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Chapter 28
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Case on A Patient with Biliary Strictures
in One-Half of the Liver After Liver
Transplantation
Geert Kazemier and Herold J. Metselaar
Keywords Biliary strictures • Liver transplantation • Hepatocellular carcinoma •
Steatohepatitis • Liver cirrhosis
Diagnosis and Indication for Surgery
A 57-year-old male patient with end-stage liver disease because of nonalcoholic
steatohepatitis-induced liver cirrhosis and three hepatocellular carcinomas smaller
than 2 cm each was placed on the waiting list for liver transplantation. His medical
history revealed no other abnormalities, apart from the liver disease. Physical examination showed a patient in good clinical condition with slight jaundice. He was
depended on diuretic medication to control ascites. Severity of cirrhosis was considered Child-Pugh B and his Model for End-Stage Liver disease score was 17. CT
scanning showed no signs of metastatic disease, and portal vein, hepatic artery,
hepatic veins, and inferior vena cava were patent.
Liver Transplantation
After a waiting time of 5 months, a blood type compatible liver from a 51-year-old
brain dead, heart beating donor became available. The donation pocedure was
uneventful. Explorative laparotomy in the recipient through a J-shaped incision
G. Kazemier , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: g.kazemier@vumc.nl
H.J. Metselaar
Department of Gastroenterology , Erasmus Medical Center , Rotterdam , The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_28,
© Springer International Publishing Switzerland 2014
153
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revealed no evidence for tumor spread outside the liver and removal of the diseased
liver was straightforward. The liver graft was reperfused after the side-to-side cavocavostomy and portal venous anastomosis were performed. Cold-ischaemia time was
510 min and warm ischemia time was 23 min. The arterial anastomosis was performed after reperfusion and took 19 min to complete. An end-to-end biliary anastomosis was performed without the use of a T-tube to restore bile fl ow. The estimated
total blood loss was 2,300 mL and no blood transfusions were administered. Intraand direct postoperative Doppler color ultrasonography showed intact arterial, portal,
and hepatic venous blood fl ow. However, on the fi rst postoperative day, turbulent fl ow
was noticed in several right portal vein branches during routine Doppler ultrasonography. Arterial fl ow and fl ow in the left portal vein and hepatic veins were normal.
G. Kazemier and H.J. Metselaar
Postoperative Course
Postoperatively, liver function was recovering quickly with peak transaminases of
400 IU/L Therefore, surgical intervention was deemed unnecessary. Ultrasound
imaging on the following days showed persistent turbulent fl ow in the right portal
vein branches but normal fl ow patterns in all other vessels. Postoperative recovery
was complicated by a wound infection which was treated by draining the wound
and the patient was discharged on the 24th postoperative day. Immunosuppressive
therapy consisted of tacrolimus and low-dose prednisone.
Follow-Up and Second Operation
During the following months, the patient suffered from recurrent attacks of cholangitis with high fever, bilirubin levels up to 150 μmol/L, and positive blood cultures
with Gram-positive and Gram-negative bacteria. On subsequent endoscopic retrograde cholangiopancreatographic interventions (ERCPs), multiple strictures in the
right posterior, and inferior branches of the biliary tree were diagnosed, while bile
ducts in the left half of the liver and the biliary anastomosis remained unaffected
(Fig. 28.1 ). Portal venous fl ow was uncompromised in the left half of the liver, but
portal fl ow to the right hemiliver was diminished due to thrombosis of portal braches
in the right anterior and posterior liver. All other vascular structures were unaffected. Several endoscopic procedures of dilatation and stenting of different biliary
stenosis in the right hemiliver were only temporarily successful. Additional treatment with ursodeoxycholic acid did not resolve symptoms.
Eventually, 15 months after transplantation, a right hemihepatectomy was performed (Illustration 28.1 ). This operation was cumbersome due to extensive adhe-
sions of the right hemi liver and diffi culty to identify and control hilar structures.
