Langenbeck’s Arch Surg (2002) 387:37–44
DOI 10.1007/s00423-002-0282-1
Massimo Malagó
Giuliano Testa
Martin Hertl
Hauke Lang
Andreas Paul
Andrea Frilling
Ulrich Treichel
Christoph E. Broelsch
Received: 14 November 2001
Accepted: 21 January 2002
Published online: 27 March 2002
© Springer-Verlag 2002
M. Malagó (✉) · G. Testa · M. Hertl
H. Lang · A. Paul · A. Frilling
C.E. Broelsch
Klinik und Poliklinik für Allgemeinund Transplantationschirurgie,
Operatives Zentrum II,
Universitätsklinikum Essen,
Hufelandstrasse 55,
45122 Essen, Germany
e-mail: [email protected]
Tel.: +49-201-7231101
Fax: +49-201-7231113
U. Treichel
Abteilung für Gastroenterologie,
Universitätsklinikum Essen,
Essen, Germany
HOW TO DO IT
Biliary reconstruction following right adult
living donor liver transplantation end-to-end
or end-to-side duct-to-duct anastomosis
Abstract Background and aims:
Bile duct complications are the
modern Achilles’ heel of adult-toadult living donor liver transplantation. A duct-to-duct anastomosis is
currently performed in the presence
of single graft ducts, while cholangiojejunostomy is used to drain multiple ducts. Our aim is to describe
the feasibility of duct-to-duct anastomoses independent of the presence
of one or multiple graft bile ducts.
Methods: The probe technique for
right bile duct dissection in donors
and a proximal hilar bile duct division in recipients are illustrated. The
BARIGA LDLT (biliary anastomosis
in right graft for adult living donor
liver transplantation recipients) with
end-to-side or end-to-end hepaticohepaticostomy was used in five recipients of right grafts (segments 5–8).
Introduction
Adult-to-adult right living donor liver transplantation
(RLDLT) is increasingly utilized because of the organ
shortage currently prevalent in both the eastern and
western hemispheres. As in the primordial era of liver
transplantation (LT) [1], the biliary drainage is still the
Achilles’ heel of the procedure. At present, the biliary
anastomosis is the most common site of complications
reported in living donor liver transplantation (LDLT).
Biliary complications are responsible for the most
frequent surgical morbidity following RLDLT, reaching up to 30% [2, 3]. For recipients, they still represent
the main disadvantage of RLDLT compared to standard LT.
Results: All donors and recipients are
doing well; all grafts are functional
at 13 months. Duct-to-duct anastomoses to single, double, or triple graft
ducts have been performed. Two early anastomotic stenoses at 5 and
10 weeks were successfully treated
endoscopically. Conclusion: The
duct-to-duct anastomosis represents
a valid alternative to the standard hepaticojejunostomy for right living
donor liver grafts. Using this method,
biliary complications can be treated
endoscopically. End-to-side or endto-end BARIGA LDLT has the potential to become a standard method
in segmental transplantation, including split liver.
Keywords Biliary anastomosis
in right live donor grafts
The first successful RLDLT worldwide was performed in 1990 in Kyoto by Yamaoka, Tanaka, and
Ozawa [4]; the second was performed by our group in
Hamburg in 1993 [5]. In both cases the biliary tree was
reconstructed using a Roux-en-Y hepaticojejunostomy;
the indications were biliary atresia and Alagille syndrome in two children. The first report of an end-to-end
(E-E) anastomosis was by Wachs and Kam in Denver
[6]. The anastomosis was revised to a Roux-en-Y reconstruction 6 months post-transplant because of a stricture.
In RLDLT most surgeons nowadays perform a
Roux-en-Y anastomosis for its safety and because, unexpectedly, there is not a single duct, but rather multiple
ducts in right living donor grafts [7, 8]. For protection of
the donor biliary system and for various anatomical rea-
38
sons, dissection of the right liver grafts more frequently
than expected end up with an anterior and a posterior
sectorial bile duct to be anastomosed.
