AMBROSINO, G

ESQUIVEL, CO

GORDON, RD

IWATSUKI, S

KAHN, D

LERUT, J

MAKOWKA, L

MARSH, JW

MIELES, L

STARZL, TE

STIEBER, AC

TODO, S

TZAKIS, AG

English

PubMed

Stieber, AC

Ambrosino, G

Kahn, D

Mieles, L

Makowka, L

Lerut, J

Iwatsuki, S

Todo, S

Marsh, JW

Tzakis, AG

Gordon, RD

Esquivel, CO

Starzl, TE

Name not available

An unusual complication of choledochocholedochostomy in orthotopic liver transplantation

D-Scholarship@Pitt

An Cnusual Complication of Choledochocholedochostomy in Orthotopic Liver Transplantation A.C Stieber. G. Ambrosino, D. Kahn, l. Mieles. L. Makowka, J. Lerut, S. Iwatsukl, S. Todo, J.W. Marsh, A.G. Tzakls: R.D. Gordon. C.O. Esquivel, and T.E. Starzl BI L 1.\ R Y reconstruction was long consid-ered the Achilles heel of the liver trans-plant operation. The refinement in the tech-niques described by various authors ' has dramatically reduced the incidence of biliary complications. These complications still oc-cur. however. and carry a disproportionately high penalty in terms of morbidity and mor-talityK~ The obstructive type of these compli-cations sometimes has a very insidious presen-tation and course that requires a high index of suspicion for a correct diagnosis. Our group favors the end-to-end choledochocholedochos-tomy (CC) repair whenever feasible. 3 Over the past few years. a certain complication of this type of repair. heretofore unreported. has emerged: the diffuse dilatation E~lF of both donor and recipient common bile ducts (C 80s) without any obvious mechanical obstruction. MATERIALS AND METHODS Dunng the period from March l. 1980. to June 30. 1987.886 patrents underwent orthotopic liver transplan-tation (OL TX) at the L'niversity of Pittsburgh Health Center; there were 557 adults (age over 18) and 329 children (aged 18 or under). The biliary reconstruction ... as performed with 3 CC in 441 patients (46%) and with a Roux-en- Y choledochojejunoslOmy (RY) or some other method in 475 patients (54%). RESULTS Of the patients who underwent reconstruc-tion by ee, 65 (15.8%) had some significant complication: 23 (35.4%) DO of the eBO Without any apparent stricture (ST). 22 03.8%) bile leaks, and 20 (30.8%) ST. The time of onset of OD was an average of 34.6 weeks after OL TX (range, I to 330 Weeks). The presentation was usually with an eleva-tion of the bilirubin and liver enzyme levels. Some patients had been already treated for presumed rejection with several pulses of intravenous steroids before the bile duct prob-lem was finally diagnosed. DISCUSSION In our experience. it appears that the most frequent complication of the ee is DD of the CBD. without any obvious physical obstruc-tion (ST) (Fig I). The DD develops gradually in the majority of the patients and causes a rather insidious elevation of the levels of serum bilirubin and liver enzymes. Frequent-ly. these changes are interpreted as bouts of rejection and treated with pulses of steroids with variable (but usually incomplete) results. Even the histological presentation. on biopsy specimens. can be misleading because it may mimic rejection or early chronic active hepati-tis. The direct study of the C 8 D by a percuta-neous transhepatic cholangiogram (PTe) or endoscopic retrograde cholangiopancreato-gram is the best way to diagnose the condition (Fig 2). We postulate that the DD is the result of a papillary dyskinesia that is caused by either devasculariza tion or denervation of the papilla of Vater during the recipient hepatectomy. To us. the denervation mechanism seems both more likely and more logical. In this latter case. the result is an outlet obstruction-type of syndrome, If this holds true, treatment must consist of From the Deparrment of Surgery, L'niversity of Pius-burgh. K~ddree reprint requests to A.C. Stieber, MD. Depart-ment of Surgery. L'niversit}' of PilTsburgh, Folk CliniC 5C. 3601 Fifth Ave. PillSburgh. PA /52/3. e /QR8 by Grunt' & Strallon. Inc. 004/-/345/88;::00 /-/22 3503.00;0 TranSPlantatIon Proceedings. Vol XX, No 1, Suppl 1 (February). 1988. pp 619-621 619 620 a decompression procedure: we favor a recon-struction by means of an R Y. which we find technically rather simple as well as safe and nclfectiYe. Only two patients (8. 70{ ) of the ones converted to RY anastomosis had any compli-cation. and this was easily corrected surgically or percutaneously. There was no death in this group. An attempt at balloon dilation after PTe may be helpful in avoiding open surgery. Although endoscopic papillotom) could be advocated b) some. it does not appear to be a STIEBER ET AL Fig 1. Diffuse dilatation of the CBO. diagnosed by PTC. No obvious stricture of the papilla is apparent. viable alternative because the length of the involved segment (3 to 4 cm) seems too big for the efficient and safe use of this method. Finally. if a study could be devised that would permit the identification of those patients" ho would suffer a denervation of their papillary mechanism during hepatecto-my. a primar) RY could be directly per-formed. even in the absence of any other contraindications to ec. in this way avoiding the de\elopment of DD at a later time. 3tLE DUCT ECTASIA IN L!VER TRANSPLANTATION Fig 2. Diffusely dilated CaD by ERCP (the recipient', duct is more dilated than the donor's) 6 years after Ol TX. REFERENCES 1. Starzl TE. Iwatsuki S. VanThiei D. et al: Hepatol-ogy 2:614. 1982 621 2. lerut J. Gordon RD. Iwatsuki S. et al: Transplanta-tion 43:47.1987 3. Caine RY: In Caine RY (ed): liver Transplanta-tion. Philadelphia. Grune & Stratton. 198 5. p 169 

AN UNUSUAL COMPLICATION OF CHOLEDOCHOCHOLEDOCHOSTOMY IN ORTHOTOPIC LIVER-TRANSPLANTATION

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AN UNUSUAL COMPLICATION OF CHOLEDOCHOCHOLEDOCHOSTOMY IN ORTHOTOPIC LIVER-TRANSPLANTATION

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