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How to prevent and manage biliary complications in living donor liver transplantation?

2005; Elsevier BV; Volume: 43; Issue: 1 Linguagem: Inglês

10.1016/j.jhep.2005.05.004

1600-0641

Satoru Todo, Hiroyuki Furukawa, Toshiya Kamiyama,

Organ Donation and Transplantation

Ever since the introduction of deceased donor (DD) liver transplantation, biliary complications have been the ‘Achilles' heel’ of the procedure [[1]Starzl T.E. Demetris A.J. Liver transplantation. Yearbook Medical Publishers Inc., Chicago1990Google Scholar]. 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]Greif F. Bronsther O.L. Van Thiel D.H. Casavilla A. Iwatsuki S. Tzakis A. et al.The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation.Ann Surg. 1994; 219: 40-45Crossref PubMed Scopus (427) Google Scholar], 11.5% of the recipients suffered various biliary complications including strictures (42.8%), leaks (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 (Table 1, Table 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]Hashikura Y. Makuuchi M. Kawasaki S. Matsunami H. Ikegami T. Nakazawa Y. et al.Successful living-related partial liver transplantation to an adult patient.Lancet. 1994; 343: 1233-1234Abstract PubMed Scopus (323) Google Scholar]. 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 duct-to-duct reconstruction in LDLT became already apparent with the first case [[4]Wachs M.E. Bak T.E. Karrer F.M. Everson G.T. Shrestha R. Trouillot T.E. et al.Adult living donor liver transplantation using a right hepatic lobe.Transplantation. 1998; 66: 1313-1316Crossref PubMed Scopus (284) Google Scholar]. The patient developed an anastomotic stricture 4 weeks later, and subsequently required conversion to a hepatico-jejunostomy.Table 1Biliary complication in pediatric LDLTCenterYearCasesBiliary complication (%)ReferenceAllAnastomotic leakageAnastomotic strictureUCSF, USA1998326 (18.8)6 (18.8)0 (0)[5]Reichert P.R. Renz J.F. Rosenthal P. Bacchetti P. Lim R.C. Roberts J.P. et al.Biliary complications of reduced-organ liver transplantation.Liver Transpl Surg. 1998; 4: 343-349Crossref PubMed Scopus (60) Google ScholarBrussels, Belgium19994214 (34)3 (7)10 (24)[6]Reding R. de Goyet Jde V Delbeke I. Sokal E. Jamart J. Janssen M. et al.Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts.Pediatrics. 1999; 134: 280-286Abstract Full Text Full Text PDF Scopus (153) Google ScholarKyoto, Japan2001400aIncludes 55 adult cases.71 (18.2)45 (11.5)35 (9.0)[7]Egawa H. Inomata Y. Uemoto S. Asonuma K. Kiuchi T. Fujita S. et al.Biliary anastomotic complications in 400 living related liver transplantations.World J Surg. 2001; 25: 1300-1307Crossref PubMed Scopus (183) Google ScholarHamburg, Germany2004442 (4.6)NANA[8]Broering D.C. Kim J.S. Mueller T. Fischer L. Ganschow R. Bicak T. et al.One hundred thirty-two consecutive pediatric liver transplants without hospital mortality: lessons learned and outlook for the future.Ann Surg. 2004; 240 ([discussion 1012]): 1002-1012Crossref PubMed Scopus (94) Google ScholarJohns Hopkins, USA20044816 (33.3)10 (20.8)2 (4.2)[9]Kling K. Lau H. Colombani P. Biliary complications of living related pediatric liver transplant patients.Pediatr Transplant. 2004; 8: 178-184Crossref PubMed Scopus (68) Google Scholara Includes 55 adult cases. Open table in a new tab Table 2Biliary complication in adult right hemiliver LDLTCenterYearCaseAnastomosisBiliary complication (%)ReferenceH–JD–DAllAutomatic leakageAutomatic strictureTennessee, USA200114aWith hilar blood supply preservation.8–5 (62.5)3 (37.5)0[10]Shokouh-Amiri M.H. Grewal H.P. Vera S.R. Stratta R.J. Bagous W. Gaber A.O. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation.J Am Coll Surg. 2001; 192: 798-803Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar–64 (66.7)0 (0)0 (0)Paul-Brusse, France200110aWith hilar blood supply preservation.3–0 (0)0 (0)0 (0)[11]Azoulay D. Marin-Hargreaves G. Castaing D. ReneAdam Bismuth H. Duct-to-duct biliary anastomosis in living related liver transplantation: the Paul Brousse technique.Arch Surg. 2001; 136: 1197-1200Crossref PubMed Scopus (55) Google Scholar–71 (14.2)0 (0)0 (0)Essen, Germany2000302198 (26.7)4 (13.3)1 (3.3)[12]Testa G. Malago M. Valentin-Gamazo C. Lindell G. Broelsch C.E. Biliary anastomosis in living related liver transplantation using the right liver lobe: techniques and complications.Liver Transpl. 