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Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation

Abstract

Background

One of the major issues related to the living donor liver transplantation recipient outcome is still the high rate of biliary complication, especially when multiple biliary ducts are present and multiple anastomoses have to be performed.

Case presentation and conclusion

We report a case of adult-to-adult right lobe living donor liver transplantation performed for a recipient affected by alcohol-related cirrhosis with MELD score of 17. End-stage liver disease was complicated by refractory ascites, portal hypertension, small esophageal varices and portal gastropathy, hypersplenism, and abundant right pleural effusion. Here in the attached video we described the adult-to-adult LDLT procedures, where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. LDLT required a biliary reconstruction using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic catheter. None major complications were detected during post-operative clinical courses. Actually, the donor and the recipient are alive and well. The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure. No living donor right lobe transplantation should be refused because of the presence of multiple biliary ducts.

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Background

Living donor liver transplantation (LDLT) is a useful tool to increase the donor pool, and this is particularly important in area of the word where deceased donor rate is low [1, 2].

One of the major issues related to the recipient outcome is still the high rate of biliary complication, which has been reported being present in one third up to 40% of the cases [3, 4].

Especially when multiple biliary ducts are present and multiple anastomoses have to be performed, the rate of donor turned down and the rate of biliary complications in the recipient are augmented [5, 6].

Ideally, duct-to-duct anastomoses should be preferred to a hepatico-jejunostomy [7] because of the more physiologic preservation of the bilio-enteric continuity, the faster and more simple surgical technique and the possibility to treat endoscopically complications after surgery [8].

In this setting the idea to use the cystic duct together with the right duct or the common hepatic duct has been used in right lobe living donor transplantation since many years [9] and many techniques have been reported [10].

Here in this video (Additional file 1: Video) we describe a case of adult-to-adult LDLT where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. Biliary reconstruction had been performed using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic stents where multiple holes in both sides were shaped and both stents were not secured by sutures.

Case presentation

We report a 66-year-old male with well-controlled type 2 diabetes and a single previous episode of transient ischemic attack, who had been diagnosed with Child’s B9 liver cirrhosis secondary to alcoholic abuse. His Model of End-stage Liver Disease (MELD) score was 17, and clinical condition was complicated by episodes of refractory ascites, portal hypertension recanalization of the umbilical vein associated with venous ectasias in the context of the rectus abdominis and with caput medusae, small esophageal varices, hypersplenism, and abundant right pleural effusion. For persistent ascites refractory to diuretic therapy, with necessity of several evacuative paracentesis, and difficult management of diuretic therapy for secondary renal insufficiency, he underwent to transjugular porto-systemic shunt (TIPS) placement on November 19, 2019. According to the Italian system of allocation, this value is the minimum score required to be transplanted [11], he was listed in our Center for an elective LDLT on July 21, 2020.

His 31 year-old son decided to be evaluated and, considering the proper donor/recipient match, he was listed as right hepatic lobe live donor. Donor and recipient’s pre-operative live donation parameters are shown in Table 1. We have proceeded with LDLT surgery on September 22, 2020. The live donor surgical procedure consisted of an open right hepatectomy (Couinaud segment 5-8) and the recipient surgery was a liver transplant performed with the piggyback technique and total veno-venous bypass. Imaging evaluation and surgical maneuvers concerning the techniques adopted are reported in the attached video. We performed a double biliary anastomosis (two ducts in the right hepatic graft) the first between the cystic duct of the recipient duct for the posterior segments with 6-0 polydioxanone protected by a 6 Fr sylastic stent, and the second anastomosis between the choledochus and the bile duct for the anterior segments with 6-0 polydioxanone protected by an 8 Fr sylastic stent. The diameter of the graft bile ducts was respectively 5 and 7 mm. The total ischemic time of the graft was 120 min.

Table 1 Pre-transplantation anthropometric, biochemical, and volumetric data of the donor and the recipient are reported

Both donor and recipient surgical procedure were uneventful; the donor was discharged to home on post-operative day 9 without any complaints. Although the recipient’s hospital course was complicated by right pleural effusion, which was treated with percutaneous trans-thoracic drainage, no major complications developed in the recipient and he was discharged home in good clinical condition after 3 weeks.

Discussion and conclusion

Biliary leak and biliary stricture are still a major concern after LDLT [12], however biliary complications seem do not worsen the overall survival after transplant which is otherwise impacted by other factor such as correct liver volume match, portal flow modulation and clinical nutritional status of the recipient [13].