Although an E-E direct bile duct (BD) anastomosis is
a well-described reconstruction [9, 10, 11], there are no
reports of its long-term results. In addition, a single or
multiple end-to-side (E-S) right hepatico-hepaticostomy
has not yet been described in LDLT or split liver transplantation (SLT). The present report describes five cases
illustrating different methods of direct reconstruction of
the biliary tree following RLDLT.
Case reports
Fig. 1 The bilary anastomoses: a E-E×1 – one graft bile duct;
b E-E×2 – two graft bile ducts; c E-S×2 – two graft bile ducts;
d E-S×1 – one graft bile duct; e E-S×2 – three graft bile ducts
Case 1: E-E single right hepatico-hepaticostomy
Patients
A 31-year-old male with HVB cirrhosis and hepatocellular carcinoma (HCC) received a right graft from his 30-year-old wife. The
donor/recipient body weight ratio (DRBWR) and graft/recipient
body weight ratio (GRBWR) were 0.7 and 0.81, respectively.
(Table 1)
Clinical course
The patient had no complications, he is alive and well and fully
active at work 19 months after liver transplantation. The follow-up
laboratory values are normal (Table 2).
Surgical anatomy
A single right graft BD was obtained. An E-E right hepaticohepaticostomy was performed (Fig. 1 a). The cold ischemic (CIT)
and warm ischemic times (WIT) were 4 h, 20 min, and 50 min, respectively.
Case 2: E-E segment 7-right hepaticostomy and E-E hepatico-cystic
anastomosis to two graft ducts
Patients
A 59-year-old female with autoimmune cirrhosis received a right
graft from her 34-year-old son. The DRBWR and GRBWR were
1.5 and 2.01, respectively (Table 1).
Table 1 Donor and recipient characteristics. HBV, HCC hepatocellular carcinoma, AI, ETOH, HCV, DRWR, GRWR
Case no.
Age
1
2
3
4
5
Indication
Donor
Recipient
30
34
27
33
44
31
59
57
58
51
Relation
HBV; HCC
AI
ETOH
HCV; HCC
HBV-∂; HCC
Weight (kg)
Wife
Son
Daughter
Daughter
Brother
Table 2 Operative and follow-up data of the recipients. E-E endto-end, E-S end-to-side, HTK histidine tryptophan ketoglutarate,
Donor
Recipient
60
80
62
73
70
80.2
53.2
75
73
80
DRWR%
GRWR%
0.7
1.5
1.2
1.01
0.87
0.81
2.01
1.7
1.5
1.19
UW University of Wisconsin, CIT cold ischemic time, WIT warm
ischemic time, BD bile duct, GT, AP, AST , ALT
Case
no.
Number
of graft
ducts
Anastomosis
Perfusate
type (ml)
CIT
(min)
WIT
(min)
BD
endoscopic
manipulation
Condition
Laboratory
values
Follow-up
days
1
2
3
4
5
1
2
1
2
3
E-E×1
E-E×2
E-S×1
E-S×2
E-S×2
UW, 2000
HTK, 2000
HTK, 3000
UW, 2700
UW, 2000
260
212
158
193
88
50
60
60
55
42
N
Y
Y
N
N
Good
Good
Good
Good
Good
Normal
↑γ GT, AP
Normal
↑ AST-ALT, AP
Normal
588
568
354
332
214
39
Surgical anatomy
The donor had a posterior right BD originating from the left biliary tree 7 mm from the bifurcation. This anatomical variant prevented the retrieval of a single BD. In the recipient, the large size
and the peculiar fitting anatomy of the cystic duct, draining directly into the common bile duct (CBD), facilitated the performance
of two separate E-E biliary anastomoses. The right main BD of the
graft was sutured in E-E fashion to the cystic duct. The posteriorlateral BD to segment 7 was enlarged with a side plasty and joined
to the right hepatic duct of the recipient. The left hepatic duct of
the recipient was suture ligated. (Fig. 1b). The CIT and WIT were
3 h, 32 min, and 60 min, respectively.
Clinical course
Ten weeks post-transplant a stenosis of the posterior anastomosis
was treated with endoscopic retrograde cholangiography (ERC),
balloon dilatation, and stenting. A control ERC after 3 months
showed no stenosis of the biliary tree. The patient is doing well at
19 months, with normal transaminases, bilirubin, and a slight elevation of the alkaline phosphatase and γGT (Table 2).
