Chi Leung Liu, Chung Mau Lo, Sheung Tat Fan*

Transcription

1 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) [13] Akabayashi A, Slingsby BT, Fujita M. The first donor death after living-related liver transplantation in Japan. Transplantation 2004;77: 634 (letter). [14] Marcos A, Ham J, Fisher R, Olzinski A, Posner M. Single-center analysis of the first forty living donor transplants using the right lobe. Liver Transpl 2000;6: [15] Pomfret EA, Pomposelli JJ, Gordon FD, Erbay N, Lyn Price L, Lewis WD, et al. Liver regeneration and surgical outcome in donors of right-lobe liver grafts. Transplantation 2003;76:5 10. [16] Marcos A, Ham JM, Fisher RA, Olzinski AT, Shiffman ML, Sanyal AJ, et al. Emergency adult-to-adult living donor liver transplantation for fulminant hepatic failure. Transplantation 2000; 69: [17] Marcos A, Killackey M, Orloff MS, Mieles L, Bozorgzadeh A, Tan HP. Hepatic arterial reconstruction in 95 adult right lobe living donor liver transplants: evolution of anastomotic technique. Liver Transpl 2003;9: [18] Tan HP, Marcos A. Hepatic arterial anatomy for right liver procurement from living donors. Liver Transpl 2004;10: [19] Testa G, Malago M, Nadalin S, Hertl M, Lang H, Frilling A, et al. Right-liver living donor transplantation for decompensated end-stage liver disease. Liver Transpl 2002;8: [20] New York State Health Department. New York State Committee on quality improvement in living liver donation [21] Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Surgical management of anatomical variations of the right lobe in living donor liver transplantation. Ann Surg 2000;231: [22] Gondolesi GE, Varotti G, Florman S, Munoz L, Fishbein TM, Emre SH, et al. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 2004;77: [23] Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004;240: [24] Brown Jr RS, Russo MW, Lai M, Shiffman ML, Richardson MC, Everhart JE, et al. A survey of liver transplantation from living adult donors in the United States. N Engl J Med 2003;348: [25] Todo S, Furukawa H. Japanese study group on organ transplantation. Living donor liver transplantation for adult patients with hepatocellular carcinoma: experience in Japan. Ann Surg 2004; 240: [26] Trotter JF. Living donor liver transplantation: is the hype over? J Hepatol 2005;42: [27] Garcia-Retortillo M, Forns X, Llovet JM, Navasa M, Feliu A, Massauer A, et al. Hepatitis C recurrence is more severe after living donor compared to cadaveric liver transplantation. Hepatology 2004; 40: [28] Sugawara Y, Makuuchi M. Should living donor liver transplantation be offered to patients with hepatitis C virus cirrhosis? J Hepatol 2005; in press. [29] Shiffman ML, Stravitz RT, Cantos MJ, Mills AS, Sterling RK, Luketic VA, et al. Histologic recurrence of chronic hepatitis C virus in patients after living donor and deceased donor liver transplantation. Liver Transpl 2004;10: [30] Russo MW, Shrestha R. Is severe recurrent hepatitis C more common after living donor liver transplantation? Hepatology 2004;40: [31] Bozorgzadeh A, Jain A, Ryan C, Ornt D, Zand M, Mantry P, et al. Impact of hepatitis C viral infection in primary cadaveric liver allograft versus primary living-donor allograft in 100 consecutive liver transplant recipients receiving tacrolimus. Transplantation 2004; 77: [32] Tan HP, Madeb R, Kovach SJ, Orloff M, Mieles L, Johnson LA, et al. Hypophosphatemia after 95 right-lobe living donor hepatectomies for liver trasplantation is not a significant source of morbidity. Trasplantation 2003;76: What is the best technique for right hemiliver living donor liver transplantation? With or without the middle hepatic vein? Duct-to-- duct biliary anastomosis or Roux-en-Y hepaticojejunostomy? Chi Leung Liu, Chung Mau Lo, Sheung Tat Fan* Department of Surgery, Centre for the Study of Liver Disease, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong, China Adult-to-adult right hemiliver living donor liver transplantation (LDLT) has become an accepted procedure in both Western and Eastern societies. It provides a realistic hope of new life for thousands of recipients worldwide who otherwise would have limited or delayed access to a cadaveric organ [1]. There is much variation in the surgical technique of LDLT in different transplant centers, and * Corresponding author. Tel.:C ; fax: C address: hrmsfst@hkucc.hku.hk (S.T. Fan). Abbreviations: LDLT, living donor liver transplantation; MHV, middle hepatic vein; RHV, right hepatic vein. controversies exist in the surgical management of the patients. The necessity of providing venous drainage to the right anterior sector of a right hemiliver graft in LDLT has been controversial. Inclusion of the middle hepatic vein (MHV) in the right hemiliver graft to ensure better early graft function is also under debate. Hepatico-jejunostomy has been the standard approach for biliary reconstruction since the first reported series of right hemiliver LDLT [2]. Duct-toduct biliary anastomosis has several theoretic advantages over hepatico-jejunostomy and has gained popularity in liver transplant centers worldwide. However, the incidence of /$30.00 q 2005 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi: /j.jhep

