Gordon, RD

Koneru, B

Makowka, L

Marsh, JW

Starzl, TE

Stieber, AC

Todo, S

Tzakis, A

Wilson, B

English

Name not available

Biliary tract complications in orthotopic adult liver transplantation: Comparison of anastomotic complications with braided absorbable suture (polyglactin 910) versus a new monofilament absorbable suture (polyglyconate)

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I DOlT Biliary Tract Complications in Orthotopic Adult Liver Transplantation Barbara J. Wilson, MD, J. Wallis Marsh, MD, Leonard Makowka, MD, PhD, Andrei C. Stieber, MD, Babu Koneru, MD, Satoru Todo, MD, Andreas Tzakis, MD, Robert D. Gordon, MD, Thomas E. Starzl, MD, PhD, Pittsburgh, Pennsylvania In a series of orthotopic liver transplantations per-formed between April and August 1987 at the Uni-versity of Pittsburgh, the monofilament absorbable suture polyglyconate was compared with a braided absorbable suture, polyglactin 910, for its biliary complication rate over a 6-month postoperative pe-riod. Complications that were suture-related (ob-struction or leak from the anastomotic site) oc-curred in 1 of 21 transplantations in the polyglyconate group compared with 8 of 26 in the polyglactin 910 group (p = 0.02). Even though the patient sample was relatively small, it appears that the type of suture used for the biliary anasto-mosis directly correlates with the outcome. A larger patient trial could confirm these initial results. I n the early era ofliver transplantation, the biliary anas-tomosis was considered the operative Achilles heel. Over the past 25 years, however, the biliary drainage procedure has now been well rermed, and advances other than technical seemed the next logical avenue of pursuit. Specifically, could the choice of suture material used for this anastomosis further lower the rate of biliary compli-cations? To test this hypothesis, a new monofilament absorbable suture (polyglyconate) was compared with the standard suture in use at the University of Pittsburgh (polyglactin 910) for the biliary anastomosis. The pur-pose of the study was to determine if the type of suture used for the biliary tract reconstruction after liver trans-plantation would influence the incidence and type of com-plication seen. MATERIAL AND METHODS Beginning in April 1987, 50 consecutive cases of liver transplantation in adults were to be randomly assigned by From the Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Requests for reprints should be addressed to Barbara J. Wilson, MD, 3601 Fifth Avenue. Pittsburgh, Pennsylvania 15213. Supported by grants from Davis and Geck. Wayne. New Jersey; the Veterans Administration Medical Center, Pittsburgh. Pennsylvania: and by Pro-ject Grant AM 29961 from the National Institutes of Health. Bethesda. Maryland. a computer-generated code to have the biliary anastomo-sis performed with either polyglyconate or polyglactin 910. The type (Roux-Y versus choledochocholedochos. tomy) and technique (running versus interrupted suture placement) of the anastomosis was dictated by patient disease, size of the bile duct, and surgeon preference, Upon completion of the case, a case report record filled out by the operating surgeon and the patients followed both on an inpatient and outpatient basis. A month follow-up was mandatory for inclusion in the study to provide adequate time for suture-related cations to occur. Any patient who died within the month period was excluded, unless the death was by a biliary complication. Patients who died while study was still in progress were replaced. All patients who had a \OU .... l ...... V'-.l1V .... "'l ... '.V ... llV',.V1Jllll had a T tube in place for a minimum of 3 months. patients were routinely evaluated at least twice by giogram, before the T tube was clamped, and again fore the T tube was removed at 3 months. In <1U\ULlC'I\, cholangiograms were obtained for any suspicion of a iary complication. Patients with a Roux-Y '-'U\JllO'.