During orthotopic liver transplantation (OLT), biliary tract perfusion occurs with hepatic artery reperfusion (HARP), commonly performed after the portal vein reperfusion (PVRP). We examined whether the average time interval between PVRP and HARP impacted on postoperative biliary strictures occurrence. Patients undergoing OLT from 2007 to 2009 were included if they were ≥18 years old, had survived 3 months postoperatively, and had data for PVRP and HARP. Patients receiving allografts from DCD donors were excluded. Patients were followed for 6 months post-OLT. Seventy-five patients met the study inclusion criteria. Of these, 10 patients had a biliary stricture. There was no statistical difference between those with and without biliary stricture in age, gender, etiology, MELD score, graft survival, and time interval between PVRP and HARP. Ninety percent of patients with biliary stricture had a PVRP-HARP time interval >30 minutes, as opposed to 77% of patients without biliary stricture. However, this was not statistically significant. The cold ischemia time was significantly different between the two groups. Time interval for HARP after PVRP did not appear to affect the development of biliary strictures. However, 30 minutes may be suggested as a critical time after which there is an increase in biliary stricture occurrence. 1. Introduction Orthotopic liver transplantation (OLT) remains the gold standard for treatment of end-stage liver disease (ESLD) despite advances in medical treatment and management of complications [1]. Surgically, OLT involves hepatectomy followed by implantation. Implantation includes reestablishment of three critical structures: the portal vein, the hepatic artery, and the biliary duct in a sequential fashion. Most often, hepatic artery reperfusion (HARP) occurs after portal vein reperfusion (PVRP) and establishes the blood supply to the bile duct epithelium. Postoperative biliary complications may be attributable to hepatic artery thrombosis or stenosis, technical reasons, ischemia-reperfusion injury, and immunological injury. Most common biliary complications include stricture, leak, biloma, and biliary abscess. These complications can be early, those occurring less than 30 days after OLT, or late, those occurring after 30 days [2]. Biliary complications secondary to long warm ischemia times, independent of vascular compromise, have been reported in the literature specifically in recipients who received livers from donation after cardiac death (DCD) donors [3–6]. Ischemic cholangiopathy has been described in 9–50% of DCD
References
[1]
M. Feldman, L. S. Friedman, and L. J. Brandt, “Liver transplantation,” in Sleisenger and Fordtran's Gastrointestinal and Liver Disease, vol. 2, chapter 95, Saunders, Philadelphia, Pa, USA, 9th edition, 2010.
[2]
M. Wojcicki, P. Milkiewicz, and M. Silva, “Biliary tract complications after liver transplantation: a review,” Digestive Surgery, vol. 25, no. 4, pp. 245–257, 2008.
[3]
D. J. Reich and J. C. Hong, “Current status of donation after cardiac death liver transplantation,” Current Opinion in Organ Transplantation, vol. 15, no. 3, pp. 316–321, 2010.
[4]
D. J. Reich, D. C. Mulligan, P. L. Abt et al., “ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation,” The American Journal of Transplantation, vol. 9, no. 9, pp. 2004–2011, 2009.
[5]
H. P. Grewal, D. L. Willingham, J. Nguyen et al., “Liver transplantation using controlled donation after cardiac death donors: an analysis of a large single-center experience,” Liver Transplantation, vol. 15, no. 9, pp. 1028–1035, 2009.
[6]
A. I. Skaro, C. L. Jay, T. B. Baker et al., “The impact of ischemic cholangiopathy in liver transplantation using donors after cardiac death: the untold story,” Surgery, vol. 146, no. 4, pp. 543–553, 2009.
[7]
M. Cag, M. Audet, A. C. Saouli et al., “Does arterialisation time influence biliary tract complications after orthotopic liver transplantation?” Transplantation Proceedings, vol. 42, no. 9, pp. 3630–3633, 2010.
[8]
K. J. Halazun, A. Al-Mukhtar, A. Aldouri, S. Willis, and N. Ahmad, “Warm ischemia in transplantation: search for a consensus definition,” Transplantation Proceedings, vol. 39, no. 5, pp. 1329–1331, 2007.
[9]
A. Casavilla, C. Ramirez, R. Shapiro et al., “Liver and kidney transplantation from non-heart beating donors: the Pittsburgh experience,” Transplantation Proceedings, vol. 27, no. 1, pp. 710–712, 1995.
[10]
A. M. D'Alessandro, R. M. Hoffmann, S. J. Knechtle et al., “Successful extrarenal transplantation from non-heart-beating donors,” Transplantation, vol. 59, no. 7, pp. 977–982, 1995.
[11]
D. P. Foley, L. A. Fernandez, G. Leverson et al., “Donation after cardiac death: the University of Wisconsin experience with liver transplantation,” Annals of Surgery, vol. 242, no. 5, pp. 724–731, 2005.
[12]
P. Abt, M. Crawford, N. Desai, J. Markmann, K. Olthoff, and A. Shaked, “Liver transplantation from controlled non-heartbeating donors: an increased incidence of biliary complications,” Transplantation, vol. 75, no. 10, pp. 1659–1663, 2003.