Fig. 2 Case 3. Stenosis of the E-S hepatico-jejunostomy a before
and b after ERC balloon dilatation
Case 3: end to side single right hepatico-hepaticostomy
to a single graft duct
Patients
A 57-year-old male with alcoholic cirrhosis received a right graft
from his 27-year-old daughter. The DRBWR and GRBWR were
1.2 and 1.7, respectively (Table 1).
Surgical anatomy
The donor had a normal anatomy, the graft had a single BD. An
E-S right hepatico-hepaticostomy was performed because of size
differences between the right BD orifice and the hepatic duct of
the recipient (Fig. 1c). The CIT and WIT were 2 h, 38 min, and
60 min, respectively.
Clinical course
Five weeks post-LT, a fluctuating bilirubin level, never decreasing
below 4.5 mg/dl, prompted a cholangiogram via the still dwelling
T-drain. The patient had cholic stools and no signs of cholangitis.
A substenosis of the anastomosis was prophylactically treated
with ERC, balloon dilatation, and stent placement (Fig. 2). A control endoscopy 5 weeks post-ERC showed a normal biliary tree.
The patient is doing well 11 months post-transplant (Table 2).
Case 4: E-S right double hepaticho-hepatichostomy
to two graft ducts
Patients
A 58-year-old female with HCV cirrhosis and small central HCC
received a right graft from her 33-year-old daughter. The DRBWR
and GRBWR were 1.1 and 1.7, respectively (Table 1).
Fig. 3 Case 4. Double E-S anastomosis indicated by the size disparity between graft and recipient ducts. The arrows point out the
anastomotic sites
the graft. A distance of 5 mm between the two bile ducts of the
graft contraindicated joining them into a single orifice. Two separate E-S anastomoses were performed to the common hepatic duct
of the recipient tied at the distal end (Fig. 1d, Fig. 3). The donor’s
right BD stump was closed with a transverse plasty using
7–0 PDS; a silicon drain was inserted via the choledochotomy
used to probe the biliary tree. The CIT and WIT were 3 h, 13 m,
and 55 min, respectively.
Clinical course
Surgical anatomy
The donor had a short right main duct with an early, narrow angled first degree bifurcation. Two right bile ducts were obtained in
The recipient had a mild recurrence of HCV graft hepatitis and the
laboratory values are normal except for the increased transaminases and a minimally elevated alkaline phosphatase (Table 2).
Both donor and recipient are doing well at 10 months.
40
oral ursodeoxycholic acid 250 mg 3 times daily PO, a regimen
that was started during transplantation. A cyclosporine-steroidmycophenolate regimen preceded by a basiliximab induction was
used as immunosuppression. There was no rejection and no cytomegalovirus infection.
Materials and methods
Surgical technique and results
The optimal condition for performing an E-E BD reconstruction in a
right liver graft is the presence of one single or two very close BD
to be combined into a single orifice. Some authors consider multiple
ducts as a mandatory indication for a Roux-en-Y anastomosis [7].
The dissection and transection of the right BD in the donor trying to
obtain a single duct is then a key step of the procedure.
Fig. 4 Case 5. Intraoperative cholangiogram of the donor. Trifurcation of the right anterior (S5, S8) duct. A large posterior right
bile duct originates from the left hepatic duct far from the bifurcation
Case 5: double E-S posterior hepatico-hepaticostomy
and right anterior hepaticocholedocostomy to three right graft ducts
Patients
A 53-year-old male with HBV-δ cirrhosis and HCC received a
right graft from his 44-year-old brother. The DRBWR and
GRBWR were 0.87 and 1.19, respectively (Table 1).
