29

Obstructive Dilatation of Extrahepatic Recipient and Donor Bile Ducts Complicating Orthotopic Liver Transplantation: Imaging

American Journal of Roentgenology 1991.157:29-32.

William J. Miller1 William L. Campbell1 Albert B. Zajko1 Antonio Pinna2 Giorgio Zetti2 Andrei C. Stieber Richard G. Foster1 James W. Lecky1 Kyung V. Lee#{176}

and Laboratory

Findings

Biliary obstruction in liver transplants is most commonly due to stricture at the biliary anastomosis. The native common bile duct typically is normal. We retrospectively studied 28 patients with choledochocholedochostomy anastomoses who had marked native and donor extrahepatic bile duct dilatation associated with clinical evidence of biliary

obstruction.

Operative

cholangiograms

were

compared

with

postoperative

cho-

langiograms obtained a mean of 50 weeks (range, 2-246 weeks) later. Mean caliber of the native common bile duct increased from 7.5 ± 2.0 mm on operative cholangiograms to 14.8 ± 3.9 mm on postoperative cholangiograms (p < .001). Mean caliber of the donor common hepatic duct increased from 5.9 ± 1.3 mm on operative cholangiograms to 12.8 ± 3.8 mm on postoperative cholangiograms (p < .001). Dilatation of the cystic duct remnant was seen in 15 patients. All patients had surgical revision to choledochojejunostomy with improved results of liver function studies in most cases. Difluse dilatation of native and donor extrahepatic bile ducts may develop in liver transplant recipients. Typical features include native and donor extrahepatic ducts greater than 12 mm in diameter and a dilated cystic duct remnant on postoperative cholangiography in a patient with otherwise unexplained hepatic dysfunction. 157:29-32,

AJR

July 1991

Cholangiography is an important part of the postoperative evaluation of orthotopic liver transplant recipients, especially when complications of the biliary system are suspected [1 2]. Cholangiography is performed to look for biliary stricture, obstruction, bile leak, and choledocholithiasis. At our institution, the most common biliary surgery at the time of orthotopic liver transplantation is a choledochocholedochostomy, which consists of an anastomo,

sis between

Received December vision February 4, 1991.

3,

1990;

accepted

after re-

Presented at the annual meeting of the American Ray Society, Washington, DC, May

Roentgen 1990. 1

Department

of Radiology,

University

of Pitts-

burgh School of Medicine, Presbyterian University Hospital, DeSoto at OHara Sts., Pittsburgh, PA 15213. Address 2Department

reprint requests to W. L. Campbell. of Surgery, University of Pittsburgh

School of Medicine,

Presbyterian

University

tal, DeSoto at O’Hara Sts., Pittsburgh, 3Department of Biostatistics, burgh, Pittsburgh, PA 15213. 0361-803X/91/1

571-0029

© American Roentgen Ray Society

extrahepatic

bile ducts. A T-tube

is placed to stent

by surgical revision of the biliary anastomosis to a choledochojejunostomy. We reviewed the radiologic findings and clinical laboratory data of diffuse extrahepatic bile duct

dilatation

Materials

and

associated

with

hepatic

dysfunction

after

liver transplantation.

Methods

HospiBetween

PA 15213.

University

donor and recipient

the anastomosis, permit monitoring of bile output, and provide access for followup cholangiography. Anastomotic stricture is the most common cause of biliary obstruction after transplantation [1 ] and typically results in dilatation of the donor biliary duct. However, several patients have had laboratory evidence of biliary obstruction and dilatation of both native and donor biliary trees [3]. A number of these patients have been successfully treated for suspected obstruction at the ampulla of Vater

of Pitts-

primary tions. whom with

March

orthotopic

1 980 liver

Twenty-eight clinical a mean

and age

and

September

transplantation

1 990, with

approximately

patients

with

diffuse

extrahepatic

bile

radiologic

data

could

be retrieved.

There

of

42 years (range,

11-64

1 500

choledochocholedochostomy duct were

years). All patients

dilatation

patients

underwent

biliary

reconstruc-

were

identified

in

females and 13 males had undergone orthotopic 15

MILLER

30

ET

AL.

AJR:157,

July 1991

for the first time at our institution. All patients choledochochobedochostomy anastomoses, usually formed between the proximal donor common bile duct and either the native proximal common bile duct or distal common hepatic duct [4]. All exhibited clinical evidence of biliary obstruction and underwent subsequent biliary anastomotic revision to a Roux-en-Y choledochojejunostomy. Patients with anastomotic strictures and/or stones were liver

transplantation

had end-to-end

excluded. Cholangiograms

were retrospectively

sizes of the native extrahepatic

reviewed

to determine

duct, donor extrahepatic

the

duct, and

intrahepatic

ducts. The caliber of the donor common hepatic duct at the midpoint between the duct bifurcation and the biliary anastomosis; the caliber of the native common bile duct was measured at the midpoint between the anastomosis and the sphincter of Oddi. We attempted to use the least magnified films; no correction for radiographic magnification was made. Operative cholangiograms was

measured

American Journal of Roentgenology 1991.157:29-32.

were compared

with

the

last

postoperative

T-tube,

percutaneous

transhepatic, or endoscopic retrograde cholangiogram obtained before biliary anastomotic revision. The average time between operative cholangiography and the last cholangiogram before revision of the bile duct anastomosis was 50 weeks (range, 2-246 weeks). Biliary resting pressures were recorded in five patients through a 1 9-gauge butterfly needle inserted into the damped T-tube. Pressure was recorded with a 50-cm manometer with the zero mark positioned at the midaxillary line. Normal pressure was considered to be less than 15 cm H20; I 5-20 cm H20 was borderline abnormal [5]. Serum levels of liver enzymes (aspartate aminotransferase EAST], alanine aminotransferase [ALT], -y-glutamyltransferase [661], alkaline phosphatase), serum bilirubin levels, and results of liver biopsies done at the time of the last cholangiogram and approximately 2

Fig. 1.-A, T-tube cholangiogram obtained 5 days after transplantation shows normal-caliber bile ducts. Arrow shows choledochocholedochostomy anastomosis. B, T-tube cholangiogram obtained 1 month after transplantation reveals biblary dilatation, most marked in extrahepatic ducts. Arrow shows anastomosis. Patient was treated by revision to a choledochojejunostomy with

a Roux-en-Y

anastomosis.

weeks after biliary anastomotic revision were compared. Bile duct caliber was statistically analyzed with a paired

t test and Wilcoxon signed-rank test (data of latter not shown). Results of liver profile studies were analyzed with a sign test of the median [6].

Results Mean

size

of the

donor

common

hepatic

duct

increased

from 5.9 ± 1 .3 mm to 1 2.8 ± 3.8 mm, an increase

of 219% Mean size of the native common bile duct at transplantation was 7.5 ± 2.0 mm in diameter and increased to 14.8 ± 3.9 mm on the last cholangiogram before surgery, an increase of I 95% (p < .001). Maximal caliber of the extrahepatic bile duct before surgery ranged from 10 to 22 mm. Intrahepatic duct caliber exhibited little or no increase over time and/or compared

with

with

clinical

operative

evidence

cholangiograms

(p