Center preference, and size and number of the ducts in the donor graft may influence the decision of stenting a biliary anastomosis in LDLT.
When the distal end of the stent is brought out through the recipient bile duct as an external biliary drain, although rates of early bile leaks have been shown to be low, there is an attendant risk of infection, and the fear of bile leaks and biliary strictures following removal [28,29,30▪▪]. Some studies, however, have demonstrated excellent results using internal–external transcholedochal biliary stents (especially if the graft duct diameter is ≤3 mm), and no catheter-related infections or bile leakage at stent removal [30▪▪,31▪▪].
Internal stenting (stent across DDA, and exiting into the duodenum, for later endoscopic removal) was shown to be associated with a very high incidence of bile leaks in a recent study [32▪]. Possible explanations for this high rate of biliary complications could be lack of an intervention for dilating the ampulla of Vater, the intra-enteral location of the proximal end of the internal stent (with more chances of obstruction by intestinal contents), the presence of only a single sidehole on the ureteric catheters used for stenting, and manipulation-induced trauma to the graft bile ducts [32▪].
Hepaticojejunostomy without external stent has been shown to be an independent risk factor for anastomotic strictures in pediatric LDLT [33▪▪]. RYHJ using an external stent has three advantages in comparison to the other procedures. First, an external stent makes it possible to prevent anastomotic stricture by presence. Second, an external stent makes it possible to decompress intrahepatic biliary pressure by bile drainage. Third, the volume and appearance of biliary drainage from an external stent makes it possible to understand the anastomotic condition . Microsurgical biliary reconstruction is an alternative technique in LDLT, and could reduce biliary stricture without the need for biliary stents. The usefulness of microsurgical biliary reconstruction in reducing biliary complications again continues to be debated. [35,36]. However, appropriate use of external stents may be an easier way to reduce biliary stricture in LDLT, regardless of technical expertise .
One of the primary reasons for biliary anastomotic complications is arterial ischemia. The mucosal eversion technique or telescopic biliary reconstruction (TBR)  aims to avoid this, by everting the recipient bile duct and using posterior wall continuous inner mucosa-to-mucosa sutures (5-mm wide region). The anterior wall is similarly sutured to a 5-mm wide region of the anterior inner mucosal side of the recipient. This technique, with the addition of corner sparing sutures has been shown to significantly lower the incidence of biliary complications, and result in better survival [15,38,39▪].
The arterial blood supply is better if the biliary anastomosis is made on the mucosal side of the main biliary duct. Early period anastomotic leaks may decrease significantly. Mechanical strictures caused by anastomosis are tolerated better than strictures caused by leaks and can be more easily treated. Also, TBR allows appropriate adaptation of the donor to the recipient bile duct. Initially incompatible bile ducts can be shaped to ensure good connection .
Results of recently published large studies (over the last 3 years) on biliary reconstruction in LDLT are summarized in Table 1. Most of the studies deal with right lobe LDLT, and there continues to be a 50 : 50 distribution as regards choice of reconstruction, except in the series by Miyagi et al. (predominantly hepaticojejunostomy), and Hong et al.[31▪▪] (predominantly DDA). The incidence of biliary complications ranges from 15 to 40% in most series, with higher incidence of strictures compared with bile leaks. As mentioned before, the use of endobiliary stents continues to be debatable.
Biliary anastomosis continues to be the Achilles heel of LDLT. Apart from surgical technique, which includes correct choice of type of reconstruction technique and appropriate use of stents across ductal anastomoses, better imaging of the biliary tree, and safe isolation of the graft hepatic duct, could help reduce biliary complications in the recipient, and make donor hepatectomy safe.
Papers of particular interest, published within the annual period of review, have been highlighted as:
1. Azzam AZ, Tanaka K. Biliary complications
after living donor liver transplantation
: a retrospective analysis of the Kyoto experience 1999-2004. Indian J Gastroenterol 2017; 36:296–304.
2. Abu-Gazala S, Olthoff KM, Goldberg DS, et al. En bloc hilar dissection of the right hepatic artery in continuity with the bile duct: a technique to reduce biliary complications
after adult living-donor liver transplantation. J Gastrointest Surg 2016; 20:765–771.
3▪. De Martin E, Hessheimer A, Chadha R, et al. Report of the 24th Annual Congress of the International Liver Transplantation Society. Transplantation 2019; 103:465–469.
An overview of the proceedings of the ILTS Annual Congress in Lisbon, where several studies dealing with biliary reconstruction and outcomes in LDLT were presented.
