Management of biliary anastomotic stricture in living-donor liver transplantation

Abstract

Liver transplantation is a life-saving treatment for patients with end-stage liver diseases. The demand for the operation, however, always exceeds the supply of liver grafts donated by the deceased, and thus living-donor liver transplantation (LDLT) has been developed as an alternative to deceased-donor liver transplantation. Results have shown that LDLT can achieve survival outcomes comparable with those yielded by deceased-donor liver transplantation even in high-risk patients.

LDLT is one of the most complicated and technically demanding surgical procedures. The study on the first series of RLDLT at our centre reported high rates of morbidity and reoperation. Since then, various advances in technique and management have been made, including a better understanding of the minimum graft size requirement and anatomic variants of the right liver lobe, improved selection criteria for donors and recipients, and technical modifications particularly of venous outflow and bile duct reconstructions. These improvements have contributed to the excellent donor and recipient outcomes as well as the outstanding graft survival rate of over 90%. The rate of bile leakage has decreased dramatically to below 2 % but that of biliary anastomotic stricture (BAS) is still high. BAS not only affects the long-term outcome and quality of life but also occasionally causes graft losses and patient deaths. At our centre, the rate of BAS is around 20%. Measures must be taken to manage the problem promptly. This thesis set out to determine the risk factors and the treatment algorithm for this challenging posttransplant complication. Results of the studies show that BAS is associated with acute cellular rejection in adult right-lobe LDLT (29.1% vs. 11.0%, p=0.001) and with duct-to-duct anastomosis (DDA) in paediatric LDLT (75% vs. 13.5%, p=0.012). The overall success rate of endoscopic treatment for BAS conducted by operating surgeons is above 70%, and a pouched BAS morphology is associated with a significantly higher rate of treatment failure (success rate of 43% only). There is an association between bile leakage and pouched morphology (p=0.008). For patients with pouched strictures, prompt surgical salvage should be considered after endoscopic treatment fails for the first time. In the surgical treatment of BAS with DDA, the DDA is converted to a hepaticojejunostomy either in an end-to-side mode or in a side-to-side mode. The two modes yield similar outcomes except that the risk of hepatic artery injury is lower with the latter. The side-to-side mode also allows future endoscopic access to the site of anastomosis. In conclusion, BAS must be treated promptly to prevent significant morbidities and death. Adoption of hepaticojejunostomy instead of DDA in paediatric LDLT can decrease the rate of BAS. Endoscopic treatment conducted by operating surgeons is the first-line gold standard treatment for BAS with DDA. If endoscopic and radiological means fail in the treatment of BAS, surgical treatment should be conducted promptly.