2000; 6: 710-714Crossref PubMed Scopus (169) Google Scholar200374NANA17 (23)7 (9.5)5 (6.8)[13]Malago M. Testa G. Frilling A. Nadalin S. Valentin-Gamazo C. Paul A. et al.Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients.Ann Surg. 2003; 238 ([discussion 862–3]): 853-862Crossref PubMed Scopus (185) Google ScholarHong Kong20027428916 (43.2)5 (13.5)10 (27)[14]Fan S.T. Lo C.M. Liu C.L. Tso W.K. Wong J. Biliary reconstruction and complications of right lobe live donor liver transplantation.Ann Surg. 2002; 236: 676-683Crossref PubMed Scopus (163) Google Scholar37bBy modified methods.3 (8.1)0 (0)3 (8.1)Hong Kong200441–4110 (24.3)3 (7.3)10 (24.3)[15]Liu C.L. Lo C.M. Chan S.C. Fan S.T. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage.Transplantation. 2004; 77: 726-732Crossref PubMed Scopus (149) Google ScholarKeio U., Japan20022010–2 (20)1 (10)0 (0)[16]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 Roux-en-Y hepaticojejunostomy biliary reconstruction.Surgery. 2002; 132: 48-56Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar–108 (80)2 (20)4 (40)Kyoto, Japan200251–5117 (32.6)5 (9.6)12 (23)[17]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: 235-240Crossref PubMed Scopus (174) Google ScholarTokyo, Japan200481cIncludes 29 left lobes.–8126 (32)2 (2.5)10 (12.3)[18]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: 574-579Crossref PubMed Scopus (92) Google ScholarMt Sinai, USA200496534333 (34.3)13 (13.5)20 (20.8)[19]Gondolesi G.E. Varotti G. Florman S.S. Munoz L. Fishbein T.M. Emre S.H. et al.Biliary complications in 96 consecutive right lobe living donor transplant recipients.Transplantation. 2004; 77: 1842-1848Crossref PubMed Scopus (208) Google ScholarSamsung, Korea200431dBy high hilar dissection.–315 (16.1)0 (0)3 (9.7)[20]Lee K.W. Joh J.W. Kim S.J. Choi S.H. Heo J.S. Lee H.H. et al.High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation.Liver Transpl. 2004; 10: 1158-1162Crossref PubMed Scopus (78) Google Scholara With hilar blood supply preservation.b By modified methods.c Includes 29 left lobes.d By high hilar dissection. Open table in a new tab Biliary complications after LDLT include leakage (anastomosis, cut-surface, T-tube exit), stricture (anastomosis, biliary tract), sludge, choledocholithiasis, biliary sepsis, and others. Major anastomotic leakage and multiple or diffuse stenosis of the biliary tree most are the source of significant morbidity, resulting in fatal outcomes in 1–3% of the recipients. The reported incidence of such complications differs considerably among centers. Overall incidences of biliary complications in pediatric recipients range from 5 to 34% [5Reichert P.R. Renz J.F. Rosenthal P. Bacchetti P. Lim R.C. Roberts J.P. et al.Biliary complications of reduced-organ liver transplantation.Liver Transpl Surg. 1998; 4: 343-349Crossref PubMed Scopus (60) Google Scholar, 6Reding R. de Goyet Jde V Delbeke I. Sokal E. Jamart J. Janssen M. et al.Pediatric liver transplantation with cadaveric or living related donors: comparative results in 90 elective recipients of primary grafts.Pediatrics. 1999; 134: 280-286Abstract Full Text Full Text PDF Scopus (153) Google Scholar, 7Egawa H. Inomata Y. Uemoto S. Asonuma K. Kiuchi T. Fujita S. et al.Biliary anastomotic complications in 400 living related liver transplantations.World J Surg. 2001; 25: 1300-1307Crossref PubMed Scopus (183) Google Scholar, 8Broering D.C. Kim J.S. Mueller T. Fischer L. Ganschow R. Bicak T. et al.One hundred thirty-two consecutive pediatric liver transplants without hospital mortality: lessons learned and outlook for the future.Ann Surg. 2004; 240 ([discussion 1012]): 1002-1012Crossref PubMed Scopus (94) Google Scholar, 9Kling K. Lau H. Colombani P. Biliary complications of living related pediatric liver transplant patients.Pediatr Transplant. 