>V\..l1VJIVI junostomy did not have external access to the biliary therefore, routine studies which would have required invasive procedure were not performed. These (13 of 24 or 54.2 percent) were evaluated by ous transhepatic cholangiogram if there was any or laboratory suspicion of a biliary complication. If stricture was found and was suitable for radiologic tion, this method was attempted first [1]. If the could not be radiologically dilated or if a leak was surgical correction was required. Transplantation in these patients was for a variety of liver disorders including primary cirrhosis, sclerosing cholangitis, refractory PA ••• ,.ttn1!l Laennec's cirrhosis, alpha I-antitrypsin disease, active hepatitis, hepatoma, and autoimmune "DrDCDntE~oellll cirrhosis. Statistical analyses (chi-square) were calculated ing the statistical analysis modules in SPSS on an System 1800 microcomputer. rna, one RESULTS bacterial Fifty-nine patients were actually entered into and two study; 9 patients died while the study was still in more tha Twenty-eight patients underwent biliary nK"~""DDDD a biliary with polyglyconate; of these, 7 died and were There from the study (2 from primary non function of the COnate g I from recurrent hepatoma, I from rejection. I PQ!yglact vascular anastomosis technical failure, and 2 from ed into r. megaloviral infection). Of the 21 patients followed. (Figure] 68 THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989 0' . I ~n~ u I~ ~! I; lao llt, :UI' Figure 1. Ampullary dysfla1ctlon. Top arrow Indicates native common hepatic duct, l~ middle arrow Indicates dilated native cystic aQ\ duct, and bottom arrow Indicates donor fl~ common bile duct. ,nil :ni\ underwent choledocholedochostomy and 9 underwent Roux-Y choledochojejunostomy. u' Thirty-one patients underwent anastomosis with po-:rc Iyglactin 910. Seven of these patients died; five were , excluded from the study (one died from recurrent hepato-ma, one from rejection, one from hepatitis B, one from bacterialinfection, and one died in the operating room) and two were included (one from recurrent gastrinoma m~~ than 6 months postoperatively, one from sepsis from a biliary leak). There were four biliary complications in the polygly-COnate group versus eight biliary complications in the 910 group. The complications could be divid-nonanastomotic, that is, ampullary dysfunction •. ·KDDD·IrDD~_ 1) or anastomotic. Of the four complications in VICRYL VERSUS MAXON: BILIARY COMPLICATIONS the polyglyconate group, three were non anastomotic problems and thus could not be related to the suture material. The first patient had been reconstructed with a choledochojejunostomy and developed a stricture of the bifurcation of the common hepatic ducts (high above the anastomosis) successfully dilated by the radiologist. The second patient had been reconstructed with a choledocho-choledochostomy and developed uniform dilatation of the entire biliary system secondary to a stenosis at the ampul-la of Vater. This anastomosis was converted to a Roux-Y choledochojejunostomy. The third patient was recon-structed with a choledochocholedochostomy. Postopera-tively, the patient became disoriented and pulled out the T tube; he was converted to a Roux-Y choledochojejunos-tomy. The fourth patient had been reconstructed with a THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989 69 WILSON ET AL choledochocholedochostomy and developed an anasto-motic stricture which required conversion to a Roux-Y choledochojejunostomy. There were eight anastomotic complications in the polyglactin 910 group; four with choledochocholedochos-tomy reconstructions (two successfully dilated, two con-verted to Roux-Y choledochojejunostomies) and four with Roux-Y choledochojejunostomies (two were suc-cessfully dilated, one had a revision of the choledochoje-junostomy, and one patient died secondary to sepsis after a biliary leak at the anastomosis). All complications in-volved the anastomosis and thus could be potentially re-lated to the suture material. The possible suture-dependent complications for po-lyglyconate and polyglactin 910 were compared using the chi-square test. The difference in complication rate was statistically significant (p = 0.0243), with polyglyconate giving superior results. COMMENTS Improvement in the survival rate for liver transplanta-tion since 1963 has been largely due to improvements in immunosuppressive drugs (cyclosporine) and refine-ments in the technique of the bilary tract reconstruction [2]. Failure of the biliary anastomosis has been demon-strated to occur early after transplantation as a result of rejection, hepatic artery thrombosis, stricture, leak, or infection [3]. Due to an evolution in the understanding of the biliary tract vascular anatomy and physiology, and to the development of diagnostic radiologic methods for ear-ly identification and treatment of biliary complications, this complication rate has dropped to 10 to 15 percent from 50 percent in the early series (4]. In May 1986, the University of Pittsburgh reported results of 393 consecu-tive orthotopic liver transplants in 313 patients. There were 52 biliary tract complications (13.2 percent) with 5 directly related