Multiple biliary ducts draining the right lobe, nowadays detected in details by pre-operative magnetic resonance cholangiopancreatography (MRCP) have been considered an additional risk of serious complications in LDLT [14]. However, the presence of more than one duct should not contraindicate the use of a living donor right lobe graft [15].

Surgical expertise in this filed has now reached a level of evidence which permits a safe use of graft with biliary variants [16].

The duct-to-duct biliary reconstruction has shown to be associated with more biliary stricture when compared with hepatico-jejunstomy but less biliary leak and overall seems to be the preferred method of biliary restoration in LDLT [17,18,19]. Mucosa to mucosa approximation with fine absorbable suture, with or without stenting according to the surgeon’s discretion have been historically reported [20]. Moreover, much debate exists regarding the use of trans-anastomotic stents as well as the length of time the stent should be left in place [21,22,23]. In this scenario, the analysis of the literature recommend a selective approach to stent placement based on the diameter and the number of the ducts to be anastomosed [5].

In our experience regardless the health of the tissues we now routinely use stents in LDLT, and lately, as described in this video, our technique shifted towards the use of a 6 cm long, soft 5 French silastic stent left into the duodenum through the papilla. The patients usually eliminate spontaneously those stents within 6 weeks from surgery. If cholangitis would appear the endoscopic treatment may be performed and the stent removed [24,25,26,27,28].

At this regard we should also take in consideration the possibility to use the new generation absorbable stent developed recently which can be placed through endoscopic or surgical approach [29,30,31].

The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

LDLT:

Living donor liver transplantation

MELD:

Model of End-stage Liver Disease

TIPSS:

Transjugular Intrahepatic Portal-Systemic Shunt

MRCP:

Magnetic resonance cholangiopancreatography

References

  1. 1.

    Gruttadauria S, di Francesco F, Vizzini GB, Luca A, Spada M, Cintorino D, Petri SL, Pietrosi G, Pagano D, Gridelli B. Early graft dysfunction following adult-to-adult living-related liver transplantation: predictive factors and outcomes. World J Gastroenterol. 2009;15(36):4556–60. https://doi.org/10.3748/wjg.15.4556.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Bhangui P, Saha S. The high-end range of biliary reconstruction in living donor liver transplant. Curr Opin Organ Transplant. 2019;24(5):623–30. https://doi.org/10.1097/MOT.0000000000000693.

    Article  PubMed  Google Scholar 

  3. 3.

    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(3):121–5. https://doi.org/10.1111/ans.13827.

    Article  PubMed  Google Scholar 

  4. 4.

    Lin TS, Co JS, Chen CL, Ong AD. Optimizing biliary outcomes in living donor liver transplantation: evolution towards standardization in a high-volume center. Hepatobiliary Pancreat Dis Int. 2020;19(4):324–7. https://doi.org/10.1016/j.hbpd.2020.06.012.

    Article  PubMed  Google Scholar 

  5. 5.

    Gruttadauria S, Doria C, Cintorino D, Singhal D, Verzaro R, Foglieni CS, Marino IR, Fung JJ. Outcomes in 139 cases of biliary tract reconstructions from a transplant surgery center. Exp Clin Transplant. 2003;1(2):73–8.

    PubMed  Google Scholar 

  6. 6.

    Arikan T, Emek E, Bozkurt B, Mammadov E, Ceyhan O, Sahin T, Dibekoglu C, Serin A, Aydin U, Tokat Y. Does multiple bile duct anastomosis in living donor liver transplantation affect the postoperative biliary complications? Transplant Proc. 2019;51(7):2473–7. https://doi.org/10.1016/j.transproceed.2019.01.160.

    Article  PubMed  Google Scholar 

  7. 7.

    You MS, Paik WH, Choi YH, Shin BS, Lee SH, Ryu JK, Kim YT, Suh KS, Lee KW, Yi NJ, Hong SK. Optimal biliary drainage for patients with biliary anastomotic strictures after right lobe living donor liver transplantation. Liver Transpl. 2019;25(8):1209–19. https://doi.org/10.1002/lt.25472.

    Article  PubMed  Google Scholar 

  8. 8.

    Sato T, Kogure H, Nakai Y, Hamada T, Takahara N, Mizuno S, Kawaguchi Y, Akamatsu N, Kaneko J, Hasegawa K, Tada M, Tsujino T, Isayama H, Koike K. Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation. Liver Int. 2019;39(10):1954–63. https://doi.org/10.1111/liv.14219.

    Article  PubMed  Google Scholar 

  9. 9.

