DISCUSSION
Biliary complications following LDH are common and the incidence has been reported to range from 0 % to 38.6 %. 9Ghobrial and colleagues 10 have reported a retrospective study conducted by the A2ALL study group conducted in conjunction with 9 centers that perform LDLT and they have reported that complications are the second most common complications that are encountered in LLDs in the postoperative period with an incidence of 9.2%. Our complications are a bit lower than that has been reported in their study. However, a recent review by Simoes and colleagues11 have stated that the incidence of biliary complications among the donors ranged between 6% to 18%. Wide variations of biliary complications in LLDs reported in various studies may be due to the lack of uniform definition of these complications. In centers who report low postoperative biliary complications can be due to low rate of abdominal drains use, negligence of the subclinical bile leaks, and early discharges because of cost problems in these centers.12-14 In the present study, overall postoperative biliary complications following LDH is 7.8 %. Total biliary complication rates in LLDs have been shown to be higher in right lobe harvesting (6.6 % versus 2.9 %).9 Biliary anatomic variations of the right lobe of the liver are more frequently encountered which may explain the high complication rates observed in the present study. In our study, no statistically significant difference between right and left lobe donors in terms of biliary complications may be due to advanced experience of approximately 250-300 LDLTs annually.
The algorithm for the management of postoperative biliary complications presented in our study is the result of extensive experience of our institute, obtained through a long period of time. In some studies, flowchart-like diagrams are presented for the diagnosis and treatment of biliary complications; however, in these studies an development of an algorithm was attempted based on results obtained from low volume experience. 2,15 We think that our flowchart (Graphic-1) is a study that results from a high patient volume series and clearly demonstrates the treatment methods. To give an example, our management algorithm is very clear in the cases with low output bile leaks that stem from isolated minor bile ducts. It is noteworthy to emphasize that 30 years have passed since the first LDLT procedure and little has been published to guide the physicians regarding the management of biliary complications following LDH. We believe that the present study will provide a useful algorithm for management of postoperative living donor biliary complications in centers performing LDLT.
The necessity of HJ for management of the biliary complications in cases that cannot be treated by the interventional methods following LDH is a reality. The publications from centers that perform LDLT have major shortcomings regarding the extent of LLDs that receive HJ following biliary complications. For example, it is not clear whether “the surgical repair” and “repeat biliary reconstruction” referred to in these studies is in fact HJ or not. 15,16 We do not see much emphasis on this issue in the literature. To date, we have tried to find cases of HJ reported in LLDs. A total of 15 HJs were reported in 9 published studies except four cases of HJ that was reported from our institute (Table 1) 4-6,14,17-24 In the present study, the rate of HJ among those who experience biliary complications was 0.56%.
HJ is a major operation performed for the management of biliary complications following LDH. This has emotionally adverse effects on the LLD surgeons. Nevertheless, it is noteworthy that HJ is a life-saving procedure in the management of biliary complications because biliary complications may result in death of the donor. 2,25Of course, all non-surgical methods should be used to treat biliary complications especially in LLDs. However, unnecessary waiting of the cases that do not recover will only result in a disaster. In biliary leaks that are not resolved with percutaneous radiologic interventions, HJ should be kept in mind as a last resort for the management. In other words, we think that after a few unsuccessful attempts of minimally invasive procedures, we should not underestimate the success of a HJ procedure.
In the operations for biliary stricture, the most difficult part of this operation was to reveal the obstructed biliary duct on the dens structured hepatic hilum. We believe that this difficulty can be overcome with the percutaneous transhepatic biliary drainage catheter assisted HJ described in this study.
Furthermore, if HJ is chosen to treat a biliary complication in an LLD, it should be performed as one step procedure during the reoperation. In the present study, another procedure was needed in one LLD who was operated for biliary complication and HJ was performed. In this LLD, HJ was performed to a sufficiently wide bile duct. Intraoperative cholangiography was performed through a PTBD catheter that has been inserted prior to operation and bile ducts were visualized and the operation was ended. In fact, the visualized bile ducts belong to segment II and IV. Segment III hepatic duct remained obstructed and were not visualized. Unfortunately, we did not compare the final intraoperative cholangiography images with donor MRCP or intraoperative cholangiography images obtained at the beginning of the LDH procedure. Therefore, this patient required re-laparotomy for a second HJ anastomosis.
In LLDs with early-recognized biliary complication, presence of a skilled endoscopists and interventional radiologists has paramount importance. In this study, we mentioned 12 LLDs whose biliary complications had to be treated with HJ although we had endoscopists and interventional radiologists with extensive experience. Of course, minor bile ducts originating from the cut surface of the remnant liver should be evaluated with extreme caution during the operation. Intraoperative cholangiography should be examined diligently to evaluate any misinterpreted major biliary tract injuries and if necessary, cholangiography should be repeated from different flip angles.
This is the largest LLDs series in the literature and we have described the treatment algorithm for biliary complications and we have frankly presented HJ cases. The results of this study show that postoperative biliary complications are still a major problem following LDH. Furthermore, about 7 % of the LLDs with biliary complications require HJ for management of this complication. Donor safety during LDLT is imperative, however if this concern leads to improper transection of the graft donor, the results may be devastation for the recipient. Therefore, a good balance should be obtained during the LDH procedures. Necessary precautions should be taken to avoid damage to the donor bile ducts but we should also provide sufficient bile ducts for safe anastomosis in the recipient. However, occasionally this balance can be disrupted leading to unfavorable outcome in the donor. In countries with insufficient cadaveric organ supply, LDLT will still continue to be the major source of organ supply and biliary complications will be encountered in the LLDs. In centers performing LDLT, it should be a priority to employ early and accurate management protocol for postoperative donor biliary complications.