Repeated Introperative Cholangiography is Helpful for Donor Safety in the Procurement of Right Liver Graft with Supraportal Right Bile Duct Variants in Living-Donor Liver Transplantation K.-S. Jeng, C.-C. Huang, C.-K. Lin, C.-C. Lin, K.-H. Chen, and S.-H. Chu ABSTRACT Background. Despite recent advances in preoperative diagnostic imaging and operative techniques, biliary variation of the donor still remains a challenge in the procurement of graft. The supraportal right bile duct (BD) variant including presentation as trifurcation is a potential trap for injuring the remnant bile duct of donor. Methods. Before living/related-donor liver transplantation (LRLT), cholangiogram with magnetic resonance images of each donor was performed as a routine. After exploration of the donor before hilar dissection, intraoperative chloangiography (IOC) was routinely performed. Among the supraportal right bile duct variants, if the preoperative cholangiography showed a suspected trifurcation of the bile duct, we then performed 3 sessions of IOC during liver graft procurement, including prior to hilar dissection, before the division of bile ducts and after the division. We reviewed the cholangiogram and the postoperative laboratory data of a consecutive series of 25 donors of LRLT. Results. There was no division injury of the remnant bile duct of all of the donors. Conclusions. Repeated IOC is suggested as a routine for variants of supraportal right bile ducts especially trifurcation pattern in graft procurement to avoid the injury of donor remnant bile ducts.
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ACKING awareness of biliary variations results in complications in adult living-donor liver transplantation. Variations in biliary anatomy seem to be the rule rather than the exception [1e6]. According to Kitami et al, the running course of the right posterior sectorial duct in relation to the right anterior sectorial portal vein, regardless of the terminal junction, was classified into 3 courses: supraportal, infraportal, and other [1]. The supraportal course was significantly less frequent in those with portal vein variation, whereas the infraportal course was significantly more frequent in those with portal vein variation [1]. During harvesting of the right liver lobe, the trifurcation patterns of the hilar biliary ducts are quite important, because injury to the remnant ducts may occur. PATIENTS AND METHODS In our institution, before living/related-donor liver transplantation (LRLT), cholangiogram with magnetic resonance cholangiogiopancreatography (MRCP) of each donor was performed as 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.093 686
routine. After exploration of the donor, before hilar dissection, intraoperative cholangiography (IOC) was routinely performed. We used the results of the IOC as the criteria for the decision of bile duct division. Among the supraportal right bile duct variants, if the preoperative MRCP showed a suspected trifurcation of the bile duct, we then performed 3 sessions of IOC (Figs 1e3), in addition to during liver graft procurement, including before hilar dissection, before the division of bile ducts, and after the division. After obtaining their written informed consents, we enrolled 25 recipients receiving LRLT at our institution from January 2011 to September 2013 into this study. We reviewed both preoperative and postoperative From the Department of Surgery (K.-S.J., K.-H.C., S.-H.C.), Department of Radiology (C.-C.H.), and Division of Gastroenterology (C.-K.L., C.-C.L.), Far Eastern Memorial Hospital, Taipei, Taiwan. Address reprint requests to Kuo-Shyang Jeng, MD, Department of Surgery, Far Eastern Memorial Hospital. No 21, Sec 2, Nanya S Rd, Banciao Dist, New Taipei City 220, Taiwan. E-mail: [email protected] ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 686e688 (2014)
REPEATED CHOLANGIOGRAPHY DURING LIVER TRANSPLANTATION
687
Fig 1. Intraoperative cholangiography: 1st session, before hilar dissection.
Fig 3. Intraoperative cholangiography: 3rd session, after bile duct division.
cholangiograms and the postoperative laboratory data of a consecutive series of 25 donors of LRLT. Injury of remnant bile duct of the donor was defined if the postoperative cholangiography or laboratory data revealed cholangitis or obstructive jaunclice.
group) had trifurcation of bile ducts. However, there was no division injury of the remnant bile duct of all of the donors. DISCUSSION
RESULTS
Among the 25 donors, 18 showed the supraportal right bile duct (SRBD) pattern. Among them, 2 (11.1% of the SRBD
Fig 2. Intraoperative cholangiography: 2nd session, after hilar dissection but before bile duct division.