    Suh KS, Choi SH, Yi NJ, Kwon CH, Lee KU. Biliary reconstruction using the cystic duct in right lobe living donor liver transplantation. J Am Coll Surg. 2004;199(4):661–4. https://doi.org/10.1016/j.jamcollsurg.2004.05.278.

    Article  PubMed  Google Scholar 

  10. 10.

    Asonuma K, Okajima H, Ueno M, Takeichi T, Zeledon Ramirez ME, Inomata Y. Feasibility of using the cystic duct for biliary reconstruction in right-lobe living donor liver transplantation. Liver Transpl. 2005;11(11):1431–4. https://doi.org/10.1002/lt.20496.

    Article  PubMed  Google Scholar 

  11. 11.

    Gruttadauria S, Pagano D, di Francesco F, Foglio A, Cammà C, Di Marco V, Petridis I, Cintorino D. Adult to adult living donor liver transplantation in recipients with Low MELD: a strategy intended to overcome donor shortage. Dig Dis Sci. 2020. https://doi.org/10.1007/s10620-020-06522-w.

    Article  PubMed  Google Scholar 

  12. 12.

    Jung DH, Ikegami T, Balci D, Bhangui P. Biliary reconstruction and complications in living donor liver transplantation. Int J Surg. 2020;82S:138–44. https://doi.org/10.1016/j.ijsu.2020.04.069.

    Article  PubMed  Google Scholar 

  13. 13.

    Gruttadauria S, Pagano D, Liotta R, Tropea A, Tuzzolino F, Marrone G, Mamone G, Marsh JW, Miraglia R, Luca A, Vizzini G, Gridelli BG. Liver volume restoration and hepatic microarchitecture in small-for-size syndrome. Ann Transplant. 2015;20:381–9. https://doi.org/10.12659/AOT.894082.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Kollmann D, Goldaracena N, Sapisochin G, Linares I, Selzner N, Hansen BE, Bhat M, Cattral MS, Greig PD, Lilly L, McGilvray ID, Ghanekar A, Grant DR, Selzner M. 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(11):1512–22. https://doi.org/10.1002/lt.25197.

    Article  PubMed  Google Scholar 

  15. 15.

    Pagano D, Cintorino D, Li Petri S, Paci M, Tropea A, Ricotta C, Bonsignore P, Saffioti MC, Spada M, Miraglia R, Gridelli BG, Gruttadauria S. Intra-operative contrast cholangiography in living donor liver transplantation: the ISMETT experience. Transplant Proc. 2015;47(7):2159–60. https://doi.org/10.1016/j.transproceed.2014.11.069.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Tang W, Qiu JG, Cai Y, Cheng L, Du CY. increased surgical complications but improved overall survival with adult living donor compared to deceased donor liver transplantation: a systematic review and meta-analysis. Biomed Res Int. 2020. https://doi.org/10.1155/2020/1320830.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Colquhoun SD. The realities of liver transplantation and biliary anastomosis-heroes, heroics, heels, and healing. JAMA Surg. 2019;154(5):440. https://doi.org/10.1001/jamasurg.2018.5538.

    Article  PubMed  Google Scholar 

  18. 18.

    Kaldas FM, Korayem IM, Russell TA, Agopian VG, Aziz A, DiNorcia J, Farmer DG, Yersiz H, Hiatt JR, Busuttil RW. Assessment of anastomotic biliary complications in adult patients undergoing high-acuity liver transplant. JAMA Surg. 2019;154(5):431–9. https://doi.org/10.1001/jamasurg.2018.5527.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Pamecha V, Sasturkar SV, Sinha PK, Mohapatra N, Patil N. Biliary reconstruction in adult living donor liver transplantation: the all-knots-outside technique. Liver Transpl. 2020. https://doi.org/10.1002/lt.25862.

    Article  PubMed  Google Scholar 

  20. 20.

    Mercado MA, Chan C, Orozco H, Cano-Gutiérrez G, Chaparro JM, Galindo E, Vilatobá M, Samaniego-Arvizu G. To stent or not to stent bilioenteric anastomosis after iatrogenic injury: a dilemma not answered? Arch Surg. 2002;137(1):60–3. https://doi.org/10.1001/archsurg.137.1.60.

    Article  PubMed  Google Scholar 

  21. 21.

