Cholangiojejunostomy for multiple biliary ducts in living donor liver transplant

Fei Xiao, Li-Ying Sun, Lin Wei, Zhi-Gui Zeng, Wei Qu, Ying Liu, Hai-Ming Zhang, Zhi-Jun Zhu

Fei Xiao, Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China

Fei Xiao, Department of Organ Transplantation, Liao Cheng People's Hospital, Liaocheng 252000, Shandong Province, China

Li-Ying Sun, Zhi-Jun Zhu, Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing 100050, China

Li-Ying Sun, Zhi-Jun Zhu, Beijing Key Laboratory of Tolerance Induction and Organ Protection in Transplantation, Capital Medical University, Beijing 100050, China

Li-Ying Sun, Department of Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China

Lin Wei, Zhi-Gui Zeng, Wei Qu, Ying Liu, Hai-Ming Zhang, Zhi-Jun Zhu, Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Capital Medical University,Beijing 100050, China

Abstract BACKGROUND Laparoscopic living donor hepatectomy (LLDH) has been successfully carried out in several transplant centers. Biliary reconstruction is key in living donor liver transplantation (LDLT). Reliable biliary reconstruction can effectively prevent postoperative biliary stricture and leakage. Although preoperative magnetic resonance cholangiopancreatography and intraoperative indocyanine green cholangiography have been shown to be helpful in determining optimal division points, biliary variability and limitations associated with LLDH, multiple biliary tracts are often encountered during surgery, which inhibits biliary reconstruction.A reliable cholangiojejunostomy for multiple biliary ducts has been utilized in LDLT. This procedure provides a reference for multiple biliary reconstructions after LLDH.CASE SUMMARY A 2-year-old girl diagnosed with ornithine transcarbamylase deficiency required liver transplantation. Due to the scarcity of deceased donors, she was put on the waiting list for LDLT. Her father was a suitable donor; however, after a rigorous evaluation, preoperative magnetic resonance cholangiopancreatography examination of the donor indicated the possibility of multivessel variation in the biliary tract. Therefore, a laparoscopic left lateral section was performed on the donor, which met the estimated graft-to-recipient weight ratio. Under intraoperative indocyanine green cholangiography, 4 biliary tracts were confirmed in the graft. It was difficult to reform the intrahepatic bile ducts due to their openings of more than 5 mm. A reliable cholangiojejunostomy was,therefore, utilized: Suture of the jejunum to the adjacent liver was performed around the bile duct openings with 6/0 absorbable sutures. At the last follow-up(1 year after surgery), the patient was complication-free.CONCLUSION Intrahepatic cholangiojejunostomy is reliable for multiple biliary ducts after LLDH in LDLT.

Key Words: Cholangiojejunostomy; Living donor liver transplantation; Laparoscopic left lateral section; Multiple biliary ducts; Treatment; Case report

lNTRODUCTlON

Biliary anastomosis is key in living donor liver transplantation (LDLT), with biliary complications varying from 5% to 40%. Biliary leaks and strictures are common complications. According to research, biliary complication rates of up to 53.7%, with anastomotic strictures occupying 41.5% of the complications[1,2]were reported.Depending on laparoscopic surgical skills of resident surgeons, laparoscopic living donor hepatectomy (LLDH) has been performed in some transplant centers[3]. Due to biliary anatomic variations and laparoscopic surgical limitations[4], multiple hepatic duct orifices are often seen during surgery. A technical problem of bile duct reconstruction during LDLT, is caused by multiple biliary ducts that receive a poor blood supply from both donor and recipient[5]. The impact of various graft biliary orifices on biliary complications in the recipient have not been established[6]. The results of those receiving grafts with a single or paired bile ducts were compared in recent research. It was observed that living donor grafts with 2 biliary ducts are safe and have no negative influence on biliary complication rates after 1-year of followup[7]. At another center, multiple anastomoses were performed during surgery. At a median follow-up of 36 mo, the biliary complication rate was 16.9%, greater than that with one biliary duct[8]. This study describes cholangiojejunostomy for multiple biliary ducts during LDLT.

CASE PRESENTATION

Chief complaints

A 2-year-old girl was admitted to our center with complaints of hyperammonemia and lethargy for 4 mo.

History of present illness

For four months, the patient had experienced lethargy and intermittent abdominal pain. After seeing doctors in local hospitals, she was diagnosed with hyperammonemia. However, the disease could not be cured at local hospitals, therefore, she gradually developed liver failure.

History of past illness

The patient had no significant medical history and chronic diseases were denied.

Personal and family history

No significant personal and family medical history.

Physical examination

According to her physical examination, confusion, disorientation, and amnesia were noted. Muscular rigidity, nystagmus, overt hepatic encephalopathy and Grade III hepatic disease were also observed.

Laboratory examinations

Genetic testing revealed ornithine transcarbamylase deficiency (OTCD). Laboratory examinations upon admission revealed blood NH3 level of 153 µmol/L, alanine aminotransferase (83 U/L), albumin (24.9 g/L), total bilirubin (4.8 µmol/L), direct bilirubin (0.5 µmol/L) and creatinine (4.3 µmol/L). Her prothrombin time was 19.50 s compared to the normalized ratio of 1.52.

Imaging examinations

Abdominal ultrasonography and computed tomography were unremarkable.Magnetic resonance cholangiopancreatography (MRCP) examination of the donor indicated the possibility of multivessel variation in the biliary tract (Figure 1).

FINAL DIAGNOSIS

Based on the above findings, OTCD was diagnosed.