In this study, we performed 3 sessions of IOC during procurement of right liver graft to avoid injury remnant bile duct of the donor, especially in trifurcation bile ducts among supraportal bile duct variants. No complications of donor bile ducts occurred. Biliary tract variations are quite common, and biliary complications are the most frequent cause of morbidity and mortality after LDLT [1e11]. The key point in preventing biliary complications is to map the bile duct clearly, avoiding unnecessary dissection at the hilum, and designing the procedure to obtain a single bile duct orifice in the graft, if possible, to spare multiple duct anastomoses [4e12]. Among the common biliary variations, the most encountered problem were trifurcation of right anterior, right posterior, and left hepatic ducts and right posterior or right anterior hepatic duct draining into the left or common hepatic duct [2,3,7,12,13]. Cheng et al emphasized that unusual intrahepatic duct routes require a change in the cutting plane of bile duct during graft retrieval to avoid potential complications to both donors and recipients [7]. Preoperative cholangiography for screening intrahepatic duct variations is important to establishing safe bile drainage for both donors and recipients. We routinely used MRCP for both donors and recipients. However, the images obtained are not consistently satisfactory. IOC remains the best modality for evaluating the biliary tree and allows the identification of the optimal point for bile duct division [14,15]. Despite good visualization of
688
the detailed biliary tree by IOC, preoperative imaging study remains helpful to avoid inaccurate decision or unnecessary procedures if preoperative images show unacceptable biliary anatomy. Some authors have compared MRCP and IOC findings and found that the sensitivity and negative predictive value of MRCP were lower. Interestingly, donors with portal variations had a 70% rate of biliary tract variation. Because the sensitivity of preoperative MRCP is not high, repeated IOC for careful examination of the biliary tract in 3 sessions (Figs 1e3) is very important in donors, especially with supraportal bile duct variations [6,16]. Repeated IOC is suggested as a routine for variants of supraportal right bile ducts, especially trifurcation pattern, in graft procurement to avoid the injury of donor remnant bile ducts. REFERENCES [1] Kitami M, Takase K, Murakami G, et al. Types and frequencies of biliary tract variations associated with a major portal venous anomaly: analysis with multi-detector row CT cholangiography. Radiology 2006;238:156e66. [2] Li C, Li C, Wen T, et al. Biliary variations and biliary complications in living donor liver transplantation. Hepatogastroenterology 2012;59:1526e8. [3] Yoshida J, Chijiiwa K, Yamaguchi K, et al. Practical classification of the branching types of the biliary tree: an analysis of 1,094 consecutive direct cholangiograms. J Am Coll Surg 1996; 182:37e40. [4] Lee SG, Hwang S, Kim KH, et al. Approach to anatomic variations of the graft portal vein in right lobe living-donor liver transplantation. Transplantation 2003;75(3 Suppl):S28e32. [5] Yaprak O, Demirbas T, Duran C, et al. Living donor liver hilar variations: surgical approaches and implications. Hepatobiliary Pancreat Dis Int 2011;10:474e9.
JENG, HUANG, LIN ET AL [6] Chen YS, Cheng YF, de Villa VH, et al. Evaluation of living liver donors. Transplantation 2003;75(3 Suppl):S16e9. [7] Cheng YF, Huang TL, Chen CL, et al. Variations of the intrahepatic bile ducts: application in living related liver transplantation and splitting liver transplantation. Clin Transplant 1997;11:337e40. [8] Limanond P, Raman SS, Ghobrial RM, et al. The utility of MRCP in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant donors. J Magn Reson Imaging 2004;19:209e15. [9] Fulcher AS, Turner MA. Orthotopic liver transplantation: evaluation with MR cholangiography. Radiology 1999;211:715e22. [10] Hsu HW, Tsang LL, Yap A, et al. Magnetic resonance cholangiography in living donor liver transplantation. Transplantation 2011;92:94e9. [11] Zheng RQ, Chen GH, Xu EJ, et al. Evaluating biliary anatomy and variations in living liver donors by a new technique: three-dimensional contrast-enhanced ultrasonic cholangiography. Ultrasound Med Biol 2010;36:1282e7. [12] Jeon YM, Lee KW, Yi NJ, et al. The right posterior bile duct anatomy of the donor is important in biliary complications of the recipients after living-donor liver transplantation. Ann Surg 2013;257:702e7. [13] McSweeney SE, Kim TK, Jang HJ, et al. Biliary anatomy in potential right hepatic lobe living donor liver transplantation (LDLT): the utility of CT cholangiography in the setting of inconclusive MRCP. Eur J Radiol 2012;81:6e12. [14] Ochiai T, Ikoma H, Inoue K, et al. Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications. J Gastrointest Surg 2011;15:2159e64. [15] Xu X, Wei X, Ling Q, et al. Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation. Eur J Radiol 2012;81: e457e460. [16] Kapoor V, Peterson MS, Baron RL, et al. Intrahepatic biliary anatomy of living adult liver donors: correlation of mangafodipir trisodium-enhanced MR cholangiography and intraoperative cholangiography. AJR Am J Roentgenol 2002;179: 1281e6.
