) undergone HJ reconstruction and 2 out of 11 patients (18.2%) undergone both HJ and duct-to-duct anastomosis developed biliary anastomotic stricture. The recipients’ demographic data were comparable. Number of graft bile duct openings (p=0.516) and size of graft smallest bile duct (5mm vs. 5mm; p=0.430) were not significantly different in two groups of patients. Recipient warm ischaemic time (55 minutes vs. 51 minutes; p=0.026), graft cold ischaemic time (120 minutes vs. 108 minutes; p=0.046), postoperative acute cellular rejection (p=0.001) and use of different perfusant (p=0.005) were associated with a significant higher rate of bile duct anastomotic stricture. Cold ischaemic time (Odds ratio: 1.012; 95% CI: 1.002-1.023, p=0.017) and acute rejection (Odds ratio: 3.080; 95% CI: 1.474-6.435, p=0.003) were two independent predictive factors for stricture formation on multivariate analysis. Graft survival between two groups was comparable. Patients with bile duct stricture would be treated with ERCP, PTBD and surgery accordingly. One patient required re-transplantation due to secondary biliary cirrhosis. CONCLUSION: Biliary anastomotic stricture remains common in RLDLT using either duct-to-duct or HJ reconstruction. Cold ischaemic time and history of acute rejection were two independent predictive risk factors for bile duct anastomotic stricture formation in RLDLT.