[13]
M. E. de Vera, R. Lopez-Solis, I. Dvorchik et al., “Liver transplantation using donation after cardiac death donors: long-term follow-up from a single center,” The American Journal of Transplantation, vol. 9, no. 4, pp. 773–781, 2009.
[14]
A. Maheshwari, W. Maley, Z. Li, and P. J. Thuluvath, “Biliary complications and outcomes of liver transplantation from donors after cardiac death,” Liver Transplantation, vol. 13, no. 12, pp. 1645–1653, 2007.
[15]
S. Fujita, S. Mizuno, T. Fujikawa et al., “Liver transplantation from donation after cardiac death: a single center experience,” Transplantation, vol. 84, no. 1, pp. 46–49, 2007.
[16]
D. J. Reich, “Non-heart-beating donor organ procurement,” in Atlas of Organ Transplantation, A. Humar, W. D. Payne, and A. J. Matas, Eds., pp. 23–33, Springer, London, UK, 2006.
[17]
F. Greif, O. L. Bronsther, D. H. van Thiel et al., “The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation,” Annals of Surgery, vol. 219, no. 1, pp. 40–45, 1994.
[18]
D. J. Verran, S. K. Asfar, C. N. Ghent, D. R. Grant, and W. J. Wall, “Biliary reconstruction without T tubes or stents in liver transplantation: report of 502 consecutive cases,” Liver Transplantation and Surgery, vol. 3, no. 4, pp. 365–373, 1997.
[19]
P. Neuhaus, G. Blumhardt, W. O. Bechstein, R. Steffen, K. Platz, and H. Keck, “Technique and results of biliary reconstruction using side-to-side choledochocholedochostomy in 300 orthotopic liver transplants,” Annals of Surgery, vol. 219, no. 4, pp. 426–434, 1994.
[20]
T. P. O'Connor, W. D. Lewis, and R. L. Jenkins, “Biliary tract complications after liver transplantation,” Archives of Surgery, vol. 130, no. 3, pp. 312–317, 1995.
[21]
J. M. Rabkin, S. L. Orloff, M. H. Reed et al., “Biliary tract complications of side-to-side without T tube versus end-to-end with or without tt tube choledochocholedochostomy in liver transplant recipients,” Transplantation, vol. 65, no. 2, pp. 193–199, 1998.
[22]
B. R. Davidson, R. Rai, T. R. Kurzawinski et al., “Prospective randomized trial of end-to-end versus side-to-side biliary reconstruction after orthotopic liver transplantation,” The British Journal of Surgery, vol. 86, no. 4, pp. 447–452, 1999.
[23]
T. H. Welling, D. G. Heidt, M. J. Englesbe et al., “Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient, and technical factors,” Liver Transplantation, vol. 14, no. 1, pp. 73–80, 2008.
[24]
J. O. Colonna II, A. Shaked, A. S. Gomes et al., “Biliary strictures complicating liver transplantation: incidence, pathogenesis, management, and outcome,” Annals of Surgery, vol. 216, no. 3, pp. 344–352, 1992.
[25]
R. J. Stratta, R. P. Wood, A. N. Langnas et al., “Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation,” Surgery, vol. 106, no. 4, pp. 675–684, 1989.
[26]
B. Y. Tung and M. B. Kimmey, “Biliary complications of orthotopic liver transplantation,” Digestive Diseases, vol. 17, no. 3, pp. 133–144, 1999.
[27]
S. Jagannath and A. N. Kalloo, “Biliary complications after liver transplantation,” Current Treatment Options in Gastroenterology, vol. 5, no. 2, pp. 101–112, 2002.
[28]
B. Macfarlane, B. Davidson, J. S. Dooley et al., “Endoscopic retrograde cholangiography in the diagnosis and endoscopic management of biliary complications after liver transplantation,” European Journal of Gastroenterology and Hepatology, vol. 8, no. 10, pp. 1003–1006, 1996.
[29]
A. F. Rossi, C. Grosso, G. Zanasi et al., “Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation,” Endoscopy, vol. 30, no. 4, pp. 360–366, 1998.
[30]
R. V. Mahajani, S. J. Cotler, and M. F. Uzer, “Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation,” Endoscopy, vol. 32, no. 12, pp. 943–949, 2000.
[31]
D. A. Schwartz, B. T. Petersen, J. J. Poterucha, and C. J. Gostout, “Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation,” Gastrointestinal Endoscopy, vol. 51, no. 2, pp. 169–174, 2000.
[32]
D. P. Foley, R. Ricciardi, A. N. Traylor et al., “Effect of hepatic artery flow on bile secretory function after cold ischemia,” The American Journal of Transplantation, vol. 3, no. 2, pp. 148–155, 2003.
[33]
M. Gastaca, “Bilary complications after orthotopic liver transplantation: a review of incidence and risk factors,” Transplantation Proceedings, vol. 44, no. 6, pp. 1545–1549, 2012.