L
ACKING awareness of biliary variations results in complications in adult living-donor liver transplantation. Variations in biliary anatomy seem to be the rule rather than the exception [1e6]. According to Kitami et al, the running course of the right posterior sectorial duct in relation to the right anterior sectorial portal vein, regardless of the terminal junction, was classified into 3 courses: supraportal, infraportal, and other [1]. The supraportal course was significantly less frequent in those with portal vein variation, whereas the infraportal course was significantly more frequent in those with portal vein variation [1]. During harvesting of the right liver lobe, the trifurcation patterns of the hilar biliary ducts are quite important, because injury to the remnant ducts may occur. PATIENTS AND METHODS In our institution, before living/related-donor liver transplantation (LRLT), cholangiogram with magnetic resonance cholangiogiopancreatography (MRCP) of each donor was performed as 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.093 686
routine. After exploration of the donor, before hilar dissection, intraoperative cholangiography (IOC) was routinely performed. We used the results of the IOC as the criteria for the decision of bile duct division. Among the supraportal right bile duct variants, if the preoperative MRCP showed a suspected trifurcation of the bile duct, we then performed 3 sessions of IOC (Figs 1e3), in addition to during liver graft procurement, including before hilar dissection, before the division of bile ducts, and after the division. After obtaining their written informed consents, we enrolled 25 recipients receiving LRLT at our institution from January 2011 to September 2013 into this study. We reviewed both preoperative and postoperative From the Department of Surgery (K.-S.J., K.-H.C., S.-H.C.), Department of Radiology (C.-C.H.), and Division of Gastroenterology (C.-K.L., C.-C.L.), Far Eastern Memorial Hospital, Taipei, Taiwan. Address reprint requests to Kuo-Shyang Jeng, MD, Department of Surgery, Far Eastern Memorial Hospital. No 21, Sec 2, Nanya S Rd, Banciao Dist, New Taipei City 220, Taiwan. E-mail: [email protected] ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 686e688 (2014)
REPEATED CHOLANGIOGRAPHY DURING LIVER TRANSPLANTATION
687
Fig 1. Intraoperative cholangiography: 1st session, before hilar dissection.
Fig 3. Intraoperative cholangiography: 3rd session, after bile duct division.
cholangiograms and the postoperative laboratory data of a consecutive series of 25 donors of LRLT. Injury of remnant bile duct of the donor was defined if the postoperative cholangiography or laboratory data revealed cholangitis or obstructive jaunclice.
group) had trifurcation of bile ducts. However, there was no division injury of the remnant bile duct of all of the donors. DISCUSSION
RESULTS
Among the 25 donors, 18 showed the supraportal right bile duct (SRBD) pattern. Among them, 2 (11.1% of the SRBD
Fig 2. Intraoperative cholangiography: 2nd session, after hilar dissection but before bile duct division.