Surgical anatomy
The donor had a large right posterior duct from the left main BD
(Fig. 4). Additionally, two ducts to segments 5 and 8 were separately originating from the main BD 1 mm apart, in a trifurcation
pattern. The donor also had two separate right portal veins. The
probe technique made it possible to obtain three bile ducts without
compromising the main and left biliary tree of the donor: the ducts
to segments 5 and 8 were 1.5 mm apart and the posterior sectorial
duct lay behind the posterior portal vein. Two separate E-S anastomoses were performed to three bile ducts. The posterior sectorial
duct was joined to the proximal side of the hepatic duct. The two
anterior segmental ducts (S5, S8) were not joined in a single orifice, but still anastomosed together to the side of the CBD
(Fig. 1e). The CIT was1 h 22min. The WIT was 42 min.
Clinical course
There were no complications. The patient is doing well 7 months
post-LT with normal laboratory values (Table 2). The five grafts
were abundantly perfused via both the hepatic artery and the portal vein with either histidine tryptophan ketoglutarate (HTK) or
University of Wisconsin (UW) solution (see Table 2). During the
recipient’s hepatectomy, a temporary portacaval shunt was performed and and no extracorporal bypass was used. The reperfusion of the portal vein preceded the arterial reperfusion in the first
three cases. Simultaneous reperfusion was achieved in the last
two. All biliary anastomoses were performed in interrupted polyglycolpropylene sutures (6–0, 7–0 PDS) using a 3.5–4.5 × magnification. The CBD was always drained either with a small size
T-drain or a transanastomotic silicon drain. All recipients received
Donor
The fact that the right graft has quite often two or more bile ducts
depends both upon anatomical variations and on the surgical plane
of transection of the right BD. Right ducts arising separately from
the main or left biliary system, a trifurcation, or an early and narrow angled bifurcation, make the yield of a single anastomotic orifice quite difficult or even impossible. The line of resection at the
biliary hilus can be kept more to the left or to the right in a safe,
conservative way. The more to the left the transection is performed, the greater is the chance of obtaining one single bile duct
or two close to each other. However, approaching the bifurcation
can create difficulties in the closure of the right duct stump and increase the risk of causing injury to the main and left hepatic duct
of the donor.
The second determinant in obtaining a single duct in the right
graft, is the surgical tactic and the technique of division of the
right biliary tree. In cases of favorable anatomy, trying to follow a
plane of division parallel to the course of the left BD helps in obtaining a single right duct. The more parallel and close to the
course of the left duct the division is performed, the higher is the
chance of obtaining a single right duct. (Fig. 5)
Technique of right bile dissection: The right bile ducts are divided sharply en-bloc with the glissonian plate. The transection
occurs just before the parenchymal division, after the preparation
of the hilar structures and of the retrohepatic veins. The caudate
process behind the hilar bifurcation is divided prior to the division
of the BD to facilitate the detachment of the hilar plate from the
fascia hepatis.
The biliary tree is examined with a small blunt metallic probe.
In a minority of cases the hepatic duct can be reached by cannulating the cystic duct. Otherwise we examine the bile ducts through
a 1 mm anterior choledochotomy. It is particularly important to
identify the right posterior duct to segment 7 and ducts possibly
crossing from segment 4, segment 1, or separate right segmental
ducts originating from the proximity of the hilus. An intraoperative cholangiogram is reserved to unclear, problematic anatomy, as
recognized by the preoperative anatomical work-up or intraoperatively by the probe technique. The exploration with a metallic
blunt probe allows an exact and tridimensional location of the bifurcation as well as the recognition of the position and angle of all
ducts, particularly of the posterior-lateral right and caudate ducts
(Fig. 6). When inserted into the left BD, following the curve of the
bifurcation, the probe protects the left BD just at the moment of
the right BD transection.
The BD stumps of the donors are sutured in a transverse or
oblique fashion to avoid a stenosis. The choledochotomy used to
access the CBD with the probe can be easily closed with a transverse suture in interrupted 6–0 or 7–0 polyglycolpropylene (PDS).
41
The cystic duct is divided leaving a long stump for instrumentation or for a cholangiogram. Favorable conditions for utilizing
the cystic duct for an end-to-end anastomosis are a reasonable
size, a direct and proximal connection to the CBD, and the absence of distal Houston’s valves. In cases of a cholangio-cystic
anastomosis the cystic duct is cut as short as possible.
In our patients, no re-operation was required and patient and
graft survival are 100% at a mean follow-up of 13 months (range
7–19 months).