2004; 8: 178-184Crossref PubMed Scopus (68) Google Scholar]. The rates of anastomotic leakage and stricture are between 7.0 and 21%, and 0–24%, respectively (Table 1). Regardless of the type of segmental graft and biliary reconstruction, the overall incidence of biliary complication in adult LDLT patients ranges from 0 to 60% [10Shokouh-Amiri M.H. Grewal H.P. Vera S.R. Stratta R.J. Bagous W. Gaber A.O. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation.J Am Coll Surg. 2001; 192: 798-803Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Azoulay D. Marin-Hargreaves G. Castaing D. ReneAdam Bismuth H. Duct-to-duct biliary anastomosis in living related liver transplantation: the Paul Brousse technique.Arch Surg. 2001; 136: 1197-1200Crossref PubMed Scopus (55) Google Scholar, 12Testa G. Malago M. Valentin-Gamazo C. Lindell G. Broelsch C.E. Biliary anastomosis in living related liver transplantation using the right liver lobe: techniques and complications.Liver Transpl. 2000; 6: 710-714Crossref PubMed Scopus (169) Google Scholar, 13Malago M. Testa G. Frilling A. Nadalin S. Valentin-Gamazo C. Paul A. et al.Right living donor liver transplantation: an option for adult patients: single institution experience with 74 patients.Ann Surg. 2003; 238 ([discussion 862–3]): 853-862Crossref PubMed Scopus (185) Google Scholar, 14Fan S.T. Lo C.M. Liu C.L. Tso W.K. Wong J. Biliary reconstruction and complications of right lobe live donor liver transplantation.Ann Surg. 2002; 236: 676-683Crossref PubMed Scopus (163) Google Scholar, 15Liu C.L. Lo C.M. Chan S.C. Fan S.T. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage.Transplantation. 2004; 77: 726-732Crossref PubMed Scopus (149) Google Scholar, 16Kawachi 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 Roux-en-Y hepaticojejunostomy biliary reconstruction.Surgery. 2002; 132: 48-56Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 17Ishiko 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: 235-240Crossref PubMed Scopus (174) Google Scholar, 18Dulundu 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: 574-579Crossref PubMed Scopus (92) Google Scholar, 19Gondolesi G.E. Varotti G. Florman S.S. Munoz L. Fishbein T.M. Emre S.H. et al.Biliary complications in 96 consecutive right lobe living donor transplant recipients.Transplantation. 2004; 77: 1842-1848Crossref PubMed Scopus (208) Google Scholar, 20Lee K.W. Joh J.W. Kim S.J. Choi S.H. Heo J.S. Lee H.H. et al.High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation.Liver Transpl. 2004; 10: 1158-1162Crossref PubMed Scopus (78) Google Scholar], with anastomotic leakage occurring in 0–37% and stricture in 0–40% (Table 2). The etiology of biliary complications is multifactorial. Risk factors include age and gender of recipients, severity of original disease, variations in the biliary tract anatomy, number and size of reconstructed bile dust(s), techniques in graft procurement and diseased liver removal, ischemic damage to bile duct (hepatic artery complication, warm/cold ischemia, bile duct blood supply), method of biliary reconstruction (type, suture methods, suture material, stent, or T-tube use), immunological issues (ABO incompatibility, preformed antibody), infection (biliary sepsis, cytomegalovirus). In 400 LDLT cases reported by the Kyoto group [[4]Wachs M.E. Bak T.E. Karrer F.M. Everson G.T. Shrestha R. Trouillot T.E. et al.Adult living donor liver transplantation using a right hepatic lobe.Transplantation. 1998; 66: 1313-1316Crossref PubMed Scopus (284) Google Scholar] including 55 adult recipients, biliary complications occurred in 11.5% of the patients. Biliary stent, intrapulmonary shunting, and female recipients were at higher risk for leakage. Risk factors for stricture were anastomotic leak, cytomegatovirus infection, hepatic artery complication, and female recipient. Issues that must be considered in order to prevent biliary complications after LDLT fall into two categories: anatomical and technical. Accurate knowledge of bile duct anatomy is critical to secure donor safety and to minimize complications in the recipients. According to Couinaud [[21]Couinau C. Etudes anatomiques et chirurgicales. vol. 1. Masson, Paris1979Google Scholar], patterns of the hepatic duct confluence are classified into six groups; (A) typical