Objectives: Biliary complications after liver transplant are a major concern with their high incidence, the need for repeated and long-term treatment, and their potential effects on graft and patient survival. We report our experience with biliary anastomosis using a spiral polytetrafluoroethylene graft.
Materials and Methods: Between December 8, 1988, and July 2016, we performed 538 liver transplant procedures. We used a spiral polytetrafluoroethylene graft for biliary anastomosis in 10 patients: for biliary stricture reconstruction after liver transplant in 4 patients and during the primary liver transplant in 6 patients.
Results: Four patients who underwent biliary stricture reconstruction are doing well, with normal liver function. Of the 6 patients who received the graft during primary liver transplant, 2 died from sepsis, although they maintained normal liver function. Of the 4 living patients, 1 had a biliary complication that was reconstructed surgically. The 4 living patients are currently doing well, with normal liver function.
Conclusions: Our small series of patients shows that the use of a spiral polytetrafluoroethylene graft is effective at reducing biliary complications in transplant patients.
Key words : Biliary complication, Liver transplantation, PTFE graft
Biliary complications are often referred to as the “Achilles heel” of liver transplant (LT), with their high incidence, the need for repeated and long-term treatment, and their potential effects on graft and patient survival.2 As the main cause of these complications is the development of fibrosis in the anastomotic area, decreasing the rate of fibrosis on both sides of the anastomosis will prevent biliary complications. In our previous experimental study in a porcine model, we showed that using a spiral polytetrafluoroethylene (PTFE) graft decreases the complication rate to almost zero. We now use this technique as a standard procedure and have performed anastomosis using a spiral PTFE graft in 10 human patients. Herein, we review the results.
Materials and Methods
Between December 8, 1988, and July 2016, we performed 538 LT procedures at our centers (patient age range, 6 mo-64 y). Of these, 388 were living-donor LT procedures (73%) and 150 were deceased-donor LT procedures (27%). We performed a retrospective review of the records of the 10 patients who received a spiral PTFE graft. These grafts were used for reconstruction of a biliary stricture after LT in 4 patients and in primary LT in 6 patients. All biliary anastomoses were performed using loop magnification (×2.5). The biliary anastomosis was performed using either duct-to-duct (DD) technique (Figure 1) or bilioenteric (HJ) technique (Figure 2). The anastomosis through the spiral PTFE graft was performed using 6-0 or 7-0 monofilament sutures.
First, we performed end-to-end anastomosis between the spiral PTFE graft and the graft bile duct. Two untied sutures were placed at the corners of the graft bile duct. The anterior wall of the graft bile duct was spatulated according to the diameter of the spiral PTFE graft. A double-needle suture was then placed at the corners of both the graft bile duct and the spiral PTFE graft. A single arm of that suture was continued to the other corner of the anastomosis. After finishing the posterior wall, both open-loop stitch ends were pulled to the left and right corners to eliminate slack, and the posterior walls of the graft bile duct and the spiral PTFE graft were tightly approximated. Next, the untied sutures at the left and right corners were tied. The anterior wall of the anastomosis was continuously sutured externally. The distal anastomosis, between the spiral PTFE graft and the native bile duct or jejunum, was performed in the same manner.
Table 1 summarizes the demographic and reconstruction details of the 4 patients who received a spiral PTFE graft during reconstruction for a posttransplant biliary stricture. All 4 patients were male and received their liver graft from a relative. Two patients were children, and 2 were adults; we used DD anastomosis in the adult patients and HJ anastomosis in the pediatric patients. All 4 reconstruction patients are doing well, with normal liver function.
Table 2 summarizes the remaining 6 patients (4 male, 2 female). We performed bile duct reconstruction using a spiral PTFE graft during LT in 3 pediatric and 3 adult patients. One patient had an auxiliary partial orthotopic living-donor LT, and 2 patients received whole grafts from deceased donors. We performed 4 DD anastomoses and 2 HJ anastomosis using spiral PTFE grafts. Two patients died of sepsis, although they maintained normal liver function. The remaining 4 patients are doing well, with normal liver function. One female patient was 15 years of age at the time of deceased-donor LT. During her follow-up, we detected biliary leakage from the distal anastomosis on the 20th day after LT. After internal stenting via endoscopic retrograde cholangiopancreatography, we performed a laparotomy and inserted a T-tube through the distal anastomosis. After 3 weeks, the T-tube was removed, and she is now doing well, with normal liver function.
The use of LT is standard for patients with end-stage liver disease. Improvements in surgical techniques, immunosuppression therapies, and postoperative management have resulted in better patient and graft outcomes. Biliary strictures and leakages are still the most frequent complications of LT, with a reported incidence of 10% to 35%.3-5 Biliary complications are associated with higher morbidity and mortality, reportedly 2% to 7%.6,7 Biliary complications result in frequent interventions, hospital readmissions, and higher costs, and they can even lead to acute and chronic liver injury.8,9 We previously reported that our incidence of biliary complications after LT is 35%.10 Our biliary complications occur more often in living-donor LT than in deceased-donor LT (37% vs 28%), in pediatric LT over adult (36% vs 34%), and in DD anastomosis over HJ anastomosis (38% vs 15.9%). The incidence of biliary complications depends on a variety of factors: the type of LT procedure, organ preservation, hepatic artery thrombosis, external versus internal drainage of the bile duct anastomosis, the presence of ischemia and reperfusion injury, immunologic factors, and specific donor and recipient factors.5,11-14 The type of biliary reconstruction plays a major role and is the so-called Achilles heel of LT. The choice of reconstruction technique depends on the primary disease, the difference in size between the bile ducts, and any prior biliary surgery (DD or HJ). Prophylaxis against biliary complications remains a major issue.
