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.