    Cameron JL, Skinner DB, Zuidema GD. Long term transhepatic intubation for hilar hepatic duct strictures. Ann Surg. 1976;183(5):488–95. https://doi.org/10.1097/00000658-197605000-00005.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Cameron JL, Gayler BW, Zuidema GD. The use of silastic transhepatic stents in benign and malignant biliary strictures. Ann Surg. 1978;188(4):552–61. https://doi.org/10.1097/00000658-197810000-00012.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Jarnagin WR, Blumgart LH. Operative repair of bile duct injuries involving the hepatic duct confluence. Arch Surg. 1999;134(7):769–75. https://doi.org/10.1001/archsurg.134.7.769.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Gruttadauria S, Vasta F, Minervini MI, Piazza T, Arcadipane A, Marcos A, Gridelli B. Significance of the effective remnant liver volume in major hepatectomies. Am Surg. 2005;71(3):235–40.

    Article  Google Scholar 

  25. 25.

    Maruzzelli L, Miraglia R, Caruso S, Milazzo M, Mamone G, Gruttadauria S, Spada M, Luca A, Gridelli B. Percutaneous endovascular treatment of hepatic artery stenosis in adult and pediatric patients after liver transplantation. Cardiovasc Intervent Radiol. 2010;33(6):1111–9. https://doi.org/10.1007/s00270-010-9848-4.

    Article  PubMed  Google Scholar 

  26. 26.

    Marrone G, Crino’ F, Caruso S, Mamone G, Carollo V, Milazzo M, Gruttadauria S, Luca A, Gridelli B. Multidisciplinary imaging of liver hydatidosis. World J Gastroenterol. 2012;18(13):1438–47. https://doi.org/10.3748/wjg.v18.i13.1438.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Gruttadauria S, Saint Georges Chaumet M, Pagano D, Marsh JW, Bartoccelli C, Cintorino D, Arcadipane A, Vizzini G, Spada M, Gridelli B. Impact of blood transfusion on early outcome of liver resection for colorectal hepatic metastases. J Surg Oncol. 2011;103(2):140–7. https://doi.org/10.1002/jso.21796.

    Article  PubMed  Google Scholar 

  28. 28.

    Gruttadauria S, Pagano D, Petridis I, Vizzini G, Volpes R, Grossi PA, Gridelli B. Hepatitis C virus infection in a living-related liver donor. Am J Transplant. 2010;10(1):191. https://doi.org/10.1111/j.1600-6143.2009.02874.x.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Janousek L, Maly S, Oliverius M, Kocik M, Kucera M, Fronek J. Bile duct anastomosis supplied with biodegradable stent in liver transplantation: the initial experience. Transplant Proc. 2016;48(10):3312–6. https://doi.org/10.1016/j.transproceed.2016.09.039.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Girard E, Chagnon G, Broisat A, Dejean S, Soubies A, Gil H, Sharkawi T, Boucher F, Roth GS, Trilling B, Nottelet B. From in vitro evaluation to human postmortem pre-validation of a radiopaque and resorbable internal biliary stent for liver transplantation applications. Acta Biomater. 2020;106:70–81. https://doi.org/10.1016/j.actbio.2020.01.043.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Girard E, Chagnon G, Moreau-Gaudry A, Letoublon C, Favier D, Dejean S, Trilling B, Nottelet B. Evaluation of a biodegradable PLA-PEG-PLA internal biliary stent for liver transplantation: in vitro degradation and mechanical properties. J Biomed Mater Res B Appl Biomater. 2020. https://doi.org/10.1002/jbm.b.34709.

    Article  PubMed  Google Scholar 

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Funding

No funding was required nor obtained for this case report.

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Affiliations

Authors

Contributions

SG, SC, SLP, DC, and FDF were the involved in the liver transplant. SG, AT, DP, SC, SLP, PB, CR, and DC were surgeons who cared for the patient in the post-operative setting and followed up on the patient upon discharge. SG obtained informed consent from the patient for the publication and wrote the first draft of the case report. SG and DP edited the manuscript. SG, AT, and FDF edited the video. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Salvatore Gruttadauria.

Ethics declarations

Ethics approval and consent to participate

The research has been performed in accordance with the Declaration of Helsinki. The name of the ethics committee that approved the study is sectional Ethical Committee IRCCS ISMETT, and the committee’s reference number is: IRRB/42/16. Informed consents were obtained from the patients to use them medical records for research and publication, and attached as Related Files.

Consent for publication.

Written consent was obtained from the patient and institution.

Competing interests

The authors declare no competing interests.

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Supplementary Information

Additional file 1: Video.

Imaging evaluation and surgical maneuvers.

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Gruttadauria, S., Tropea, A., Pagano, D. et al. Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation. BMC Surg 21, 44 (2021). https://doi.org/10.1186/s12893-020-01045-7

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Keywords

  • Liver transplantation
  • Living donor liver transplantation
  • Biliary anastomoses
  • Cystic duct