deaths [4]. Improvements in suture development have led to the availability of synthetic absorbable sutures which have a reproducible absorption rate not influenced by wound conditions (inflammation or infection) or body fluids [5,6]. In contrast to animal~matter suture material, syn-thetic absorbable sutures undergo nonenzymatic hydrol-ysis, thereby generating less inflammatory reaction than the enzymatic phagocytosis of surgical gut [5,6]. Prior to the availability of the new monofilament su-ture polyglyconate, the suture used for the biliary anasto-mosis at the University of Pittsburgh had been polyglac-tin 910, a braided absorbable material. Experimental studies have shown that braided material can significant-ly increase the wound infection rate [7]. The mechanism by which this occurs has beell attributed to bacterial adherence to the braided suture. Bacterial adherence of braided suture is 5 to 8 times that of monofilament nylon and correlates with the incidence of infection [8-10]. Polyglyconate is a synthetic monofilament suture, a copolymer consisting of glycolic acid and trimethylene carbonate. It is completely absorbed by nonenzymatic hydrolysis and is essentially absorbed in 180 days and completely absorbed in 210 days. It maintains 70 percent of its original tensile strength after 2 weeks and 55 per. cent of its strength after 3 weeks [7]. Coated polyglactin 910 is a braided synthetic, absorb. able suture. It is composed of polyglactin 910 which is 90 percent polyglycolic acid and 10 percent lactic acid. It, too, is absorbed by nonenzymatic hydrolysis, being essen. tially absorbed between 60 and 90 days. It maintains 55 percent of its original tensile strength at 2 weeks and 20 percent at 3 weeks. , This study of biliary anastomotic complications using I monofilament polyglyconate versus braided polyglactin 910 in transplant patients who have compromised wound healing secondary to immunosuppression demonstrated the superiority of polyglyconate. Transplant patients, as a rule, typify the most extreme population of patients upon whom trials of this sort are performed; these patients are immunosuppressed, often malnourished and very cata· bolic, and many have had multiple previous surgeries. The fact that there was a significant difference between the complication rate for each suture in this small series of patients suggests that polyglyconate would also be of benefit in the nonimmunosuppressed patient undergoing biliary tract surgery. REFERENCES 1. Mueller PR, vanSonnenberg E, Ferrucci JT Jr, et al. Biliary stricture dilation: multicenter review of clinical management in 73 patients. Radiology 1986; 160: 17-22. 2. Starz! TE, Iwatsuki SI, Van Thiel DH, et al. Evolution of liver transplantation. Hepatology 1982; 20: 614. 3. Tzakis AG, Gordon RD, Shaw BW Jr, et al. Clinical presenta· tion of hepatic artery thrombosis after liver transplantation in the cyclosporine era. Transplantation 1985; 40: 667. 4. Lerut J, Gordon RD, Iwatsuki SI, et al. Biliary tract complica. tions in human orthotopic liver transplantation. Transplantation 1987, 43: 47-5l. 5. Laufman H, Rubel T. Synthetic absorbable sutures. Surg Gyne-colObstet 1981; 145: 597-608. 6. Hartko WJ, Ghanekar G, Kemmann E. Suture materials cur. rently used by obstetric surgery in the United States. A question· naire survey. Surg Gynecol Obstet 1982; 59: 241-6. 7. Gere JM, Timoshenko SP. Mechanics of material. 2nd ed. Mon' terey, CA: Brooks/Cole, 1984: 417. 8. McGeehan D, Hunt D, Chaudhuri A, et al. An experimental study of the relationship between synergistic wound sepsis and suture materials. Br J Surg 1980; 67: 636-8. 9. Katz S, Izharm M, Mirelman D. Bacterial adherence to surgical sutures: a possible factor in suture induced infection. Ann Sur! 1981; 194: 35-4l. 10. Paterson-Brown S, Cheslyn-Curtis S, Biglin J, et al. Suture materials in contaminated wounds: a detailed comparison of a ne'l suture with those currently in use. Br J Surg 1987; 74: 734-5. 11. Zajko AB, Bron KM, Campbell WL, Behal R, Van Thiel DB, Starzl TE. Percutaneous transhepatic cholangiography and biliarY drainage after liver transplantation: a five-year experience. Gat trointest Radiol 1987; 12: 137-43. 70 THE AMERICAN JOURNAL OF SURGERY VOLUME 158 JULY 1989 

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Biliary tract complications in orthotopic adult liver transplantation: Comparison of anastomotic complications with braided absorbable suture (polyglactin 910) versus a new monofilament absorbable suture (polyglyconate)

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