How I Do It

Dig Surg 1999;16:102106

Received: August 27, 1997 Accepted: August 29, 1997

The Bile Duct Anastomosis in Liver Transplantation

Ch.A. Seiler
Department of Visceral and Transplantation Surgery, Bern, Switzerland

Key Words Liver transplantation W Bile duct anastomosis W Complications W Surgical techniques W Biliary structure W Biliary leak

Abstract In spite of the dramatic improvement of survival after orthotopic liver transplantation over the last decades, biliary tract complications are still the achilles heal of liver transplantation with a potential risk of significant morbidity and mortality. Biliary leaks or strictures, the major types of biliary complications, may occur after direct choledocho-choledochostomy (CC) or Roux-Y choledocho-jejunostomy (CRY). The majority of these biliary complications, however, are often a consequence of surgical technique and therefore potentially amenable to improved surgical technique.

Introduction

the old techniques of biliary reconstruction after OLT, namely cholecysto-jejunostomy and cholecysto-duodenostomy, which had proven to be a burden with increased morbidity, are no longer performed. Although the current results of biliary complications still remains high and still reaches a rate of up to 25% [2], the Pittsburg group achieved a reduction of biliary complications from 19% in 1983 down to 13% in 1987 and 11.5% in 1994 in their series of over 1,792 hepatic transplantations [3]. Post-OLT biliary complications may be caused by occult hepatic artery thrombosis, extended cold ischemia time (1 12 h) of the graft or other injuries to the biliary epithelium resulting in intrahepatic stricture formation such as chronic rejection. However, the majority of the reasons for biliary complications are still related to the surgical technique [15]. Biliary reconstruction during liver transplantation today is generally performed by endto-end, sometimes side-to-side [6] choledocho-choledochostomy (CC) or Roux-Y choledocho-jejunostomy (CRY). The method of choice in patients with healthy native bile ducts of suitable caliber is the CC while CRY is preferred in cases of preexisting biliary tract disease or previous biliary tract surgery.

A dramatic increase of survival after orthotopic liver transplantation (OLT) over the last decades has been achieved due to advances in organ preservation, immunosuppressive agents and refinement of surgical techniques; however, complications with substantial morbidity and mortality still occur. Biliary tract complications are for good reasons called the Achilles heel of liver transplantation as they considerably impair results [1]. Consequently

Presentation and Timing of Biliary Complications after Liver Transplantation

The onset of biliary complications after liver transplantation according to the large Pittsburg series is between a few days postoperatively up to as late as 7 years

ABC
Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com

1999 S. Karger AG, Basel 02534886/99/01620102$17.50/0 Accessible online at: http://BioMedNet.com/karger

Ch.A. Seiler, MD, FACS Department of Visceral and Transplantation Surgery University of Bern, Inselspital CH3010 Bern (Switzerland) Tel. +41 31 632 24 04, Fax +41 31 632 97 23

post-OLT. Biliary complications, however, occur predominantly early postoperatively. More than 38% of those complications happen during the first 30 days after surgery and 66% of biliary complications appear within the first 3 months. In general, leaks occur within the first weeks after transplantation, whereas strictures develop later. Biliary leaks presenting later than the first month are almost invariably associated with T-tube complications [3]. These T-tube-related complications lead some authors even to omit T-tubes after liver transplantation [4]. Biliary strictures and biliary leaks represent 70% of all biliary complications after liver transplantation, regardless of whether the reconstruction was a CC or a CRY [3, 5]. In 87% of the cases the biliary obstruction is located at the site of the anastomosis. About half of all leaks are located at the anastomosis, followed by leaks at the T-tube outlet (18%). In addition, leaks may appear at aberrant bile ducts and may be even a consequence of hepatic artery thrombosis (17%) [3]. Analyzing this data makes it clear that almost all biliary complications after OLT are somehow related to the biliary anastomosis. First of all this means to us that we are talking about a surgically induced, respectively iatrogenic injury to the biliary system. Comparing the two common types of surgical reconstruction of the biliary system, CC or CRY, we find in regards of leakage rate no difference in the incidence of leaks (27.1 vs. 25.9%). However, there is a tendency of strictures to occur more often in the Roux-Y reconstruction (CRY) (36.4 vs. 52.9%). Seventy-six percent of all biliary tract-related deaths are associated with biliary leaks! The incidence of biliary leaks is interestingly nearly equal in both techniques (CC vs. CRY), however leaksrelated mortality is increased in patients with a primary CRY (54% in CRY vs. 8% in CC). This is not surprising since a leak after CRY is in fact associated with a disruption of a gastrointestinal anastomosis. So, biliary complications do not only harbor a variety of mostly surgicallyinduced morbidities, but they bear a substantial risk of death following biliary reconstruction after OLT as well. The mortality rate in patients suffering from biliary complications is still 10%, however early reconstruction of biliary complications and prompt therapy can effectively prevent long-term sequelae [7]. The majority of post-OLT biliary leaks and strictures can successfully be treated nonoperatively with interventional endoscopic or radiological techniques [8, 9]. The goal of every transplant surgeon however is the reduction and prevention of the incidence of biliary complications after OLT which is most effectively achieved by good surgical technique.

