Reconstructive surgery for ischemic - Type lesions at the bile duct bifurcation after liver transplantation

Objective To assess the feasibility, morbidity, mortality, and clinical suc cess rate of surgical reconstruction of the biliary system in patients with ischemic-type biliary lesions in their liver graft. Summary Background Data After liver transplantation, strictures in the bili ary tree with secondary sludge formation can occur in the absence of vascul ar problems. Jaundice, pruritus, and recurrent cholangitis are predominant clinical features leading to considerable morbidity. Interventional measure s are the first-line treatment but are frequently only of transient success . Retransplantation is usually considered when interventional treatment is not effective. Methods Surgical exploration and reconstruction was performed in 17 patient s with ischemic-type biliary strictures at a median of 2 years after liver transplantation. Findings during surgery, surgical strategies, and postsurg ical courses are described. Clinical symptoms and biochemical parameters of cholestasis and liver function were analyzed in the postsurgical course. Results During surgery, all 17 patients were found to have strictures or sc lerotic changes involving the hepatic bifurcation and extrahepatic bile duc t. Sludge or stones were present in nine patients. In 14 patients with viab le bile ducts proximal to the bifurcation, surgical reconstruction was perf ormed by resection of the bifurcation and hepaticojejunostomy. In three pat ients with more extensive biliary destruction, portoenterostomy with or wit hout peripheral hepatojejunostomy was performed. The prevalence rate of bil iary infection at surgery was 93%; the predominant organisms were Candida a nd enterococci. The perioperative mortality rate was 0%. Clinical symptoms and biochemical parameters became normal or were considerably improved in 1 4 of 16 patients (88%). Conclusions The hepatic bifurcation seems to be a predominant site for isch emic-type biliary changes after liver transplantation. Surgical treatment b y resection of the bifurcation and reconstruction by high hepaticojejunosto my is a safe and highly effective approach leading to cure or persistent ma jor improvement in most patients.