THE BACKTABLE GUIDE WIRE REPLACEMENT AND STENTING BILE DUCT IN LIVER TRANSPLANTATION

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THE BACK-TABLE GUIDE WIRE REPLACEMENT AND
STENTING BILE DUCT IN LIVER TRANSPLANTATION

• M.Haberal, F. Boyvat, G. Moray, H. Karakayali, R.
  Emiroglu, A. Dalgiç
• Baskent University
• Ankara TURKEY

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Achilles heel of liver transplantation

• Despite advances in immunosuppression, organ
  preservation, intraoperative management, and
  various refinements of surgical technique, 10 to
  25 of patients who undergo OCLT develop biliary
  complications.
• The corresponding range for LDLT is 15 to 64

3

• In this study we tried to describe the
  intra-operative transhepatic biliary catheter
  insertion technique in biliary reconstruction
  that we have been used since December 2004 for 29
  patients and its preliminary results.

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Liver Transplantations (92) From April 2001 to
June 2005
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Donor Hepatectomy
Hilum dissection
Cholangiography
Peroperative cholangiography (Donor)
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Tissue-link
Ultracision
Ultrasonic aspirator
Divided right hepatic duct
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Weighing the graft
8
Reconstruction of right hepatic ducts at back
table
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Glide wire
Kumpe Catheter 5F
Dilator 5F
16 G Needle
Instruments used for intraoperative transhepatic
biliary catheter insertion
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Dilator 5F
Glide wire (stiff end )
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Right lobe
Left lateral
Whole liver
12
Choledochocholedochostomy (Posterior wall)
Glide wire
13
Roux-en Y hepaticojejunuostomy
Left hepatic duct
Glide wire (stiff)
Jejunum limb
14
16 G Needle
Glide wire
Glide wire
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Kumpe Catheter 5F
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Advancing the Kumpe catheter distal to the
anastomosis
Biliary reconstruction
Arterial reconstruction
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Right lobe LDLT (mother to son) Duct to duct
anastomosis
Right lobe LDLT (son to father) Duct to duct
anastomosis
Peroperative Cholangiography (Recipient, Right
lobe)
18
Left lobe LDLT (Father to 1 year old son) Byler
disease and incidental HCC. Duct to duct
anastomosis
Left lobe LDLT (Mother to 10 years old
son) Tyrosinaemia and incidental HCC. Duct to
duct anastomosis
Left lobe LDLT (father to 6 years old
son) Alpha-1 antitrypsin deficiency. RYHJ . His
common bile duct was lt2mm.
Peroperative Cholangiography (Recipient, Left
Lobe)
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Postoperative Cholangiography Cadaveric Whole
livers
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Postoperative Cholangiography LDLT Right Lobes
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Postoperative Cholangiography LDLT Left Lobes
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Intra-operative transhepatic biliary catheter
insertion patients

• 10 children
• 6.0  4.4 years old (range from 6 months to 14
  years)
• 19 adults
• 43.0  13.7 years old (range from 18 to 62)

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Etiology in intra-operative transhepatic biliary
drainage catheter insertion patients

• Hepatitis 13
• 3 fulminant hepatitis A,
• 2 HBV
• 3 HBV and delta infection
• 1 HCV
• 1 HBV HCV
• 3 HCC in the ground of HBV
• 2 alcoholic cirrhosis,
• 2 primary biliary cirrhosis,
• 2 HCC in ground of Byler disease and
  tirosynaemia,
• 2 biliary atresia,
• 2 Wilson cirrhosis (ALF)

• 1 alpha-1 antitrypsine deficiency
• 1 autoimmune hepatitis
• 1 familial intrahepatic cholestasis
• 1 cryptogenic cirrhosis
• 1 alveolar cysthydatic
• 1 hepatoblastoma
• 3 of the HCC patients were adults and known
  before the transplantation, 2 were children and
  were diagnosed incidentally after the evaluation
  of the recipients hepatectomy specimen.

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Donors and Grafts

• Cadavers 10
• First-degree relatives 16
• Grandfather 1
• Spouses 2
• Whole liver 10 (2 child, and 8 adults)
• Right lobe 11 (adults)
• Left lateral or Left lobe 8 (children)
• The mean graft weight in living donors was 598 gr
  (range 270-975gr).
• The mean graft / body ration in LDLT were 1.6
  (range 0.8 to 4.1).

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Biliary reconstructions

• 17 duct to duct anastomosis (DD)
• 10 choledocholedocostomy (CC)
• 2 Roux-en Y hepaticojejunostomy (RYHJ)
• One in a child who had alpha-1 antitrypsin
  deficiency with a common bile duct of lt2mm,
• The other was also a child who had biliary
  atresia and his common bile duct stenotic.

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• There was only one (3.4) biliary anastomosis
  leakage.
• 56 years old male,
• The graft was a cadaveric whole liver,
• The biliary reconstruction was CC.
• The intraoperatively placed catheter was
  withdrawn accidentally at the post-operative
  first week by himself.
• A bilioma was detected at the first month
• Treated with percutaneous bilioma drainage and
  percutaneous external bilary drainage catheter
  placement.
• This result is significantly better than our
  previous DD biliary reconstruction techinique in
  LDLT. There were 3 biliary anastomosis leakages
  in 23 cases (10.3).

Dalgic A, Moray G, Emiroglu R, Sozen H,
Karakayali H, Boyacioglu S, Bilgin N, Haberal M.
Duct-to-duct biliary anastomosis in living
related liver transplantation. Exp Clin
Transplant. 2004 Dec 2(2) suppl, 21
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Cadaveric Whole liver
Postop 27th day
Postop 21th day
Postop 61th day
Postop 61th day
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• This is the biggest series for left / left
  lateral lobe duct to duct biliary anastomosis in
  pediatric patient group in literature for now. (6
  children)
• Wiederkehr and et al from Parana, Brasil were
  reported a similar technique in 6 patients (1
  adults and 5 children). They were performed a
  duct to duct biliary reconstruction in five
  pediatric left / left lateral lobe liver
  transplantations.

Wiederkehr JC, Lemos IM, Avilla SG, Schulz C,
Moreira M, Ekerman M, Pereira JC. Transhepatic
biliary catheterization before graft implant in
living donor liver transplantation. Transplant
Proc. 2005 Mar37 (2)1124-5.
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Conclusion

• This new biliary reconstruction technique is
  significantly improved our results.
• Transhepatic biliary catheters prevent biliary
  complications and also by maintaining an access
  route for percutaneous interventions they
  simplify to treat biliary complications.
• Intra-operative transhepatic biliary catheter
  insertion at the back-table is an alternative and
  safe method of biliary drainage in liver
  transplantation.