Type of donor aortic preservation solution and not cold ischemia time is amajor determinant of biliary strictures after liver transplantation

The development of biliary strictures (BSs) after liver transplantation (LT ) continues to affect 10% to 30% of patients, causing substantial morbidity . The cause of BSs is multifactorial, including technical, immune, and, in particular, ischemic factors. The importance of adequate flushing of the pe ribiliary arterial tree has been stressed. We hypothesized that high-viscos ity (HV) preservation solutions in the donor do not completely flush the sm all donor peribiliary plexus, leading to inadequate preservation of the bil e ducts and posttransplant BSs. To test this hypothesis, we retrospectively compared the incidence of BSs in 2 groups of adults undergoing LT using di fferent types of aortic preservation solution in the donor: group I (n = 24 ), low-viscosity (LV) Marshall solution; and group 2 (n = 27), HV Universit y of Wisconsin (UW) solution. All donors in both groups received additional portal flushes with UW. All LTs were performed between November 1995 and A ugust 1998 at 2 centers by the same surgeon, eliminating a technical bias. Terminal duct-to-duct anastomosis was performed in all recipients except 1 patient in group 1, who underwent a bile duct-to-jejunum anastomosis. BSs w ere first suspected on clinical and biochemical grounds and then confirmed by endoscopic retrograde cholangiopancreatography. Identical medical protoc ols were used in all patients. One-year patient survival rates in groups 1 and 2 were 92% and 100%, respectively (P = .9). One-year graft survival was identical to patient survival. The incidence of BSs in group 1 was 4.1% (1 of 24 patients), compared to 29.7% in group 2 (8 of 27 patients; P = .02). The BS in group 1 occurred 4 months post-LT and was anastomotic. BSs in gr oup 2 occurred between 1 and 12 months post-LT and were anastomotic, extrah epatic, intrahepatic, or combined intrahepatic and extrahepatic. There were no significant differences in the following factors between groups 1 and 2 : donor age, local versus imported liver, split-liver or full-liver transpl antation, incidence of multiple vessels in the donor liver, indications for LT, recipient age, T-tube versus no T-tube, post-LT peak aspartate aminotr ansferase level, and treatment for rejection. There was no hepatic artery t hrombosis or primary nonfunction in either group. Interestingly, cold ische mia time (CIT) was longer in group 1, which had the least incidence of BSs (692 +/- 190 v 535 +/- 129 minutes in group 2; P = .001). Follow-up was lon ger in group 1 (28.9 +/- 8.3 v 15.6 +/- 8 months in group 2; P = .0001). Pr eservation costs per procurement were 1.9 times greater in the UW group tha n in the Marshall group. Donor aortic flushing with an HV preservation solu tion leads to more frequent BSs compared with an LV preservation solution. The impact of preservation solution out-weights the previously described de leterious impact of prolonged CIT. Mixed preservation solution (Marshall so lution in the aorta, UW solution in the portal vein) might protect against BS formation while providing optimal liver graft preservation, function, an d survival despite a mean CIT longer than 10 hours.