anatomy (57%), (B) triple confluence (12%), (C) ectopic drainage of a right duct (anterior or posterior) into the common hepatic duct (20%), (D) ectopic drainage of a right duct (anterior or posterior) into the left hepatic duct (6%), (E) absence of the hepatic duct confluence (3%), and (F) absence of the right hepatic duct and ectopic drainage of the right posterior duct into the cystic duct (2%). The type and the rate of these hepatic duct anomalies are similar to those observed during hepatic [[22]Ohkubo M. Nagino M. Kamiya J. Yuasa N. Oda K. Arai T. et al.Surgical anatomy of the bile ducts at the hepatic hilum as applied to living donor liver transplantation.Ann Surg. 2004; 239: 82-86Crossref PubMed Scopus (162) Google Scholar] and LDLT donor surgery [[23]Varotti G. Gondolesi G.E. Goldman J. Wayne M. Florman S.S. Schwartz M.E. et al.Anatomic variations in right liver living donors.J Am Coll Surg. 2004; 198: 577-582Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar]. Choi et al. [[24]Choi J.W. Kim T.K. Kim K.W. Kim A.Y. Kim P.N. Ha H.K. et al.Anatomic variation in intrahepatic bile ducts: an analysis of intraoperative cholangiograms in 300 consecutive donors for living donor liver transplantation.Korean J Radiol. 2003; 4: 85-90Crossref PubMed Scopus (106) Google Scholar] found a peculiar anomaly among 300 consecutive intraoperative cholangiograms. One live donor had a total drainage of the right hepatic duct into the cystic duct. When the right graft is to be removed, precise investigation of these anomalies is paramount to minimize the number of duct reconstructions and to avoid injury to the donor bile duct near the confluence. During procurement of the left lateral segment or the left hemiliver, particular caution must be taken to recognize separate drainage of the segment II and III ducts into the hepatic confluence, or whether the left hepatic duct is absent (type E, 3%). One of these segmental ducts was accidentally ligated in three of the 400 LDLT in the Kyoto series [[4]Wachs M.E. Bak T.E. Karrer F.M. Everson G.T. Shrestha R. Trouillot T.E. et al.Adult living donor liver transplantation using a right hepatic lobe.Transplantation. 1998; 66: 1313-1316Crossref PubMed Scopus (284) Google Scholar]. Recent advances in imaging technology, particularly of multiphase three-dimensional analyses, have allowed precise information to be obtained preoperatively on the graft volume and the vascular structures (hepatic artery, portal vein, and hepatic veins). However, imaging studies of the biliary tree are less reliable [25Ayuso J.R. Ayuso C. Bombuy E. De Juan C. Llovet J.M. De Caralt T.M. et al.Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography.Liver Transpl. 2004; 10: 1391-1397Crossref PubMed Scopus (39) Google Scholar, 26Yeh B.M. Breiman R.S. Taouli B. Qayyum A. Roberts J.P. Coakley F.V. Biliary tract depiction in living potential liver donors: comparison of conventional MR, mangafodipir trisodium-enhanced excretory MR, and multi-detector row CT cholangiography—initial experience.Radiology. 2004; 230: 645-651Crossref PubMed Scopus (106) Google Scholar]. Using the sensitive mangafodipir trisodium enhanced magnetic resonance cholangiography, the accuracy of depicting the pattern of bile duct bifurcation was 88% (22/25). Patients with multiple left hepatic ducts, a trifurcation pattern, or ectopic drainage of hight hepatic duct into the cystic duct were not identified properly. Therefore, it is essential to perform intraoperative cholangiography at every donor hepatpectomy in LDLT. A C-arm fluoroscopy is particularly useful in confirming the bile duct anatomy and a point of bile duct(s) transection. The bile duct is divided into three segments: hilar, supraduodenal, and retropancreatic. The supraduodenal segment of the bile duct receives 60% of the blood supply via axial 3 O'clock and 9 O'clock arteries that arise from the posterior–superior pancreatico-duodenal artery and the gastro-duodenal artery. The bile duct receives 2% of transversal blood supply from the proper hepatic artery. A fine arterial plexus formed by these marginal arteries ascends to the confluence at the hepatic hilum and nourishes the common bile duct. The right and left hepatic arteries account for 38% of the arterial blood supply of the biliary system; they nourish the confluence and both hepatic ducts via the hilar plexus at inferior aspect of the hilar plate [27Northover J.M. Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications.Br J Surg. 1979; 66: 379-384Crossref PubMed Scopus (401) Google Scholar, 28Terblanche J. Allison H.F. Northover J.M. An ischemic basis for biliary strictures.Surgery. 1983; 94: 52-57PubMed Google Scholar]. Thus, as stressed by others [10Shokouh-Amiri M.H. Grewal H.P. Vera S.R. Stratta R.J. Bagous W. Gaber A.O. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation.J Am Coll Surg. 2001; 192: 798-803Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Azoulay D. Marin-Hargreaves G. Castaing D. ReneAdam Bismuth H. Duct-to-duct biliary anastomosis in living related liver transplantation: the Paul Brousse technique.Arch Surg. 2001; 136: 1197-1200Crossref PubMed Scopus (55) Google Scholar] interruption of blood supply to the hilar plate during donor hepatectomy and that to the supra-duodenal segment during recipient liver removal should be avoided. Injury to the duct blood supply may lead to bile duct ischemia, resulting in anastomotic leakage, stricture, or even necrosis of the bile duct. Standard techniques of graft removal, learned from partial hepatectomies and whole liver or split-liver transplantations, have well been described elsewhere with minor variations. Particular attention is needed to confirm the plane of intrahepatic bile duct division using intraoperative cholangiography or fluoroscopy. Dissection between the hepatic duct and the hepatic artery beyond the transection should be avoided to maintain a viable blood supply to the hepatic duct(s). The stump, at least 2 mm apart from the confluence, should be left for safe closure. Any damage to the graft bile duct(s) by a cautery, clips or blunt trauma should be strictly avoided. Any tiny bleeding at bile duct openings requires suture ligation with fine needles. Similarly, methods of native liver removal in recipients are essentially the same as those applied in DD liver transplantation. When a duct–duct reconstruction is planned, however, care should be taken not to interrupt the arterial blood supply to the biliary tract and to leave enough length of the bile duct for a tension-free anastomosis. Toward this end, the connective tissue around the hepatic artery and the bile duct should be kept intact as high as possible in the hilum. Using these modifications, Shokouh-Amiri et al. [[10]Shokouh-Amiri M.H. Grewal H.P. Vera S.R. Stratta R.J. Bagous W. Gaber A.O. Duct-to-duct biliary reconstruction in right lobe adult living donor liver transplantation.J Am Coll Surg. 2001; 192: 798-803Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar] and Azoulay et al. [[11]Azoulay D. Marin-Hargreaves G. Castaing D. ReneAdam Bismuth H. Duct-to-duct biliary anastomosis in living related liver transplantation: the Paul Brousse technique.Arch Surg. 2001; 136: 1197-1200Crossref PubMed Scopus (55) Google Scholar] experienced no anastomotic leakage and stricture after duct–duct reconstruction in consecutive series of 6 and 7 patients, respectively. Recently, Lee et al. [[20]Lee K.W. Joh J.W. Kim S.J. Choi S.H. Heo J.S. Lee H.H. et al.High hilar dissection: new technique to reduce biliary complication in living donor liver transplantation.Liver Transpl. 2004; 10: 1158-1162Crossref PubMed Scopus (78) Google Scholar] proposed a new intrahepatic Glissonian approach for recipient hepatectomy to reduce biliary complications. The high hilar dissection method, in which intrahepatic pedicles are divided at the third level or beyond, allowed tension-free duct–duct anastomosis with good preservation of blood supply to the bile duct. No anastomotic leakage occurred in 33 consecutive adult DD liver transplantation patients, and none required a hepatico-jejunostomy conversion, although three anastomotic strictures occurred during a mean follow-up of 11 months. Hepatico-jejunostomy is inevitable for biliary reconstruction in pediatric LDLT, as well as in patients with bile duct