2 18 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) biliary complications remains high after LDLT. In this review, the current status of LDLT with reference to the venous drainage of the right anterior sector and biliary reconstruction of the right hemiliver graft is discussed. 1. Venous drainage of the anterior sector of the right hemiliver graft Although graft size is one of the important factors for the success of liver transplantation, the importance of a uniformly good venous drainage of the anterior sector of the right hemiliver graft as a crucial factor for the postoperative liver function in LDLT has been recognized [3]. Venous congestion of Couinaud s segments V and VIII of the right hemiliver graft is frequently observed if MHV tributaries from these segments are ligated and the MHV is not included in the liver graft. The consequences of compromised venous outflow can be evident in some cases after portal vein reperfusion. Segments V and VIII can become swollen and turgid, and have a dusky discoloration. Graft rupture has been reported in the situation of severe congestion of the anterior sector after reperfusion [4]. Recipients may also manifest a small-for-size graft syndrome characterized by prolonged cholestasis, coagulopathy, and persistent ascites because the right posterior sector may sustain damage by the increased blood flow. Furthermore, poor venous outflow increases the risk of hepatic artery thrombosis and impairs graft regeneration by elevating sinusoidal pressure and disrupting sinusoidal endothelium [5,6]. Although venous congestion can resolve when intrahepatic venous collaterals to the right hepatic vein (RHV) enlarge during the first postoperative week [7], it may persist and contribute to the development of graft dysfunction and failure. In order to have a good quality functional right hemiliver graft without venous congestion to the anterior sector and to ensure satisfactory operative outcomes of the recipients, different approaches have been adopted in various transplant centers, ranging from selective reconstruction of the venous drainage on the basis of criteria such as appearance of dusky area, result of hepatic artery or hepatic vein occlusion test [8], donor recipient body weight ratio, or presence of dominant segments V and VIII hepatic veins [9], to routine inclusion of the MHV in the graft [10]. Lee et al. reported the initial experience of five LDLTs without drainage of the right anterior sector in 2001 [11]. Two of the five recipients showed graft congestion, massive ascites, sepsis, or poor graft function, and one of them died 20 days after operation. It was suggested that preservation and reconstruction of the MHV tributaries are required to prevent congestion of the right hemiliver graft. Lee et al. advocated reconstruction of hepatic venous drainage of the segments V and VIII into the inferior vena cava using recipient s autogenous interposition vein graft including an external iliac vein or saphenous vein [12]. Using these modified right liver grafts, they reported a satisfactory survival outcome of the recipients [13]. Makuuchi et al. proposed to provide venous drainage to the right anterior sector in selected cases [8]. Instead of routine inclusion of the MHV in the graft, the prominent segments V and VIII hepatic vein branches are anastomosed to the recipient MHV and left hepatic vein using a homologous or cryo-preserved vein graft. Two tests were proposed to predict graft congestion and the need for the provision of venous drainage to the right anterior sector. The first test is to clamp the MHV at donor operation and observe the flow pattern in the right anterior sector portal vein by intraoperative ultrasonography. If reverse flow in the portal vein is seen, reconstruction of segments V and VIII branches is necessary [14]. The second test is to clamp the right hepatic artery and MHV at donor operation. If the right anterior sector is dusky, hepatic vein reconstruction is needed [8]. Among the 30 LDLT recipients reported by the Tokyo group [8], MHV tributaries were reconstructed according to the results of the tests described in 18 grafts. Plasty of recipient hepatic veins