4▪. Kim B, Kim SY, Kim KW, et al. MRI in donor candidates for living donor liver transplant: Technical and practical considerations. J Magn Reson Imaging 2018; 48:1453–1467.
Showed that accurate preoperative evaluation of the biliary anatomy in living liver donors is critical for minimizing the number of ductal reconstructions, preventing biliary complications, and aiding a well tolerated surgical procedure.
5. Xu YB, Bai YL, Min ZG, Qin SY. Magnetic resonance cholangiography in assessing biliary anatomy in living donors: a meta-analysis. World J Gastroenterol 2013; 19:8427–8434.
6▪▪. Kang HJ, Lee JM, Yoon JH, et al. Additional values of high-resolution gadoxetic acid-enhanced MR cholangiography for evaluating the biliary anatomy of living liver donors: Comparison with T2 -weighted MR cholangiography and conventional gadoxetic acid-enhanced MR cholangiography. J Magn Reson Imaging 2018; 47:152–159.
A comparison of three MR cholangiography techniques for delineation of segmental intrahepatic bile ducts, biliary anatomy with its confidence level, and expected number of bile duct openings at right hemihepatectomy. Concluded that the addition of sFOV HR-T1 W-MRC to T2 W-MRC significantly improves increased bile duct visibility, including B1 branch visibility, and interobserver agreement regarding biliary anatomy with a higher confidence level, which is important to prevent postoperative biliary complications of LDLT.
7▪. Santosh D, Goel A, Birchall IW, et al. Evaluation of biliary ductal anatomy in potential living liver donors: comparison between MRCP and Gd-EOB-DTPA-enhanced MRI. Abdom Radiol (NY) 2017; 42:2428–2435.
A comparison of the efficacy of MRCP and Gd-EOB-DTPA-enhanced MRI in evaluation of biliary ductal anatomy in potential living liver donors, showed that that Gd-EOB-DTPA-enhanced MRI provided additional diagnostic confidence over MRCP by providing statistically superior visualization of the right second-order hepatic ducts.
8. Kwon HJ, Kim KW, Choi SH, et al. MR cholangiography in potential liver donors: quantitative and qualitative improvement with administration of an oral effervescent agent. J Magn Reson Imaging 2017; 46:1656–1663.
9. Wakasa Y, Kudo D, Ishido K, et al. Living-donor liver transplantation with the use of a left-lobe graft from a donor with anomalous biliary anatomy in which B4 joins the right anterior sectional duct: a case report. Transplant Proc 2017; 49:1615–1618.
10▪▪. Hong SK, Lee KW, Kim HS, et al. Optimal bile duct division using real-time indocyanine green near-infrared fluorescence cholangiography during laparoscopic donor hepatectomy. Liver Transpl 2017; 23:847–852.
This study tested the real-time applicability of ICG near-infrared fluorescence cholangiography during pure 3D laparoscopic donor hepatectomy, to precisely determine the optimal bile duct division points. Use of ICG was well tolerated, effectively demonstrated biliary anatomy allowing optimal bile duct division after dissection of the hilar plate, and also correlated well with preoperative MRCP. Its use also avoided difficult cystic duct cannulation, and radiation exposure if IOC was to be done.
11. Suh KS, Hong SK, Lee KW, et al. Pure laparoscopic living donor hepatectomy: focus on 55 donors undergoing right hepatectomy. Am J Transplant 2018; 18:434–443.
12▪. Wei L, Zhang ZT, Zhu ZJ, et al. A new approach to accomplish intraoperative cholangiography in left lateral segmentectomy of living liver donation. Ann Transplant 2019; 24:155–161.
A new approach to cholangiography by using the bile duct stump of the fourth liver segment (B4 stump) to achieve left lateral segmentectomy in pediatric living donor liver transplantation. The authors were successful in catheterizing B4 stumps in all 221 patients. Preservation of the donor gall bladder (thus preventing possible postcholecystectomy syndrome, and risk of digestive tract cancers), clear images of the biliary anatomy, thus guiding the surgical division of the biliary tract, and safety in terms of biliary complications in the donor are the purported advantages.
13. Takatsuki M, Eguchi S, Tokai H, et al. A secured technique for bile duct division during living donor right hepatectomy. Liver Transpl 2006; 12:1435–1436.
14. Soin AS, Kumaran V, Rastogi AN, et al. Evolution of a reliable biliary reconstructive technique in 400 consecutive living donor liver transplants. J Am Coll Surg 2010; 211:24–32.