Biliary Complications and Their Relation to Surgical Technique

The incidence of biliary complications with 11.525% is stil substantial. Main symptoms are either leaks of which 66% occur within the first 3 months post-OLT while strictures generally occur later. In the majority of the cases, leaks and strictures do occur at the site of surgery and are most probably the mirror of surgical injury during reconstruction. Late biliary complications are predominantly due to leaks located at the outlet of the Ttube, requiring an improved technique in cases where Ttubes still are used. CC compared to CRY shows an analogous incidence of leaks while the rate of strictures is higher in CRY which is in fact a biliary enteric anastomosis, reflected in the increased incidence of death after primary choledocho-jejunostomy. In summary, most of these different biliary complications are somehow related to surgery and therefore will be potentially amenable to improved surgical technique.

Surgical Technique
Bile Duct Anastomosis In addition to the recipient condition, donor organ quality, adequate organ preservation and ischemia time, it is as mentioned the surgical technique of the bile duct anastomosis which is of utmost importance in order to minimize bile duct complications after orthotopic liver transplantation. Surgery of the bile duct in liver transplantation starts already at the donor operation, where it is important to preserve as much length of the bile duct as possible without denudation or injury of the bile duct on its whole length. No ligature is used to close the bile duct of the recipient side. During the backtable preparation, the no-touch technique, in order to protect the bile duct, is continued and the bile duct is not dissected at all. The backtable perfusion of the bile duct with perfusion solution is performed as cautiously as possible. The same careful technique is used during the recipient hepatectomy where the bile duct is maintained as long as possible and cut off close to or above the bifurcation without major dissection of the recipients ligament. This preservation of length of the bile ducts of the recipient and the donor gives maximal length and the possibility to shorten the bile ducts on both ends (!) during OLT when needed. Routinely both ends are shortened during the anastomosis in order to anastomose optimally perfused, unmanipulated bile ducts. The bile duct anastomosis in liver transplantation is commonly performed after reperfusion of the liver and thus the patient is at that time in a maximally vasodilated (hyperdynamic) circulatory status. This is reflected by a significant bleeding through the three- and nine oclock vessels of both (recipient and donor) bile ducts. No evident bleeding is a bad sign and the bile duct should then be shortened. Maximal attention is given at that time not to touch the bile duct with the cautery (which is never used in the vicinity of the bile duct). The three- and nine oclock vessels of the bile duct are tied

The Bile Duct Anastomosis in Liver Transplantation

Dig Surg 1999;16:102106

103

2
Fig. 1. The three and nine oclock vessels of both bile ducts are tied with 7.0 PDS stitches just at the bleeding, respectively resection site. Fig. 2. T-drain preparation before insertion: special attention is given to cut off triangles at the bile duct site of the T-drain (arrow). Fig. 3. The T-drain exit is closed with PDS 6.0 stitches on both ends in order to close the bile duct watertight. Care is taken to only sew the bile duct without stenosing it. Fig. 4. The bile duct anastomosis is started at six oclock and the thread is tied in its middle. Fig. 5. The anastomosis is completed with sewing the three oclock circumference and the nine oclock circumference with a running suture tying both ends of the thread together at twelve oclock.