was performed in 15 patients. All patients survived the operation and regeneration of the anterior and posterior sectors of the right hemiliver grafts was equivalent on subsequent computed tomography. De Villa et al. proposed an algorithm based on donor recipient body weight ratio, right hemiliver-to-recipient standard liver volume estimation, and donor hepatic venous anatomy to determine whether the MHV should be included in the right hemiliver graft in LDLT [9]. The MHV is not included in the graft if the donor is bigger than the recipient. If the estimated graft volume by computed tomographic volumetry is greater than 50% of the standard liver volume after correction for steatosis, the RHV is large, and segments V and VIII hepatic veins are less than 5 mm in size, the MHV is also not included in the right hemiliver graft. Although various criteria have been adopted by different investigators for selective inclusion of the MHV in the liver graft or selective reconstruction of the segments V and VIII venous tributaries, there is no consensus on the indications for the selective approach on venous reconstruction. Moreover, the long-term patency of venous conduit draining segments V and VIII are not known. In order to obtain uniformly satisfactory operative outcomes of LDLT recipients with a uniformly good venous drainage of the liver graft, we recommend routine inclusion of the MHV with the grafts [10]. It is considered crucial in providing sufficient functioning liver volume with good venous drainage to meet the high metabolic demand of recipients with poor liver function reserve. In patients with fulminant hepatic failure or acute decompensation of chronic liver failure, this has resulted in favorable survival outcome [15]. Instead of separate end-to-end venous anastomoses of the donor RHV and MHV to recipient RHV and MHV, respectively, we proposed a technique of hepatic venoplasty [16]. The MHV is joined to the RHV in the right hemiliver graft at the back table to form a triangular common orifice.

3 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) Fig. 1. (a, b) The orifice of the right hepatic vein in the recipient is enlarged to form a triangular opening to match the hepatic vein cuff of the graft. (c, d) The hepatic vein cuff is anastomosed to the caval opening using 5/0 polypropylene sutures. The septum in between the two hepatic veins is divided and sutured transversely to remove the ridge in between to create a large opening. The common orifice is anastomosed to a matched-size triangular opening in the recipient s vena cava (Fig. 1). Using this modification of the technique for venous anastomosis of the graft including the MHV, 1-year and 2-year graft survival rates of 100 and 96%, respectively, were reported [17]. Because of the perceived potential increase in surgical morbidity and mortality risk in the right hemiliver donor, controversies still exist concerning whether the MHV should be routinely included in the right hemiliver graft for LDLT. However, there are scarce data supporting the contention that inclusion of the MHV in the right hemiliver graft is associated with an increased postoperative complication rate in the donor [18]. Cattral et al. [19] reported a retrospective analysis on 56 right hemiliver donors, comparing the outcomes of the donors in whom the MHV was left intact (nz28) with those of the donors in whom the MHV was included in the graft (nz28). Operative time was significantly shorter in the group of donors who had the MHV included in the grafts. There was no difference in estimated blood loss, transfusion requirements, postoperative liver function, operative morbidity, and length of hospitalization. It was therefore concluded that including the MHV with the right hemiliver graft was not associated with an increase in operative risks of the donors. Similar observations on the operative and postoperative outcomes of liver donors with or without inclusion of the MHV in the right hemiliver grafts were also reported by Scatton et al. [20]. The operative outcomes were comparable in both groups of donors, except that liver function in terms of the prothrombin time ratio was significantly worse in the group with MHV included in the liver graft in the early postoperative period. However, the liver function was comparable in both groups of donors by the end of the first week after operation. The overall operative morbidity was comparable in both groups, and the donors remnant liver regeneration was similar as evaluated by computed tomography. The authors concluded that right hepatectomy including the MHV neither affects morbidity nor impairs early liver function and regeneration of the liver remnant in the donors for LDLT. However, it is undeniable that the segment IV is congested when the MHV is absent. The regeneration rate is reduced, but there is compensatory hypertrophy in segments II and III, resulting in the same amount of regeneration as segments II IV when the MHV is present [21]. In summary, there is an increasing trend of including the MHV in the right hemiliver graft in LDLT. Even without the MHV in the right hemiliver graft, increasing attention is paid to restore the venous drainage of segments V and VIII nowadays. 