TREATMENT

OTCD is a metabolic disease, protein diet restriction and medications that stimulate the removal of nitrogen from the body may prevent progression of the disease.Unfortunately, these measures cannot prevent the emergence of hyperammonemia and metabolic encephalopathy; thus, liver transplantation is indicated. Due to the scarcity of deceased donors, we proposed a laparoscopic left lateral sectionectomy in donors for liver transplantation among children. The liver graft includes the left lateral section (segments 2 and 3 based on Couinaud's classification), left branch of the hepatic artery and left portal branch, left bile duct, and left hepatic vein. Preoperative MRCP evaluation of donor biliary anatomy indicated bile duct variations (Figure 1).Intraoperative indocyanine green near-infrared fluorescence cholangiography was routinely performed (Figure 2A), and 4 biliary tracts were confirmed in the graft(Figure 2B), which inhibited bile duct reconstruction. The intrahepatic bile ducts cannot be joined because the gap between the two openings was too large. Suture of the jejunum to the nearby liver was performed around the bile duct opening with 6/0 absorbable sutures (Figure 2C). Surgical procedures were successfully completed after 6 h.

Figure 1 Preoperative magnetic resonance cholangiopancreatography evaluation of donor biliary anatomy indicated bile duct variations.

Figure 2 Fluorescence cholangiography. A: Intraoperative indocyanine green near-infrared fluorescence cholangiography was routinely performed; B: 4 biliary tracts were confirmed in the graft which inhibited bile duct reconstruction; C: The intrahepatic bile ducts cannot be joined as the gap between the two openings was too large. Suture of the jejunum to the nearby liver was performed around the bile duct opening with 6/0 absorbable sutures.

OUTCOME AND FOLLOW-UP

Ten days after surgery, the levels of serum total bilirubin, direct bilirubin, and alkaline phosphatase were close to normal. The absence of bile leakage within 1 wk necessitated the removal of the abdominal drainage tube and antibiotic prophylaxis(Sulbactam and Cefoperazone) was used 8 d after surgery. One year after surgery,there was no anastomotic stricture or cholangitis.

DISCUSSION

Cherquiet al[9]indicated the feasibility of laparoscopic left lateral sectionectomy in pediatric LDLT. The laparoscopic approach can be used as normal practice for harvesting left lateral lobe liver grafts[10]. A meta-analysis revealed that LLDH is a secure and efficient option for LDLT, which enhances the donors' perioperative results compared with open living donor hepatectomy[11]. However, this technique is hampered by bile duct complications, especially in LLDH. Multiple factors lead to bile duct complications. One of the most important reasons is that LLDH can cause multiple bile ducts, which are a problem for the cholangiojejunostomy. Common biliary complications include stricture, leakage, obstruction, and stone formation. Dekaet al[12]revealed that the length of the left hepatic duct varied from 1.2 mm to 30.36 mm with a median value of 6.83 mm, which shows that the length of the left hepatic duct in half of the patients varied from 1.2 mm to 6.83 mm. Moreover, preoperative MRCP and direct intraoperative vision decides the division of the bile duct. However, it is not sufficient to determine the optimal cut-off point by these procedures as it is difficult to identify the left hepatic duct by direct vision and real-time positioning is impossible by preoperative MRCP. Hence, the surgeon may inadvertently cut too much to the left, to ensure that there is sufficient safety distance on the donor side, and sacrifice part of the length of the bile duct using Hemlok to cut the bile duct, leading to multiple orifices in the graft side.

Four bile ducts were found during surgery, thereby, making the duct-to-duct bile duct reconstruction impossible. Therefore, hepaticojejunostomy was considered.However, it is difficult to reconstruct the biliary tract with multiple orifice anastomoses, and the incidence of biliary stenosis and bile leakage are higher than normal[13]. The pelvic anastomosis of multiple bile ducts adjacent to the hepatic duct stump, can effectively solve the problem of postoperative anastomotic stenosis.However, complications such as bile leakage are higher. Adjacent bile ducts subjected to plastic surgery have changed the physiological direction of the bile duct. The portal vein is compressed by biliary dilatation within the confines of the Glisson sheath,which leads to portal hypertension and persistent cholestasis, and increases the risk of cholangitis and septic events in the postoperative period. We used a “Plug-in”technique for bile duct anastomosis. Suture of the jejunum to the nearby liver was performed around the bile duct openings with intermittent 6/0 absorbable sutures.The jejunum was anastomosed with the liver tissue around the bile duct, and multiple bile duct openings were embedded in the jejunum. During the procedure, the anterior wall of the jejunum should be sutured as close as possible to the liver tissue above the anterior wall of the bile duct, in order to improve the migration of the jejunal mucosa through the liver section to the bile duct. To ensure suturing of the anastomosis, it is necessary to determine the position of each needle, especially during posterior wall anastomosis, to prevent the suture needle from penetrating the portal vein.Intermittent suture of the front wall of the anastomosis requires the inversion of the intestinal mucosa into the anastomosis, which is one of the important measures for preventing biliary leakage. Another key operation in the anastomosis is that the stitch length of the anastomotic suture and the tension of the knot is uniform. The needle can be inserted deeper when suturing, and the knot should not be too tight to prevent splitting the liver tissue. During the anastomosis, suture, traction and ligation should be gentle to avoid tearing the jejunum.

CONCLUSION

Laparoscopic living donor hepatectomy can be used in living donor liver transplantation but can lead to an increase in the number of bile ducts. The “Plug-in”cholangiojejunostomy for multiple biliary ducts is a reliable anastomosis technique.