The postoperative course was complicated by a wound infection, which was treated
by draining the wound and biliary leakage from the stump of the right bile duct
resolved by draining the biloma percutaneously and subsequent endoscopic
28 Case on A Patient with Biliary Strictures in One-Half of the Liver
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a
Fig. 28.1 ERCP images showing abnormal bile ducts on the right side of the liver ( a ) and normal
bile ducts in the left hemi-liver ( b )
b
Stenosis
155
Thrombus
Illustration 28.1 After liver transplantation, right posterior and inferior branches of the biliary
tree were stenosed causing recurrence cholangitis. Moreover portal branches of the right anterior
and posterior liver were thrombosed. Decision was taken to perform a right hemihepatectomy
stenting. Patient was discharged from the hospital on the 20th day. Histopathological
examination of the removed right hemiliver revealed extensive damage and irregularity of the biliary epithelium, ductopenia in the majority of portal tracts, intact
arterial and hepatic venous circulation, and extensive circulatory impairment and
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thrombosis of the portal venous system. The patient recovered from the surgery and
is currently asymptomatic with slightly elevated bilirubin levels, but otherwise normal liver function on low-dose tacrolimus immunosuppressive monotherapy.
G. Kazemier and H.J. Metselaar
Discussion
Biliary complications form a signifi cant cause of morbidity and mortality after liver
transplantation [ 1 ]. Early biliary complications, either leakage or stenosis at the
anastomotic site, are usually caused by surgical failure and typically occur in the
fi rst days postoperatively after liver transplantation. The majority of these complications can be treated by ERCP or percutaneously; a reoperation is rarely indicated.
Biliary complications occurring later after transplantation are mostly due to biliary
strictures not at the anastomotic site. Those non-anastomotic strictures (NAS) are
often diffusely present but sometimes affect predominantly one or more segments
or one liver half. They represent a considerable cause of graft loss as they can affect
up to 25 % of liver grafts and lead to retransplantation rate of up to 50 % in some
series. NAS can occur after hepatic artery thrombosis or with an open hepatic artery.
Both share radiological similarities, and, thus, strictures occurring with a patent
hepatic artery are often called ischemic-type biliary lesions or ITBL. Donation after
cardiac death is a major risk factor for development of ITBL, probably due to
increased ischemia–reperfusion injury in those grafts [ 2 ]. Prolonged ischemia times,
bile salt toxicity, and AB0 blood type incompatibility between donor and recipient
have also been recognized as risk factors [ 3 ]. There is increasing interest in impaired
biliary microcirculation as a possible cause of ITBL [ 4 ] and urokinase treatment of
the graft has been shown to prevent its development [ 5 ]. Intra-and extrahepatic bile
ducts have a unique anatomic feature in that they are provided with blood by a
peribiliary capillary plexus. Previous studies concluded that this plexus is exclusively provided with blood from the hepatic artery. Recent studies showed however
that impairment in portal fl ow can also lead to NAS [ 6 ] and that the contribution of
portal venous microvascular blood fl ow through the bile duct is 40 % [ 7 ]. Particularly
after liver transplantation, when the blood fl ow to the intrahepatic bile ducts through
the gastroduodenal artery is no longer possible because of complete transection of
the hepatoduodenal ligament this can become clinically important, as is illustrated
in the described patient.
28 Case on A Patient with Biliary Strictures in One-Half of the Liver
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157
References
1. Pascher A, Neuhaus P. Bile duct complications after liver transplantation. Transpl Int.
2005;18:627–42.
2. Dubbeld J, Hoekstra H, Farid W, et al. Similar liver transplantation survival with selected car-
diac death donors and brain death donors. Br J Surg. 2010;97:744–53.
3. Heidenhain C, Pratschke J, Puh G, et al. Incidence of and risk factors for ischemic-type biliary
lesions following orthotopic liver transplantation. Trans Int. 2009;23:14–22.
4. Ren J, Lu MD, Zheng RQ, et al. Evaluation of the microcirculatory disturbance of biliary isch-
emia after liver transplantation with contrast-enhanced ultrasound. Liver Transpl.
2009;15:1703–8.
5. Lang R, He Q, Jin ZK, et al. Urokinase perfusion prevents intrahepatic ischemic-type biliary
lesion in donor livers. World J Gastroenterol. 2009;15:3538–41.
6. Farid WRR, De Jonge J, Slieker JC, et al. The importance of portal venous blood fl ow in
ischemic-type biliary lesions after liver transplantation. Am J Transplant. 2011;11(4):857–62.
7. Slieker JC, Farid WR, van Eijck CH, et al. Signifi cant contribution of the portal vein to blood
fl ow through the common bile duct. Ann Surg. 2012;255:523–7.