2. Biliary reconstruction in LDLT Biliary complication remains the Achilles s heel of LDLT and is the most common cause of postoperative morbidity [22]. The complication significantly affects the quality of life of the recipients and is occasionally the cause of graft and patient loss. Hepatico-jejunostomy was once the standard biliary reconstruction technique since the first reported series on adult-to-adult right hemiliver LDLT [2,23]. However, hepatico-jejunostomy has the disadvantages of requiring longer operation time, possible contamination due to opening of the jejunal loop, and delay in return of gastrointestinal function. In addition, the re-established bilio-enteric continuity is not physiological [24]. In contrast, duct-to-duct reconstruction, which is the technique of choice for biliary anastomosis in cadaveric liver transplantation [25], has the advantage of preserving the function of sphincter of Oddi as a defense against enteric reflux and ascending infection. Duct-to-duct biliary reconstruction has recently been advocated in LDLT [26, 27]. It is considered advantageous over hepatico-jejunostomy because it can minimize contamination by bowel content during transplantation, preserve physiological bilioenteric and bowel continuity, and result in early return of bowel function after transplantation. Without creation of mesenteric defects, duct-to-duct biliary anastomosis in LDLT can completely eliminate the risk of internal hernia of the small bowel [28]. Wachs et al. [26] in 1998 first reported the experience of duct-to-duct reconstruction for right hemiliver LDLT. However, biliary stricture developed 4 weeks later and the anastomosis was subsequently converted to a hepatico-jejunostomy. Thereafter, several studies reported the feasibility of duct-to-duct biliary anastomosis after right hemiliver LDLT [27,29 31]. Although duct-to-duct biliary reconstruction offers potential advantages over a

4 20 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) hepatico-jejunostomy, complications especially biliary strictures on long-term follow-up occur in about 30% of the LDLT recipients. It also remains controversial whether internal or external biliary drainage is beneficial in reducing the rate of biliary complications [32,33]. While there are obvious advantages of duct-to-duct biliary reconstruction over hepatico-jejunostomy, some investigators advocate routine hepatico-jejunostomy in adult-toadult LDLT, because of the possibility of increased risk of postoperative complications. In a retrospective analysis on 20 consecutive LDLT recipients reported by Kawachi et al. [34], biliary complication rate was observed in 60% among the 10 recipients who had a duct-to-duct anastomosis. These included biliary leakage (20%), biliary strictures (40%), and T-tube related biliary leakage (20%). All the 5 patients who received right hemiliver grafts developed biliary stricture. The incidence of biliary complication was only 20% in those patients who had hepatico-jejunostomy for biliary reconstruction. It was therefore suggested that duct-to-duct biliary reconstruction should be applied cautiously, especially in right hemiliver LDLT recipients. Other investigators suggested the use of duct-to-duct biliary anastomosis as the preferred technique as they did not observe an increased risk of morbidity. Gondolesi et al. reported biliary complications in 96 consecutive LDLT recipients [35], and failed to show significant differences in complications between the hepaticojejunostomy and duct-to-duct reconstruction groups. Regardless of the technique used, patients with more than one ductal opening had a higher incidence of bile leaks than those with only a single duct. In another retrospective study reported by Liu et al., the operative outcomes of 41 LDLT recipients who underwent duct-toduct biliary reconstruction were compared with those of 71 LDLT recipients who underwent hepatico-jejunostomy [33]. The overall biliary complication rate of the hepaticojejunostomy group was 31%, and was comparable to the figure of 24% observed in the duct-to-duct group. The postoperative intensive care unit stay (median: 3 days vs. 5 days, PZ0.01) and hospital stay (median, 19 days vs. 24 days, P!0.001) were significantly shorter in the ductto-duct group. Hospital mortality was also significantly lower in the duct-to-duct biliary reconstruction group (0 vs. 11%, PZ0.03). The overall biliary complication rate after duct-to-duct biliary reconstruction in LDLT remains high ranging from 24 to 67% in reported series (Table 1) [27,29,31 33,36]. Possible factors associated with an increased risk of postoperative biliary complication included multiple ductal openings [22] and a high preoperative model for end-stage liver disease score (R35) [33]. Ischiko et al. suggested that using continuous suture combined with an external stent might lower the biliary complication rate [32]. However, other investigators did not identify any significant factor associated with an increased risk of biliary complication after LDLT [35]. Nevertheless, complications related to biliary drainage tube including dislodgement and biliary leakage after removal of the tube have frequently been reported [35]. It was therefore controversial whether biliary drainage tube should be inserted after duct-to-duct biliary anastomosis in LDLT. The use of biliary drainage catheter or T-tube in cadaveric donor liver transplantation is still a topic for debate. In a multicenter prospective randomized trial, Scatton et al. [36] reported a significantly higher incidence of biliary complications in the T-tube group with a 10% incidence of biliary fistula. It was also found that T-tube did not provide a safer access to the biliary tract compared with the other available types of biliary exploration. Ben Ari et al. [37] also found that T-tube insertion after orthotopic liver transplantation was associated with a higher incidence of septic complications. It is still unknown whether the experience of T-tube drainage after cadaveric donor liver transplantation can be extrapolated to LDLT where the Table 1 Summary of reported series on duct-to-duct biliary reconstruction in living donor liver transplantation (LDLT) Author [Reference] Year No. of LDLT No. of Rt hemiliver LDLT Follow-up duration (months) Bile leakage Biliary stricture Shokouh-Amiri [31] (100%) MedianZ7.7, 4 (67%) 0 67 rangeznot available Grewal [27] (100%) Not available 2 (40%) 0 40 Malago [29] (100%) MedianZ11.6, 0 2 (40%) 40 rangez Kawachi [34] (50%) MeanZ20.3, 4 (40%) 4 (40%) 60 rangeznot available Ishiko [32] (100%) MedianZnot available, 5 (10%) 12 (23%) 31 rangez6 24 Liu [33] (100%) MedianZ13.3, 3 (7%) 10 (24%) 24 rangez Dulundu [35] (57%) MedianZ22.1, rangeznot available 12 (14%) 10 (12%) 32 Overall biliary complication rate (%)

5 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) right hepatic duct openings are usually small in caliber. The Kyoto group suggested that an external biliary stent is useful in patients undergoing LDLT with duct-to-duct biliary reconstruction [32]. However, the incidences of biliary complications in series with routine biliary drainage reported by the Kyoto group (31%) [32] and the Tokyo group (32%) [35] were similar to patients without biliary drainage (24%) as reported by the Hong Kong group [33] with a similar follow-up duration. Therefore, the controversy of whether biliary drainage or stent after LDLT with a duct-to-duct reconstruction is beneficial remains unsolved and should be further explored in prospective evaluations. Whatever the technique of biliary reconstruction, the prerequisite for success is good blood supply of stumps of the donor and recipient bile ducts. Steps to preserve arterial supply, venous drainage, and cautious handling of the ductal wall during suturing are essential [38]. Currently, many surgeons practice posterior continuous and anterior interrupted suturing without stenting. The long term outcome of such a technique awaits further evaluation. In conclusion, although routine inclusion of the MHV in the right hemiliver graft in LDLT is still controversial, the importance of providing venous drainage for the right anterior sector to ensure better early graft function has gained wide recognition. Different approaches have been adopted including routine inclusion of the MHV and a selective approach in the reconstruction of the venous drainage of segment V and VIII hepatic veins. Preservation of the MHV in the donor is intuitively considered important in reducing the donor risk. However, there are scarce data supporting the contention that the postoperative donor complication is related to the absence of the MHV in the left liver remnant. Hepatico-jejunostomy was once the standard biliary reconstruction technique in LDLT. Duct-to-duct biliary reconstruction has