15. Ikegami T, Shimagaki T, Kawasaki J, et al. Eversion technique to prevent biliary stricture after living donor liver transplantation
in the universal minimal hilar dissection era. Transplantation 2017; 101:e20–e25.
16▪. Ye S, Dong JH, Duan WD, et al. The preliminary study on procurement biliary convergence from donors with complicated bile duct variant in emergency right lobe living donor liver transplantation
. J Clin Exp Hepatol 2017; 7:33–41.
Proposal of a new technique of procurement of biliary convergence from donors with complicated bile duct variants in an emergency transplant situation, wherein a more ideal donor (in terms of biliary anatomy) was not available. Includes division of CHD and left duct in the donor, and biliary anastomoses in the donor.
17. Chok KS, Chan SC, Cheung TT, et al. Bile duct anastomotic stricture after adult-to-adult right lobe living donor liver transplantation
. Liver Transpl 2011; 17:47–52.
18. Rammohan A, Govil S, Vargese J, et al. Changing pattern of biliary complications
in an evolving liver transplant unit. Liver Transpl 2017; 23:478–486.
19. 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; 243:559–566.
20. Zhang S, Zhang M, Xia Q, Zhang JJ. Biliary reconstruction and complications in adult living donor liver transplantation
: systematic review and meta-analysis. Transplant Proc 2014; 46:208–215.
21. Chok KS, Lo CM. Systematic review and meta-analysis of studies of biliary reconstruction in adult living donor liver transplantation
. ANZ J Surg 2017; 87:121–125.
22▪▪. Baker TB, Zimmerman MA, Goodrich NP, et al. Biliary reconstructive techniques and associated anatomic variants in adult living donor liver transplantations: the adult-to-adult living donor liver transplantation
cohort study experience. Liver Transpl 2017; 23:1519–1530.
The A2ALL consortium reported that recipients undergoing DDA and RYHJ had similar graft and patient survival (86 vs. 81% and 89 vs. 85% at 2.5 years, respectively). RYHJ recipients had higher incidence of hepatic artery thrombosis. For biliary complications, recipients with reconstruction using high biliary radicals (either right hepatic duct or left hepatic duct of the recipient) had the highest probability of developing a biliary complication (76%), both early bile leak and late biliary stricture.
23. Yaprak O, Dayangac M, Akyildiz M, et al. Biliary complications
after right lobe living donor liver transplantation
: a single-centre experience. HPB (Oxford) 2012; 14:49–53.
24. Kim PT, Marquez M, Jung J, et al. Long-term follow-up of biliary complications
after adult right-lobe living donor liver transplantation
. Clin Transplant 2015; 29:465–474.
25. Nakamura T, Iida T, Ushigome H, et al. Risk factors and management for biliary complications
following adult living-donor liver transplantation. Ann Transplant 2017; 22:671–676.
26▪▪. Kollmann D, Goldaracena N, Sapisochin G, et al. Living donor liver transplantation
using selected grafts with 2 bile ducts compared with 1 bile duct does not impact patient outcome. Liver Transpl 2018; 24:1512–1522.
In an analysis of 510 patients who received an adult-to-adult right-lobe LDLT between 2000 and 2015, the authors compared outcome parameters of those receiving grafts with two bile ducts to patients receiving grafts with one bile duct. There was no difference in biliary complication rates within 1 year after LDLT. Also, number of anastomoses, and the number of bile duct orifices in the graft did not influence biliary complication rate (both biliary leaks and strictures). One-year, and 10-year grafts, and patient survival were comparable between the single and the two bile duct groups.
27. 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; 236:235–240.
28. Riediger C, Muller MW, Michalski CW, et al. T-Tube or no T-tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010; 16:705–717.
29. Tranchart H, Zalinski S, Sepulveda A, et al. Removable intraductal stenting in duct-to duct biliary reconstruction in liver transplantation. Transpl Int 2012; 25:19–24.
30▪▪. Ikegami T, Yoshizumi T, Soejima Y, et al. Appropriate use of stents to prevent biliary complications
after living donor liver transplantation
. J Am Coll Surg 2018; 226:201.
The Kyushu University team has been regularly using stents (transcholedochal internal--external biliary stents) during adult LDLT with a very low incidence of bile leak (2.4%), and biliary stricture (8.5%).
31▪▪. Hong SY, Hu XG, Lee HY, et al. Longterm analysis of biliary complications
after duct-to-duct biliary reconstruction in living donor liver transplantations. Liver Transpl 2018; 24:1050–1061.
The authors showed that duct-to-duct anastomosis using 7-0 suture combined with external biliary stent could provide favorable long-term outcomes after LDLT, and proposed that this should be, thus considered the surgical technique of choice for LDLTs.