104

Dig Surg 1999;16:102106

Seiler

Fig. 6. Intraoperative demonstration: the three oclock circumference is completed and the nine oclock circumference is just ready to start with (large arrows). The hepatic artery (small arrows) and the portal vein anastomosis (arrowheads) are demonstrated.

Fig. 7. The completed bile duct anastomosis (arrows).

with 7.0 PDS stitches just at the bleeding, respectively resection site and attention is given not to tie any bile duct tissue (fig. 1). We prefer to use a very small Charrire No. 4 T-drain in order not to have any biliary leak at the time of T-drain removal. The T-drain is cut in the fashion shown in figure 2. Special attention is given to cut off triangles at the bile duct site (arrow) of the T-drain in order to prevent injury at the time of the T-drain removal when the two biliary branches of the T-drain are folded together during the maneuver of removal. Our indication for a T-drain is not really the stenting of the anastomosis (which is not possible with this miniature size T-drain) but to have a diagnostic access to the biliary tree. An Overhold clamp is then inserted approximately 1 cm into the recipientss bile duct. With a pointed knife (No. 11 blade) a small incision is performed through the bile duct towards the tip of the Overhold clamp. Attention is given not to injure the nine oclock or

three oclock vessels of the bile duct. That is why the T-drain exit is performed at about eleven oclock. The prepared T-drain is now inserted through this small bile duct incision and care is taken to have one branch of the T-drain going down the recipient bile duct, the other branch going up the recipient bile duct, extending the length of the future bile duct anastomosis. The T-drain exit is now closed with PDS 6.0 stitches on both ends in order to close the bile duct water tight and care is taken not to sew the periductal tissue but only the bile duct itself without stenosing the bile duct at this place. Finally the T-tube can be fixed with one end of these closing stitches (fig. 3). End-to-end CC is now performed with a 6.0 PDS with needles on both ends. After a final control of good perfusion of both ends of the bile duct, as well as of the potential tension-free adaptation of both ends, the anastomosis is started at six oclock of the circumference and both ducts are first dorsally adapted and the thread is tied in its

The Bile Duct Anastomosis in Liver Transplantation

Dig Surg 1999;16:102106

105

middle (fig. 4). The anastomosis is now completed in sewing the three oclock circumferencee in a running suture technique. The nine oclock circumference is then performed in the same technique, tying both ends of threads together at twelve oclock. Much attention is given to achieve a perfect mucosa-to-mucosa approach in order to attain a fast sealing of the anastomosis (fig. 57). The anastomosis and the T-drain exit location are now tested for patency with a rapid infusion of 20 ml of saline into the T-drain, which makes leaks easy to identify. In the rare cases where there is an important discrepancy in diameter of the bile duct from the recipients to the donor bile duct, the smaller diameter bile duct can be approximated to the larger bile duct diameter in cutting the smaller bile duct obliquely with its shortest, respectively longest ends at twelve- and six oclock respectively. In doing this kind of reconstruction, even more attention must be given with respect to the perfusion of the bile duct and especially to the tension freeness of the repair. Usually the mild kinking of the anastomosis through this kind of oblique anastomosis is harmless. During the first postoperative days the T-drain is now left open and drains over a one-way bacterial filter into a disposable bag where the quality of bile (not the amount) can be assessed and clinically judged. After a routine cholangiography on the fifth postoperative day the T-drain is closed and then rinsed with 2 ml of saline everyday by the patient until the T-drain is removed 3 months postoperatively, when the patient is weaned off from steroids. After a control cholangiography the T-drain is removed and the patient is observed for several hours and then discharged. In case of a biliary leak (which should be very rare due to the fact that the T-drain is so tiny and wound healing should have meanwhile built a track around the T-drain) the patient is given antibiotics and is stationary observed as long as there are symptoms of pain or infection. In cases where an underlying disease or the impossibility of anatomical adaptation of the bile duct exist, a Roux-Y reconstruction is indicated. We like to use whenever possible a 70-cm long Roux-Y loop in order to achieve a minimal incidence of (bowel contents related) ascending cholangitis in these immunosuppressed patients. Further care is taken to leave only a very short blind end after the endto-side CRY in order to prevent sump syndrome in the blind end.