Anastomosis
Fig. 5 Lines of transection of the right bile duct(s) at the hilar region of the donor. a Moving the line of transection from A1 to A2
facilitates obtaining one instead of two graft bile ducts. b The
modification of the angle of the line of trans-section from B1 to
B2 yields one instead of three bile ducts. c The line of trans-section is not important when a single right hepatic duct is present
The vascular supply of the recipient’s BD, its length, and the tension of the anastomosis are major determinants for the success of
the technique. A direct BD anastomosis is performed only if a tensionless approximation is possible. A standard Roux-en-Y anastomosis can always be used as an alternative. A mixed technique of
direct anastomosis and a Roux-en-Y is possible in cases of distant,
multiple bile ducts [9]. It has also already been used in our series
in a side-to-side (S-S) posterior-lateral duct-to-duct anastomosis
coupled with an anterior cholangiojejunostomy.
The relationship between the reconstruction and position of the
artery and the biliary tree is important in avoiding kinking and torsion of the hepatic artery. Therefore the artery should be kept long
enough to avoid any mechanical irritation. The course of the artery
was anterior to the BD in three of five of our cases; in one case
there was a replaced right artery from the superior mesentery
artery.
For E-S anastomosis a particular length of the recipient’s CBD
is required, especially if a separate posterior-lateral duct in the
graft is present. This technique demands a delicate and meticulous
preparation of the hepatic duct. A T-tube is inserted. The end of
the recipient’s hepatic duct is suture ligated after the orifices on
the side of the CBD are custom prepared to fit the size and distance of the graft ducts.
Discussion
Fig. 6 The probe used to explore the right bile ducts is still inserted in the common bile duct. The right hepatectomy has been completed
Even though in about 90% of the cases the instrumentation of
the hepatic ducts requires a violation of the CBD, the information
obtained and the protection of the left BD at the time of the transection make this maneuver absolutely worthwhile, without a particular risk to the donor. All donors are active at work and are doing well.
Recipient
In the recipient the BD shall be preserved as long as possible. The
utilization of the hepatic duct for an E-E or E-S anastomosis requires a high dissection, reaching the hilar plate. The left and right
ducts should possibly be isolated and transected separately. The
dissection of the BD will preserve all the arteries and the periductal tissue with the collateral veins surrounding it. These maneuvers
are not always easy in the presence of severe portal hypertension.
If the dissection of the hilus is difficult, the BD can alternatively
be transected above the bifurcation with a rim of parenchyma
when the portal vein is divided.
As in the initial era of LT, when the enteric drainage of
liver grafts was considered safer, many adult-to-adult
LDLT programs use a Roux-en-Y hepatichojejunostomy
[12]. In standard LT, as time went by, the direct duct-toduct biliary anastomosis proved to be as safe and uncomplicated, offering many advantages [13]. We foresee the
same development in RLDLT.
The Roux-en-Y biliary anastomosis is still considered
the gold standard technique in segmental liver grafting:
it is suitable in the most disparate conditions and it can
fit an infinite number of bile ducts, it can also be used as
a means of rescue in complicated cases. Nevertheless,
particular efforts should be made to aim for physiological primary anastomoses.
The performance of an E-E direct BD anastomosis is
usually determined by the presence of a single orifice on
the graft and by a correct size match between the bile
ducts of donors and recipients. Both conditions together
are difficult to encounter, which explains the relative
rarity of this type of anastomosis. An E-E anastomosis is
possible if two bile ducts laying close enough to each
other can be joined into a single orifice using a plasty.
This practice has not always been effective in avoiding
42
complications in our previous experience, especially if
the ducts are laid farther apart than 2 mm [14].
The principal advantages of a duct-to-duct anastomosis are: a more physiologic reconstruction, the avoidance
of bowel manipulation, a quicker operation, an easy access and imaging via ERC both in the early and especially in the late postoperative period, with the possibility of
endoscopic management of complications.
The disadvantages are: a more laborious dissection of
the recipient BD and some technical difficulty in accommodating size mismatched bile ducts, which is nevertheless peculiar only to the E-E technique.