Researchers are attempting to understand the causes of biliary complications and are creating innovations to overcome them. Some of these advances are in the comprehensive understanding of the liver and biliary tree blood supply,15-19 the conception of novel techniques for dissection and biliary reconstruction, the use of T-tubes and stents, and the application of microsurgical techniques.20-22
Haberal and associates designed a new technique for biliary anastomosis.1 Fourteen pigs, weighing between 45 and 120 kg, were separated into 2 groups. In group one, 5 end-to-end biliary anastomoses (choledochoduodenostomy or choledochocholedochostomy) were performed. In group two, 9 biliary anastomoses were performed using a spiral PTFE graft, 1 cm in length and 6 mm in diameter. After 4 weeks, the porcine abdomens were explored for biliary leaks, intraabdominal collections, disrupted anastomoses, or anastomotic strictures. The operative specimen in each included the liver and extrahepatic bile duct before scarification. In group one, 2 bile leaks and 4 strictures were seen. In group 2, the biliary anastomoses with grafts showed neither leakage nor strictures. In 3 pigs from group 2, gross partial adhesion of the expanded PTFE patch to the bile duct as a free luminal foreign body was found; the expanded PTFE was completely integrated with the surrounding tissue in the remaining 6 pigs (67%). The stented biliary anastomoses in group 2 showed neither occlusion nor stenosis, and the lumens of both the grafts and the ducts were smooth (Figure 3A-D). Microscopic examination showed that the luminal epithelium was intact in almost all animals (Figure 3E). Only 1 pig (11.1%) in group 2 showed evidence of ulceration in the epithelium of the duct (Figure 3F). The remaining 2 pigs (22.2%) had epithelial proliferation throughout the lumen of the duct (Figure 3G), and 3 pigs (66.7%) had normal epithelium. Microscopically, the expanded PTFE graft was completely integrated with the surrounding tissue in 6 pigs (Figure 3H). On gross examination, a partial (n = 1; 20%) or circumferential (n = 3; 60%) stricture was found at the site of the anastomoses in all but 1 pig from group 1 (Figure 3I-L). Significant differences were found between group 1 and group 2 in the incidence of bile leakage and stenosis (P < .05). Of the 3 circumferential strictures in group one, 2 were associated with bile leakage. None of the pigs from group 1 had epithelial ulceration. Of the 5 pigs in group one, 3 had epithelial proliferation and 2 had normal epithelium (Figure 3M and 3N). Of the 9 pigs in group two, 5 had microscopic evidence of moderate inflammation at the anastomosis site (Figure 3F and 3H), whereas 4 of 5 pigs in group 1 had moderate to severe inflammation at the anastomosis site (Figure 3N). A statistically significant difference was found between group 1 and group 2 in stromal inflammation (P < .05). Only 1 pig in group 2 had fibrosis at the anastomotic site (Figure 3O), whereas 4 pigs in group 1 had this finding (Figure 3P). A significant difference was found between the groups in fibrosis development (P < .05).
In our previous experimental study, we showed that biliary anastomosis using a spiral extended PTFE graft is feasible, with a satisfactory anastomotic circumference and histologic evidence of healing. This technique is promising for decreasing the incidence of bile duct leakage and stricture, and we now use it as standard procedure. To date, we have performed biliary anastomosis using a PTFE graft in 10 patients (4 posttransplant biliary stricture reconstructions and 6 primary biliary reconstructions). The liver function in these patients is promising. We lost 2 patients to sepsis, and we had a single biliary complication. The patient with the complication is now well, with normal liver-function test results after surgical revision of the biliary anastomosis.
Biliary complications are the most frequently seen issue after LT and lead to significant morbidity and mortality. Biliary anastomosis using a spiral PTFE graft is feasible, yields a satisfactory anastomotic circumference, and shows histologic evidence of healing. The main cause of biliary complications is the development of fibrosis in the anastomotic area. Biliary anastomosis using a spiral PTFE graft prevents the development of biliary complications by decreasing the rate of fibrosis on both sides of the anastomosis. Our previous experimental studies and this small series of patients show that use of the spiral PTFE graft is effective at reducing biliary complications in LT.
Volume : 15
Issue : 1
Pages : 71 - 75
DOI : 10.6002/ect.mesot2016.O57
From the 1Departmentof Transplant Surgery and the 2Department of Anesthesiology,
Baskent University Faculty of Medicine, Turkey
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Prof. Mehmet Haberal, MD, FACS (Hon), FICS (Hon), FASA (Hon), Department of General Surgery, Baskent University, Ankara, Turkey
Phone: +90 312 212 7393
Fax: +90 312 215 0835
Figure 1. Duct-to-Duct Anastomosis Using a Spiral Polytetrafluoroethylene Graft
Figure 2. Bilioenteric Anastomosis Using a Spiral Polytetrafluoroethylene Graft
Figure 3. Pathologic and Macroscopic Findings in a Porcine Model
Table 1. Patient Demographics and Stricture-Reconstruction Details
Table 2. Patient Demographics and Primary Anastomosis Details