32▪. Kumar KS, Shaji Mathew J, Balakrishnan D, et al. Intraductal transanastomotic stenting in duct-to-duct biliary reconstruction after living donor liver transplantation
: a randomized trial. J Am Coll Surg 2017; 225:747–754.
A randomized trial to study the impact of intraductal biliary stents (distal end exiting in duodenum) on postoperative biliary complications following LDLT in which a duct-to-duct anastomosis was performed found a higher incidences of biliary leakage and biliary stricture in the stented patients. Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis.
33▪▪. Sanada Y, Katano T, Hirata Y, et al. Biliary complications
following pediatric living donor liver transplantation
: risk factors, treatments and prognosis. Transplantation 2019; doi: 10.1097/TP.0000000000002572. [Epub ahead of print].
Hepaticojejunostomy without use of an external stent was found to be an independent risk factor for anastomotic strictures in pediatric liver transplant. Presence of a stent also facilitated early treatments using double-balloon enteroscopy or percutaneous transhepatic biliary drainage.
34. Yoshizumi T, Harada N, Mori M. Biliary stricture: the Achilles heel of pediatric living donor liver transplantation
. Transplantation 2019; doi: 10.1097/TP.0000000000002573. [Epub ahead of print].
35. Lin TS, Chen CL, Concejero AM, et al. Early and long-term results of routine microsurgical biliary reconstruction in living donor liver transplantation
. Liver Transpl 2013; 19:207–214.
36. Miyagi S, Kawagishi N, Kashiwadate T, et al. Relationship between bile duct reconstruction and complications in living donor liver transplantation
. Transplant Proc 2016; 48:1166–1169.
37. Chen CL, Concejero AM, Lin TS, et al. Outcome of routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation
. J Hepatobiliary Pancreat Sci 2013; 20:492–497.
38. Kim SH, Lee KW, Kim YK, et al. Tailored telescopic reconstruction of the bile duct in living donor liver transplantation
. Liver Transpl 2010; 16:1069–1074.
39▪. Karakas S, Sarici KB, Ozdemir F, et al. Telescopic biliary reconstruction in patients undergoing liver transplantation with 1-year follow-up. Transplant Proc 2017; 49:562–565.
Adapting the telescopic biliary reconstruction technique in 56 patients, the authors showed a significant reduction in biliary complication compared with standard duct-to-duct anastomosis in adult LDLT.
40. Vij V, Makki K, Chorasiya VK, et al. Targeting the Achilles’ heel of adult living donor liver transplant: corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:14–23.
41. Azoulay D, Bhangui P, Andreani P, et al. Short- and long-term donor morbidity in right lobe living donor liver transplantation
: 91 consecutive cases in a European Center. Am J Transplant 2011; 11:101–110.
42. Braun HJ, Ascher NL, Roll GR, Roberts JP. Biliary complications
following living donor hepatectomy. Transplant Rev 2016; 30:247–252.
43. Shio S, Yazumi S, Ogawa K, et al. Biliary complications
in donors for living donor liver transplantation
. Am J Gastroenterol 2008; 103:1393–1398.
44▪. Tanemura A, Mizuno S, Hayasaki A, et al. Biliary complications
during and after donor hepatectomy in living donor liver transplantation
focusing on characteristics of biliary leakage and treatment for intraoperative bile duct injury. Transplant Proc 2018; 50:2705–2710.
Evaluated risk factors for donor biliary complication in adult-to-adult LDLT. Large remnant liver volume was a significant risk factor for biliary complications, especially biliary leakage. For intraoperative bile duct injury, they suggested that a duct-to-duct anastomosis with biliary stent is a feasible method to recover.
45▪. Shaji Mathew J, Manikandan K, Santosh Kumar KY, et al. Biliary complications
among live donors following live donor liver transplantation. Surgeon 2018; 16:214–219.
In a series of 452 donor hepatectomies, the incidence of bile leak in the donor was 3.3%, which included one bronchobiliary fistula and biliopleural fistula. Analysis revealed no association between postoperative biliary complications and type of graft, portal vein anatomy or biliary anatomy.
46▪. Woo HY, Lee IS, Chang JH, et al. Outcome of donor biliary complications
following living donor liver transplantation
. Korean J Intern Med 2018; 33:705–715.
On multivariate analysis, bile leak was associated with the number of right lobe bile duct orifices. All donors with biliary complications were successfully treated nonsurgically, with most improving after endoscopic placement of endobiliary stents and none showing recurrence on long-term follow-up.