Duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲ a hilar cholangiocarcinoma

At present, radical resection remains the only effective treatment for patients with hilar cholangiocarcinoma. The surgical approach for R0 resection of hilar cholangiocarcinoma is complex and diverse, but for the biliary reconstruction after resection, almost all surgeons use Roux-en-Y hepaticojejunostomy. A viable alternative to Roux-en-Y reconstruction after radical resection of hilar cholangiocarcinoma has not yet been proposed. We report a case of performing duct-to-duct biliary reconstruction after radical resection of Bismuth Ⅲa hilar cholangiocarcinoma. End-to-end anastomosis between the left hepatic duct and the distal common bile duct was used for the biliary reconstruction, and a singlelayer continuous suture was performed along the bile duct using 5-0 prolene. The patient was discharged favorably without biliary fistula 2 wk later. Evidence for tumor recurrence was not found after an 18 mo follow- up. Performing bile duct end-to-end anastomosis in hilar cholangiocarcinoma can simplify the complex digestive tract reconstruction process.

Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation

To evaluate risk factors of biliary anastomotic complications （BACs） and outcomes according to type of biliary reconstruction. METHODS： A total of 33 consecutive adult living donor liver transplantation （LDLT） were reviewed, 17 of which had undergone Duct-to-Duct anastomosis （D-D）. The remaining 16 patients received Roux-en-Y anastomosis （R-Y）. The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively. RESULTS： The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy （71.4% vs 10%, P = 0.050）. There was no significant difference in the incidence of biliary leakage in patients with D-D vs. those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D （60%） than in R-Y （0%） （P = 0.026）. However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D （71.4% vs 0%, P = 0.008）. In D-D, use of T-tube stent remarkably reduced the incidence of 8ACs, compared with straight tube stent （0% vs 50%, P = 0.049）. CONCLUSION： Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.

Outcomes of side-to-side conversion hepaticojejunostomy for biliary anastomotic stricture after right-liver living donor liver transplantation

BACKGROUND:Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture,a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis,after failed endoscopic treatment.The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of endto-side hepaticojejunostomy.METHODS:Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed.Diagnosis of biliary anastomotic stricture was made based on clinical,biochemical,histological and radiological results.Endoscopic treatment was the first-line treatment of biliary anastomotic stricture.RESULTS:Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients,so they underwent conversion hepaticojejunostomy.Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy.In the end-to-side group,two patients sustained hepatic artery injury requiring repeated microvascular anastomosis,two developed restenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation,and two required revision hepaticojejunostomy.In the side-to-side group,one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation.No re-operation was needed in this group.Otherwise,outcomes in the two groups were similar in terms of liver function and graft survival.CONCLUSIONS:Despite the similar outcomes,side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops.However,more large-scale studies are warranted to validate the results.