Hepaticojejunostomy Shows Better Longterm Outcome Than DD reconstruction in Adult Living Donor Liver

1
Hepaticojejunostomy Shows Better Long-term
Outcome Than DD reconstruction in AdultLiving
Donor Liver Transplantation

• Yi NJ, Suh KS, Kwon CH, Cho JY, Lee KU
• Department of Surgery, College of Medicine,
• Seoul National University, Seoul, Korea

2
Introduction (I)

• In the past, biliary complication in deceased
  donor liver transplantation (DDLT)
• Achilles heel of liver transplantation
• - Most common
• - Most serious problems
• However, biliary complication rate has
  dramatically dropped over the past 10 years

3
Introduction (II)

• Biliary Reconstruction in adult living donor
  liver trasnplantation (LDLT)
• Roux-en-Y Hepaticojejunostomy (RYHJ)
• - Standard procedure.
• - Recent complication rate 8-26 . Fan
  ST, et al. Ann Surg 2002
• Duct-to-duct reconstruction (DD)
• - The 1st report. Wachs ME, et al.
  Transplantation 1998
• - Reduces op.time, preserve physiologic
  continuity, has no enteric contamination, and
  allows easier access of biliary tree than RYHJ.
• Ishiko T, et al. Ann Surg 2002

4
Introduction (III)

• DD has recently become the preferred technique
  than RYHJ in major transplantation centers of
  adult LDLT.
• However, only few studies reported on a
  substantial number of patients with a significant
  follow-up duration to address the long-term
  outcome of DD compared with RYHJ.

5
Aims

• To compare the long-term outcome of DD and RYHJ
  in adult LDLT.

6
Patients Methods

• From Jan. 1999. Dec. 2002.
• Adult LDLT in Seoul National University Hospital
  
• 74 recipients who survived 2 years.
• Perioperative evaluation of bile duct
• Selective MRCP A routine op. cholangiography

7
Types of Biliary Reconstruction

• RYHJ (n18)
• in the early period of our adult LDLT program.
• DD (n56)
• beginning from Dec. 2000.

DD (n56, 75.0)
8
Types of DD Reconstruction (n56)

• DD with a stent (DDS, n35)
• - The first 35 cases, Dec. 2000 - Apr. 2002
• - over T tube or internal stent.
• DD without a stent (DD-S, n21)
• - The later 21 cases, May. - Dec. 2002

9
Preservation of Periductal Microcirculation in DD
10
Biliary Complication

• Bile leak, bile duct stricture, complete
  obstruction
• - Clinical symptoms
• - Abnormal liver function test
• - Requiring intervention
• Early (3 mon.)

11
Recipient Characteristics
p 12
Types of Complication
p

a Recurrent cholangitis due to the right
posterior hepatic artery obstruction.

b Late leak associated with T-tube removal in 6,
and progressed to bile duct stricture in two of
them.

c Missing duct during donor operation.

13
Management of Complication
Nonsurgical 22 of 26 (84.6) vs Surgical 4 of
26 (15.4)
The frequency of intervention 3-6 times
14
Summary

• The rate of biliary complication in adult LDLT
  was 26 cases in 24 of 74 recipients (35.1).
• Complication rate of RYHJ was 11.1 and DD was
  42.9.
• - Bile leaks occurred only in DDS (17.6).
• - The incidence of bile duct stricture was
  acutely increased in DD (23.2).
• Most of them (84.6, 22 of 26 cases) were
  resolved by nonsurgical management.

15
Conclusion

• In adult LDLT, RYHJ showed the better long-term
  outcome than DD.
• In view of the historical review nature of this
  study, randomized prospective studies are needed
  to confirm our findings.

16
(No Transcript)
17
Preservation of Periductal Microcirculation in DD