diseases, prior biliary surgery, re-transplantation, significant duct size discrepancy, and the presence of multiple or small bile ducts. Although the superiority of either hepatico-jejunostomy or duct to duct for biliary reconstruction in adult LDTT has been a debate (see previous article by CL Liu, CM Lo, and ST Fan in this forum and Table 2), surgeons should follow the principle of tension-free and viable anastomosis, and be accustomed to both procedures. When the left hemiliver is used, bile duct reconstruction is generally straight forward, except in the presence of separate segmental II and III ducts or a segment IV duct draining into the confluence. Very small caudate lobe ducts can be joined successfully to a jejunal loop by non-anatomotic reconstruction [[29]Kubota K. Takayama T. Sano K. Hasegawa K. Aoki T. Sugawara Y. Makuuchi M. Small bile duct reconstruction of the caudate lobe in living-related liver transplantation.Ann Surg. 2002; 235: 174-177Crossref PubMed Scopus (17) Google Scholar]. However, in right hemiliver LDLT, all grafts, except for those with typical biliary anatomy (type A by Cuinaud's classification), will require a ductoplasty (type B), or two or more anastomoses (types C–F) [[30]Nakamura T. Tanaka K. Kiuchi T. Kasahara M. Oike F. Ueda M. et al.Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases.Transplantation. 2002; 73: 1896-1903Crossref PubMed Scopus (223) Google Scholar]. Risks associated with the use of stents or T-tubes have been controversial. Many centers prefer them to ease postoperative patient management because they provide early information on graft function, biliary imaging, and easy access. As highlighted in the previous article by CL Liu, CM Lo, and ST Fan in this forum a prospective randomized trial is needed to definitively settle the controversy. Here also no consensus has been reached; for example the Kyoto group recommends that the biliary anastomosis be constructed with continuous absorbable sutures [[17]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: 235-240Crossref PubMed Scopus (174) Google Scholar], while the Hong Kong group prefers interrupted sutures with non-absorbable monofilaments [[15]Liu C.L. Lo C.M. Chan S.C. Fan S.T. Safety of duct-to-duct biliary reconstruction in right-lobe live-donor liver transplantation without biliary drainage.Transplantation. 2004; 77: 726-732Crossref PubMed Scopus (149) Google Scholar]. ABO incompatibility is a relative contraindication to DD liver transplantation, but faced with a shortage of both deceased donors and blood type compatible living donors, blood type incompatible LDLT has been attempted under sophisticated preoperative and postoperative patient management protocols [[31]Egawa H. Oike F. Buhler L. Shapiro A.M. Minamiguchi S. Haga H. et al.Impact of recipient age on outcome of ABO-incompatible living-donor liver transplantation.Transplantation. 2004; 77: 403-411Crossref PubMed Scopus (160) Google Scholar]. Among 66 reported cases, 21 patients less than 1 year of age had no significant problem, but 12 of the 45 adult patients developed biliary complications which were the major causes of deaths in 11 patients (24%). Longer follow-up is necessary to determine the efficacy of blood type incompatible adult LDLT. The clinical manifestations of biliary complications after liver transplantation vary considerably. Patients may have no symptoms or may present with fulminant biliary sepsis. Thus, any abnormal liver function test must be carefully followed, and, if it persists, the recipient needs to be thoroughly examined to identify whether the problem is related to technical errors (hepatic artery, portal vein, hepatic vein, and biliary tract), small-for-size graft syndrome, rejection, infection, or recurrence of the original liver disease. Cholangiography via external stent, T-tube, endoscopy or percutaneous approach is often necessary for a accurate biliary analysis. Although ultrasonography is less sensitive, it can convincingly identify bile duct dilation related to an anastomotic stricture. Additionally, Doppler ultrasonography may detect hepatic artery problems. Magnetic resonance cholangio pancreaticography (MRCP) and hepatobiliary iminodiacetic acid scan are occasionally employed when cholangiography through a T-tube, stent or endoscope is inadequate. Others may use MRCP as the first line of investigation. Causes and management of biliary complication are time-dependent. The majority of complications develop within a few days to 3 months as early complications. Bile leak at the cut surface is usually successfully managed by fine-needle aspiration and drainage, while an endoscopic nasal biliary drainage maneuver is usually successful for T-tube exit leakage, which formerly was treated by suture closure upon laparotomy. If anastomotic leakage is minor, endoscopic or percutaneous biliary stent placement is sometimes sufficient [32Hisatsune H. Yazumi S. Egawa H. Asada M. Hasegawa K. Kodama Y. et al.Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation.Transplantation. 2003; 76: 810-815Crossref PubMed Scopus (100) Google Scholar, 33Shah J.N. Ahmad N.A. Shetty K. Kochman M.L. Long W.B. Brensinger C.M. et al.Endoscopic management of biliary complications after adult living donor liver transplantation.Am J Gastroenterol. 2004; 99: 1291-1295Crossref PubMed Scopus (93) Google Scholar, 34Park J.S. Kim M.H. Lee S.K. Seo D.W. Lee S.S. Han J. et al.Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation.Gastrointest Endosc. 2003; 57: 78-85Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar]. Re-do of the biliary anastomosis, conversion from duct to duct to hepatico-jejunostomy anastomosis, or re-grafting of the liver is required when major leakage or bile duct necrosis has occurred. With regard to biliary stricture, the majority (80–90%) occurs at an anastomotic site. Percutaneous balloon dilation and stent placement or stents placed by endoscope with or without papillotomy are usually successful. In one report, of 19 recipients who developed stricture between 22 and 449 days after receiving the right hemiliver with duct to duct reconstruction, 14 (74%) were treated endoscopically with insertion of stents, three underwent anastomotic conversion, and two were followed conservatively [[32]Hisatsune H. Yazumi S. Egawa H. Asada M. Hasegawa K. Kodama Y. et al.Endoscopic management of biliary strictures after duct-to-duct biliary reconstruction in right-lobe living-donor liver transplantation.Transplantation. 2003; 76: 810-815Crossref PubMed Scopus (100) Google Scholar]. In contrast, management of late biliary complications is generally difficult and time-consuming. In particular, management of diffuse and multiple strictures of the bile duct is complex due to systemic, rather than a local nature of the cause. Early replacement of the liver graft is often warranted to avoid fatal outcome. Among 100 LDLT in Chicago [[35]Grewal H.P. Thistlewaite Jr, J.R. Loss G.E. Fisher J.S. Cronin D.C. Siegel C.T. et al.Complications in 100 living-liver donors.Ann Surg. 1998; 228: 214-219Crossref PubMed Scopus (169) Google Scholar], minor complications developed in 20% of donors, while 14% of patients encountered major complications, including five bile duct injuries and two cut edge bile leaks. Of the 1508 living donors of partial liver grafts at five Asian centers [[36]Lo C.M. Complications and long-term outcome of living liver donors: a survey of 1508 cases in five Asian centers.Transplantation. 2003; 75: S12-S15Crossref PubMed Google Scholar], 15.8% developed various complications, in which bile leakage was documented in 6.1%, and biliary stricture in 1.1%. Six patients (0.4%) required subsequent surgical repairs. According to a recent survey of 1852 donors in Japan [[37]Umeshita K. Fujiwara K. Kiyosawa K. Makuuchi M. Satomi S. Sugimachi K. et al.Operative morbidity of living liver donors in Japan.Lancet. 2003; 362: 687-690Abstract Full Text Full Text PDF PubMed Scopus (250) Google Scholar], there were 244 postoperative complications in 228 donors (12%). Biliary leaks and stricture accounted for 11% of the morbidity. Biliary complications occurred in 10% of patients after right hemiliver resections, compared to only 3.6% with the left hemiliver, and 1.9% with a bisegment II–III. Ten donors required re-operation for biliary complications.