The contraindications to a direct BD anastomosis are
insufficient length of the CBD, precluding a safe anastomosis because of excessive tension, diseases such as biliary atresia or sclerosing cholangitis involving the main
bile duct, and tumors requiring radical lymphadenectomy and skeletonization at the hilum.
Anomalies of the biliary tree are frequent and well
described. The anatomical conditions preventing the
yield of a single BD are the presence of a crossing duct
originating from the common or left hepatic duct and the
presence of a trifurcation. These conditions vary from
2.55 to 37.4% [15, 16, 17, 18]. According to Couinaud, a
single right BD is absent in 44% of 100 casts [19] and
46.7% of 107 casts [20]. A trifurcation is present in 12
and 11.21%, respectively. A right main BD shorter than
1 cm in 27 of 107 casts was also described [20]. The
chance to perform a single E-E anastomosis is then rare
only considering the anatomical conditions.
The high incidence of stenoses and leaks of the biliary anastomosis in right liver grafting seems to be due to
a poorer vascularization of the isolated right biliary tree.
A study of the intrahepatic arterial supply of the bilary
tree by Stapleton [21], determined that there is a periductal plexus in connection with the main 3 and 9 o’clock
arteries running along the CBD [22]. Once divided, the
right graft bile duct(s) is partially deprived of the ante
grade inflow and of the collateral arterial blood flow deriving from (a) the CBD plexus and (b) from the caudate
lobe. This can result in a relatively ischemic anastomotic
site. In the graft the arterial blood supply reaches the
stump(s) of the bile ducts in a retrograde way from the
periductal intrahepatic plexus, as supplied by the right
hepatic arteries. This would explain a localized relative
ischemia of the BD stumps and supports the finding of
isolated anastomotic strictures, instead of diffuse BD
ischemic injuries in our series of RLDLT [23].
In standard LT, choledochocholedochostomy has been
reported as having results as good as those achieved by
Roux-en-Y anastomosis [24]. Obviously the longer the
bile duct, the poorer the distal blood supply can be – a
condition potentially leading to complications. The
blood supply of the recipient’s BD is related to the
length of the stump [25]. Nonetheless, the vascular supply of the CBD in the recipient is good, provided no pre-
vious surgical manipulation has occurred. The CBD, if
properly dissected, has its own excellent blood supply
from the gastroduodenal, retroduodenal, and retroportal
arteries [22]. We have already used long bile ducts for
the duct-to-duct anastomoses of three recipients of left
lateral grafts (unpublished data). In standard LT both the
donor and recipient bile ducts are often shortened to assure the best possible vascular supply of the anastomotic
stumps. However, in segmental grafting the distance required to connect to the recipient bile ducts is usually
greater. The duct-to-duct anastomosis is not recommended in RLDLT, unless care has been taken to dissect a BD
as long as possible in the recipient, so as to reach into the
hilum of the graft.
In standard LT the side-to-side anastomosis has been
described by Neuhaus as very safe, with a complication
rate of 1% [26]. The rate of bile leakage was only 0.3%
and an anastomotic stenosis occurred in two of
300 cases. Other centers have had similar experiences,
but none had such a low rate of complications [27, 28].
A randomized study in standard LT, comparing E-E and
S-S anastomosis, showed that the techniques are equally
effective and have similar complication patterns and
rates [29].
Other factors, such as preservation time, quality of the
arterial supply of donor and recipient’s bile duct, immunological factors, type and quantity of preservation solutions, and biliary fluid composition, also influence the
outcome of a biliary anastomosis. These are important
aspects for the viability of the BD of the graft and for the
subsequent danger of anastomotic insufficiency or stricture formation [30, 31, 32, 33].
As demonstrated in our patients, long preservation
times are unusual in LDLT. However, the BD injury
should not be seen as an all-or-nothing response, but as a
gradual process. As found in animal experiments, the
composition of the biliary fluid, i.e., its hydrophobicity,
is an important prognostic indicator for the degree of biliary injury [34]. Its detrimental effect on the biliary epithelium is a determinant of the duration of the preservation time and the content of hydrophobic bile salts [35].
As a consequence, all patients receive therapeutic doses
of ursodeoxycholic acid.