In this study, we performed 3 sessions of IOC during procurement of right liver graft to avoid injury remnant bile duct of the donor, especially in trifurcation bile ducts among supraportal bile duct variants. No complications of donor bile ducts occurred. Biliary tract variations are quite common, and biliary complications are the most frequent cause of morbidity and mortality after LDLT [1e11]. The key point in preventing biliary complications is to map the bile duct clearly, avoiding unnecessary dissection at the hilum, and designing the procedure to obtain a single bile duct orifice in the graft, if possible, to spare multiple duct anastomoses [4e12]. Among the common biliary variations, the most encountered problem were trifurcation of right anterior, right posterior, and left hepatic ducts and right posterior or right anterior hepatic duct draining into the left or common hepatic duct [2,3,7,12,13]. Cheng et al emphasized that unusual intrahepatic duct routes require a change in the cutting plane of bile duct during graft retrieval to avoid potential complications to both donors and recipients [7]. Preoperative cholangiography for screening intrahepatic duct variations is important to establishing safe bile drainage for both donors and recipients. We routinely used MRCP for both donors and recipients. However, the images obtained are not consistently satisfactory. IOC remains the best modality for evaluating the biliary tree and allows the identification of the optimal point for bile duct division [14,15]. Despite good visualization of
688
the detailed biliary tree by IOC, preoperative imaging study remains helpful to avoid inaccurate decision or unnecessary procedures if preoperative images show unacceptable biliary anatomy. Some authors have compared MRCP and IOC findings and found that the sensitivity and negative predictive value of MRCP were lower. Interestingly, donors with portal variations had a 70% rate of biliary tract variation. Because the sensitivity of preoperative MRCP is not high, repeated IOC for careful examination of the biliary tract in 3 sessions (Figs 1e3) is very important in donors, especially with supraportal bile duct variations [6,16]. Repeated IOC is suggested as a routine for variants of supraportal right bile ducts, especially trifurcation pattern, in graft procurement to avoid the injury of donor remnant bile ducts. REFERENCES [1] Kitami M, Takase K, Murakami G, et al. Types and frequencies of biliary tract variations associated with a major portal venous anomaly: analysis with multi-detector row CT cholangiography. Radiology 2006;238:156e66. [2] Li C, Li C, Wen T, et al. Biliary variations and biliary complications in living donor liver transplantation. Hepatogastroenterology 2012;59:1526e8. [3] Yoshida J, Chijiiwa K, Yamaguchi K, et al. Practical classification of the branching types of the biliary tree: an analysis of 1,094 consecutive direct cholangiograms. J Am Coll Surg 1996; 182:37e40. [4] Lee SG, Hwang S, Kim KH, et al. Approach to anatomic variations of the graft portal vein in right lobe living-donor liver transplantation. Transplantation 2003;75(3 Suppl):S28e32. [5] Yaprak O, Demirbas T, Duran C, et al. Living donor liver hilar variations: surgical approaches and implications. Hepatobiliary Pancreat Dis Int 2011;10:474e9.
JENG, HUANG, LIN ET AL [6] Chen YS, Cheng YF, de Villa VH, et al. Evaluation of living liver donors. Transplantation 2003;75(3 Suppl):S16e9. [7] Cheng YF, Huang TL, Chen CL, et al. Variations of the intrahepatic bile ducts: application in living related liver transplantation and splitting liver transplantation. Clin Transplant 1997;11:337e40. [8] Limanond P, Raman SS, Ghobrial RM, et al. The utility of MRCP in preoperative mapping of biliary anatomy in adult-to-adult living related liver transplant donors. J Magn Reson Imaging 2004;19:209e15. [9] Fulcher AS, Turner MA. Orthotopic liver transplantation: evaluation with MR cholangiography. Radiology 1999;211:715e22. [10] Hsu HW, Tsang LL, Yap A, et al. Magnetic resonance cholangiography in living donor liver transplantation. Transplantation 2011;92:94e9. [11] Zheng RQ, Chen GH, Xu EJ, et al. Evaluating biliary anatomy and variations in living liver donors by a new technique: three-dimensional contrast-enhanced ultrasonic cholangiography. Ultrasound Med Biol 2010;36:1282e7. [12] Jeon YM, Lee KW, Yi NJ, et al. The right posterior bile duct anatomy of the donor is important in biliary complications of the recipients after living-donor liver transplantation. Ann Surg 2013;257:702e7. [13] McSweeney SE, Kim TK, Jang HJ, et al. Biliary anatomy in potential right hepatic lobe living donor liver transplantation (LDLT): the utility of CT cholangiography in the setting of inconclusive MRCP. Eur J Radiol 2012;81:6e12. [14] Ochiai T, Ikoma H, Inoue K, et al. Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications. J Gastrointest Surg 2011;15:2159e64. [15] Xu X, Wei X, Ling Q, et al. Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation. Eur J Radiol 2012;81: e457e460. [16] Kapoor V, Peterson MS, Baron RL, et al. Intrahepatic biliary anatomy of living adult liver donors: correlation of mangafodipir trisodium-enhanced MR cholangiography and intraoperative cholangiography. AJR Am J Roentgenol 2002;179: 1281e6.
