Reach for the endoscope or the wire but not the knife for biliary stricture after living donor liver transplantation

Here is my highlight from the April issue of HPB. This focuses on an excellent paper describing non-operative intervention for biliary stricture complicating living donor liver transplantation.

  1. Gun Hyung Na,
  2. Dong Goo Kim*,
  3. Ho Joong Choi,
  4. Jae Hyun Han,
  5. Tae Ho Hong and
  6. Young Kyoung You

 

Re-operating on patients after liver transplantation is never a rewarding experience and can be extremely dangerous. When a patient has undergone a living donor liver transplant (LDLT) the stakes are even higher as there may be no opportunity for deceased donor rescue in case of vascular complications. Biliary stricture is common after living donor liver transplant and can be difficult to manage. Many LDLT programmes are small and do not have the case experience to manage such complications with complete confidence. It is really important therefore to learn from centres like St Mary’s Hospital, Seoul, Korea who have a vast experience. In this edition of HPB this centre reports its approach to managing 160 biliary strictures occurring in almost 500 patients who received a right lobe LDLT with a duct to duct anastomosis. The greatest single risk for development of biliary stricture was a post transplant bile leak and urgent surgery was also associated with greater risk. The authors have shown that using a variety of techniques such as ERCP, PTBD or combinations of these procedures it is possible to manage almost all such strictures. The avoidance of major revisional surgery is undoubtedly to the advantage of these patients. The number of failures was remarkably small but sepsis combined with biliary stricture was associated with a small number of deaths. The value of these interventional approaches is shown by the observation that overall survival was not significantly different between patients with and without a biliary stricture and in both cases this exceeded 80% at 5 years.

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