The short ischemic times and the abundant flush of
the graft via both artery and portal vein might also play a
role in the success of our technique. However, there is no
conclusive study yet providing a clear explanation or a
preferred preservation solution to avoiding ischemic BD
injury lesions.
We see that a more physiologic technique, capable of
accommodating two or more ducts, seems necessary as
an alternative to the classic Roux-en-Y anastomosis.
Conditions for a double anastomosis to cystic and hepatic
ducts are rare. For double graft BD an alternative technique is the end-to-end anastomosis to both the right and
left hepatic ducts beyond the bifurcation [9, 10]. The lat-
43
ter technique has a limited use. Indeed, the frequently
encountered different size between donor and recipient
ducts would mostly require size adaptation of graft or recipient hepatic ducts. Moreover, other factors limiting
the success of the technique are the fixed distance between the left and right hepatic duct stumps as well as
the length of the CBD itself. These conditions and the
torsion required to reach the posterior-lateral right duct
could result in a kinking or occlusion of one of the anastomoses.
In our earlier experience, the right living donor graft
BD was divided far to the right, following a careful policy to protect the main BD of the donor from injuries.
This resulted in obtaining multiple ducts, sometimes
distant from each other, an indication to a Roux-en-Y
anastomosis. Furthermore, the right posterior-lateral bile
duct, laying posterior and cranial to the portal vein, was
at times quite cumbersome to manage and a major
source of biliary leaks in our previous experience. With
the aim of overcoming these problems and safely obtaining a single biliary orifice, the technique of division of
the BD in the donor has been refined (Fig. 5, Fig. 6).
However, this strategy could lead to severe complications and late sequelae in donors. It might require difficult plastic reconstructions of the right BD stump and,
sometimes, demanding operations that require a high degree of expertise in hepatobiliary surgery.
In right LDLT grafts, multiple ducts are rather typical
because of the intrinsic anatomy of the bile tree and because of the way its division has to be carried out for
protection of the donor.
We developed the E-S anastomosis with the aim of
leaving a stump for the closure of the right main BD and
at the same time accommodating two or more distant
bile ducts in a direct duct-to-duct anastomosis. The E-S
technique allows for the perfect tailoring of the size of
the orifice and the choice of the exact position and distance of the anastomotic site on the side of the CBD,
adapting it to the biliary anatomy of the graft. The use of
plasties to enlarge or join the ducts of the graft can be
avoided. In addition, the E-S anastomosis is quicker and
easier than the double E-E bifurcation technique and it
can also accommodate three bile ducts, as in the last case
described.
It is still unclear whether a BD drain is needed and if
a direct transanastomotic versus a T drain stenting of the
CBD is beneficial in this type of anastomosis.
The practice of closing bile ducts in difficult positions
on the graft in order to avoid problems in their management and complications is discouraged. The closure of
graft bile ducts is allowed if they are small or if they
communicate with the rest of the bile tree. In particular,
the situation of “small for size graft,” not infrequently
encountered in RLDLT, contraindicates the closure of
bile ducts, because the early function and the regeneration of the drained parenchyma will then be impaired
[36].
Conclusion
In RLDLT the management of disparate biliary anatomical circumstances is facilitated by the E-E and/or E-S direct biliary anastomosis. Excellent results can be expected, provided good anatomic conditions are achieved both
in donors and recipients, and the basic rules of anastomoses are observed. In living liver donors the yield of
single or double ducts can be safely obtained using the
proposed probe technique. A long, well-vascularized BD
in the recipient is a prerequisite for the performance of
multiple proximal anastomoses.
The BARIGA LDLT facilitates reconstructing the
continuity of the biliary tree in a more physiological
way. The management of multiple (up to three) ducts of
the graft is possible using the E-S anastomosis. The
BARIGA LDLT using E-S or end-to-end hepatichohepatichostomy is a more physiologic reconstruction of
the biliary tree. The endoscopic management of leaks,
strictures, or late complications can avoid a re-operation
in living donor recipients, often in precarious conditions.
The techniques described are also applicable to split
liver transplantation, in the auspicious event that right
(segment 5–8) split grafts will be more often used in the
future.
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