potential advantages becoming the preferred technique in several centers, recently. However, biliary complications such as biliary strictures on long-term follow-up occur in about 30% of the recipients. It also remains controversial whether internal or external biliary drainage is beneficial in reducing the biliary complication rate after duct-to-duct biliary anastomosis in LDLT. References [1] Trotter JF, Wachs M, Everson GT, Kam I. Adult-to-adult transplantation of the right hepatic lobe from a living donor. N Engl J Med 2002;346: [2] Lo CM, Fan ST, Liu CL, Wei WI, Lo RJ, Lai CL, et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts. Ann Surg 1997;226: [3] Marcos A, Orloff M, Mieles L, Olzinski AT, Renz JF, Sitzmann JV. Functional venous anatomy for right-lobe grafting and techniques to optimize outflow. Liver Transpl 2001;7: [4] Marcos A, Fisher RA, Ham JM, Olzinski AT, Shiffman ML, Sanyal AJ, et al. Emergency portacaval shunt for control of hemorrhage from a parenchymal fracture after adult-to-adult living donor liver transplantation. Transplantation 2000;69: [5] Maetani Y, Itoh K, Egawa H, Shibata T, Ametani F, Kubo T, et al. Factors influencing liver regeneration following living-donor liver transplantation of the right hepatic lobe. Transplantation 2003;75: [6] Man K, Fan ST, Lo CM, Liu CL, Fung PC, Liang TB, et al. Graft injury in relation to graft size in right lobe live donor liver transplantation: a study of hepatic sinusoidal injury in correlation with portal hemodynamics and intragraft gene expression. Ann Surg 2003;237: [7] Kaneko T, Kaneko K, Sugimoto H, Inoue S, Hatsuno T, Sawada K, et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000;70: [8] Sugawara Y, Makuuchi M, Sano K, Imamura H, Kaneko J, Ohkubo T, et al. Vein reconstruction in modified right liver graft for living donor liver transplantation. Ann Surg 2003;237: [9] de Villa VH, Chen CL, Chen YS, Wang CC, Lin CC, Cheng YF, et al. Right lobe living donor liver transplantation-addressing the middle hepatic vein controversy. Ann Surg 2003;238: [10] Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004;240: [11] Lee S, Park K, Hwang S, Lee Y, Choi D, Kim K, et al. Congestion of right liver graft in living donor liver transplantation. Transplantation 2001;71: [12] Lee SG, Park KM, Hwang S, Kim KH, Choi DN, Joo SH, et al. Modified right liver graft from a living donor to prevent congestion. Transplantation 2002;74: [13] Lee SG, Park KM, Hwang S, Lee YJ, Kim KH, Ahn CS, et al. Adultto-adult living donor liver transplantation at the Asan Medical Center, Korea. Asian J Surg 2002;25: [14] Sano K, Makuuchi M, Miki K, Maema A, Sugawara Y, Imamura H, et al. Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 2002;236: [15] Liu CL, Fan ST, Lo CM, Wei WI, Yong BH, Lai CL, et al. Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure. Transplantation 2003;76: [16] Liu CL, Zhao Y, Lo CM, Fan ST. Hepatic venoplasty in right lobe live donor liver transplantation. Liver Transpl 2003;9: [17] Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, et al. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004;240: [18] Fan ST, Lo CM, Liu CL, Wang WX, Wong J. Safety and necessity of including the middle hepatic vein in the right lobe graft in adultto-adult live donor liver transplantation. Ann Surg 2003;238: [19] Cattral MS, Molinari M, Vollmer Jr CM, McGilvray I, Wei A, Walsh M, et al. Living-donor right hepatectomy with or without inclusion of middle hepatic vein: comparison of morbidity and outcome in 56 patients. Am J Transplant 2004;4: [20] Scatton O, Belghiti J, Dondero F, Goere D, Sommacale D, Plasse M, et al. Harvesting the middle hepatic vein with a right hepatectomy does not increase the risk for the donor. Liver Transpl 2004;10: [21] Hata S, Sugawara Y, Kishi Y, Niiya T, Kaneko J, Sano K, et al. Volume regeneration after right liver donation. Liver Transpl 2004; 10: [22] Gondolesi GE, Varotti G, Florman SS, Munoz L, Fishbein TM, Emre SH, et al. Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 2004;77: [23] Marcos A, Fisher RA, Ham JM, Shiffman ML, Sanyal AJ, Luketic VA, et al. Right lobe living donor liver transplantation. Transplantation 1999;68:

6 22 Forum on Liver Transplantation / Journal of Hepatology 43 (2005) [24] Calne RY. A new technique for biliary drainage in orthotopic liver transplantation utilizing the gall bladder as a pedicle graft conduit between the donor and recipient common bile ducts. Ann Surg 1976; 184: [25] Vallera RA, Cotton PB, Clavien PA. Biliary reconstruction for liver transplantation and management of biliary complications: overview and survey of current practices in the United States. Liver Transpl Surg 1995;1: [26] Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, Trouillot TE, et al. Adult living donor liver transplantation using a right hepatic lobe. Transplantation 1998;66: [27] Grewal HP, Shokouh-Amiri MH, Vera S, Stratta R, Bagous W, Gaber AO. Surgical technique for right lobe adult living donor liver transplantation without venovenous bypass or portocaval shunting and with duct-to-duct biliary reconstruction. Ann Surg 2001;233: [28] Liu CL, Lo CM, Chan SC, Fan ST, Wong J. Internal hernia of the small bowel after right-lobe live donor liver transplantation. Clin Transplant 2004;18: [29] Malago M, Testa G, Hertl M, Lang H, Paul A, Frilling A, et al. Biliary reconstruction following right adult living donor liver transplantation end-to-end or end-to-side duct-to-duct anastomosis. Langenbecks Arch Surg 2002;387: [30] Miller CM, Gondolesi GE, Florman S, Matsumoto C, Munoz L, Yoshizumi T, et al. One hundred nine living donor liver transplants in adults and children: a single-center experience. Ann Surg 2001;234: [31] Shokouh-Amiri MH, Grewal HP, Vera SR, Stratta RJ, Bagous W, Gaber AO. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation. J Am Coll Surg 2001;192: [32] Ishiko T, Egawa H, Kasahara M, Nakamura T, Oike F, Kaihara S, et al. Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft. Ann Surg 2002;236: [33] Liu CL, Lo CM, Chan SC, Fan ST. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage. Transplantation 2004;77: [34] Kawachi S, Shimazu M, Wakabayashi G, Hoshino K, Tanabe M, Yoshida M, et al. Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Rouxen-Y hepaticojejunostomy biliary reconstruction. Surgery 2002;132: [35] Dulundu E, Sugawara Y, Sano K, Kishi Y, Akamatsu N, Kaneko J, et al. Duct-to-duct biliary reconstruction in adult living-donor liver transplantation. Transplantation 2004;78: [36] Scatton O, Meunier B, Cherqui D, Boillot O, Sauvanet A, Boudjema K, et al. Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 2001;233: [37] Ben Ari Z, Neville L, Davidson B, Rolles K, Burroughs AK. Infection rates with and without T-tube splintage of common bile duct anastomosis in liver transplantation. Transpl Int 1998;11: [38] Fan ST, Lo CM, Liu CL, Tso WK, Wong J. Biliary reconstruction and complications of right lobe live donor liver transplantation. Ann Surg 2002;236: How to prevent and manage biliary complications in living donor liver transplantation? Satoru Todo*, Hiroyuki Furukawa, Toshiya Kamiyama The First Department of Surgery, Hokkaido University School of Medicine, N-15, W-7, Kita-ku, Sapporo , Japan Ever since the introduction of deceased donor (DD) liver transplantation, biliary complications have been the Achilles heel of the procedure [1]. Certain techniques used in early series (e.g. cholecysto-duodenostomy, cholecysto-jejunostomy) were associated with high complication rates of approximately 50%, and thus were rapidly abandoned. Currently, choledocho-jejunostomy or choledocho-choledochostomy are the standard methods for biliary reconstruction in liver transplantation, but complications still occur in 5 20% of recipients. For example, in 1792 consecutive liver transplantations at the University of Pittsburgh [2], 11.5% of the recipients suffered various biliary complications including strictures (42.8%), leaks * Corresponding author. Tel.: C ; fax: C address: stodo@med.hokudai.ac.jp (S. Todo). Abbreviations: DD; deceased donor; LDLT; living donor liver transplantation; HJ; hepatico-jejunostomy, duct-to-duct anastomosis; MRCP; magnetic resonance cholangio pancreaticography. (26.7%), ampullary dysfunction (6.6%), and obstruction (13.8%), leading to death in 21 patients. Although patient and graft survival rates after living donor liver transplantation (LDLT) have approached those after DD liver transplantation, biliary complications have been again identified as the Achilles heel of this newer procedure, affecting approximately 20 30% of recipients (Tables 1 and 2) (see previous article by CL Liu, CM Lo, and ST Fan in this forum). Initially, LDLT was undertaken to reduce mortality among children waiting for a cadaveric organ, by grafting the left lateral segment with a Roux-en Y hepatico-jejunostomy. Now, LDLT are mostly offered to adult recipients. The first adult recipient of a living donor graft successfully received the left hemiliver with a hepatico-jejunostomy reconstruction [3]. Currently, right hemiliver transplants are preferred in most centers often choosing a duct-to-duct biliary reconstruction in the hope of offering sufficient liver mass and preventing events associated with a hepatico-jejunostomy. Problems after /$30.00 q 2005 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi: /j.jhep