After having performed a small hole into the small bowel antimesenterically, including adaptation of the mucosa with some 7.0 stitches, the end-to-side CRY is performed with 6.0 PDS in a single-layer, single-stitch technique following the Blumgart-Kelly technique [10]. No drain or stents are used with this kind of biliary reconstruction.

Results

Though the first liver transplant in Bern was performed in 1983 (which was also the first liver transplantation in Switzerland) our program is rather small compared with some international centers [11]. Between 1991 and 1996, 62 liver transplants in 60 patients have been performed (2 retransplantations). During this more than 5-year period a uniform surgical technique was performed and there was no major change in regard to the immunosuppressive or postoperative treatment. In 93% of the patients an end-to-end CC with the Charrire 4 T-drain was performed and in only 4 patients a CRY anastomosis was indicated. The incidence of biliary complications after a median follow-up of 30 (066) months was 6.5%. There were one leak and three strictures, two of them could be treated conservatively with ERCP and stent placement and two (one leak, one stricture) needed surgical intervention. Both treatment modalities could definitively correct the biliary complication. None of the deaths (overall survival 83%, or 92% in benign disease and elective cases after a mean follow-up of 30 months) died from biliary or biliary-related complications. Of 60 patients there was only 1 who had to stay in the hospital for 3 days after removal of the T-drain because eof chemical peritonitis due to a minor short-term bile leak.

References
1 Colonna JO, Shaked A, Gomes AS, Colquhoun S, Jurim O, McDiarmid S, Millis JM, Goldstein LI, Busuttil RW: Biliary strictures complicating liver transplantation. Ann Surg 1992; 216:344352. 2 Kuo PC, Lewis WD, Stokes K, Pleskow D, Simpson MA, Jenkins RL: A comparison of operation, endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation. J Am Coll Surg 1994;179:177181. 3 Greif F, Bronsther OL, Van Thiel DH, Casavilla A, Iwatsuki S, Tzakis A, Todo S, Fung JJ, Starzl TE: The incidence, timing and management of biliary tract complications after orthotopic liver transplantation. Ann Surg 1994;219: 4045. 4 Rouch DA, Emond JC, Thistlethwaite JR, Mayes JT, Broelsch CE: Choledochocholedochostomy without a t-tube or internal stent in transplantation of the liver. Surg Gynecol Obstet 1990;170:239244. 5 OConnor TP, Lewis WD, Jenkins RL: Biliary tract complications after liver transplantation. Arch Surg 1995;130:312317. 6 Neuhaus P, Blumhardt G, Bechstein WO, Steffen R, Platz KP, Keck H: Technique and results of biliary reconstruction using side-toside choledocho-choledochostomy in 300 orthotopic liver transplants. Ann Surg 1994;219: 426434. 7 Stratta RJ, Wood RP, Langnas AN, Hollins RR, Bruder KJ, Donovan JP, Burnett DA, Liebermann RP, Lund GB, Pillen TJ, Markin RS, Shaw BW: Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation. Surgery 1989;106:675684. 8 Osorio RW, Freise CE, Stock PG, Lake JR, Laberge JM, Gordon RL, Ring EJ, Ascher NL, Roberts JP: Nonoperative management of biliary leaks after orthotopic liver transplantation. Transplant 1993;55:10741077. 9 Gholson CF, Zibari G, McDonald JC: Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation. Dig Dis Sci 1996;41:10451053. 10 Blumgart LH: Hilar and intrahepatic biliaryenteric anastomosis; in Blumgart LH (ed): Surgery of the Liver and Biliary Tract. Edinburgh, Churchill Livingstone, 1988, vol 70, pp 899 913. 11 Seiler CA, Renner EL, Schilling M, Rieder H, Reichen J, Bischoff P, Bchler MW: Die Lebertransplantation am kleinen Zentrum: Machbarkeit, Effizienz und Perspektive. Chirurg 1997;68:10041010.

106

Dig Surg 1999;16:102106

Seiler