Chapter 29
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Case on Patient with a Stenosis of the
Cavocavostomy After Liver Transplantation
Geert Kazemier and Herold J. Metselaar
Keywords Cavocavostomy • Liver transplantation • Crigler–Najjar syndrome •
Complications • Budd Chiari syndrome
Diagnosis and Indication for Surgery
A 21-year-old girl suffering from Crigler–Najjar syndrome type I was successfully
treated with light therapy until her 18th life year. Due to therapy-resistant progressive hyperbulirubinaemia patient was evaluated for a liver transplantation. There
were no signs of liver cirrhosis and the MELD score was 19. Her height was 157 cm
and her weight 72 kg. CT scanning of the liver and surrounding vascular structures
including the vena cava showed no abnormalities.
Liver Transplantation
After 1 year on the waiting list, a blood group identical liver from a brain dead,
heart-beating donor was offered and accepted. The donor was 54-year-old and
weight of 80 kg. and a length of 175 cm. The donation procedure was uneventful.
During the transplantation, the liver graft was reperfused after the side-to-side cavocavostomy and portal venous anastomosis were performed. The side-to-side
cavocavostomy was diffi cult to perform because of size difference between the graft
G. Kazemier , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: g.kazemier@vumc.nl
H.J. Metselaar
Department of Gastroenterology , Erasmus Medical Center , Rotterdam , The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_29,
© Springer International Publishing Switzerland 2014
159
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Fig. 29.1 In a combined
percutaneous, trans-hepatic,
and transjugular approach, a
10 mm covered stent was
placed from the main portal
vein into the recipient vena
cava, creating adequate portal
outfl ow directly into the vena
c a v a
G. Kazemier and H.J. Metselaar
and the abdominal cavity of the recipient. Cold-ischaemia time was 415 min and
warm ischaemia time was 44 min. The arterial anastomosis was performed after
reperfusion. An end-to-end biliary anastomosis was performed without the use of a
T-tube to restore bile fl ow. The estimated total blood loss was 1,300 mL and no
blood transfusions were administered. Intra-operative Doppler color ultrasonography showed intact arterial, portal, and hepatic venous blood fl ow.
Directly postoperatively, transaminases raised considerable to 5,700 IU/L,
probably because of the large for size graft. Transaminases lowered in the following
days to values below 500 IU/L and the liver function recovered quickly with an INR
of 1.1 at day 3 after transplantation. Immunosuppressive therapy consisted of basiliximab, tacrolimus, and low-dose prednisone . Routine Doppler ultrasonography
direct postoperatively showed normal signals in all vascular structures of the transplant and a triphasic fl ow in the hepatic veins, despite a narrow cavocavostomy. At 1
week after transplantation the fl ow in the hepatic veins was monophasic. One week
later the fl ow was absent and patient developed an acute Budd–Chiari syndrome.
Triphasic , contrast enhances CT scan suggested torsion of the cavocavostomy. In a
combined percutaneous, trans-hepatic, and transjugular approach, a 10 mm covered
stent was placed from the main portal vein into the recipient vena cava, creating
adequate portal outfl ow directly into the vena cava (Fig. 29.1 ). After this procedure,
the liver function improved rapidly and patient was discharged 50 days after the liver
transplantation without coumarines or platelet aggregation suppression.
Discussion
Hepatic venous outfl ow complications after liver transplantation are rare [ 1 ].
Particularly after introduction of the side-to-side cavocavostomy as gold standard
for venous reconstruction during liver transplantation of whole organs at our institution more than 10 years ago, only once did occlusion of the left and middle hepatic
29 Case on Patient with a Stenosis of the Cavocavostomy After Liver Transplantation
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161
Liver transplantation
cavo-cavostomy
Stenosis (torsion)
cavo-cavostomy
10 mm covered stent
main portal vein
to vena cava
Illustration 29.1 After liver transplantation with a cavocavostomy. The side-to-side
cavocavostomy was diffi cult to perform because of size difference between the graft and the
abdominal cavity of the recipient. Patient developed an acute Budd–Chiari syndrome probably by
a torsion of the cavo-cavostomy. In a combined percutaneous, trans-hepatic, and transjugular
approach, a 10 mm covered stent was placed from the main portal vein into the recipient vena cava,
creating adequate portal outfl ow directly into the vena cava
vein due to technical failure lead to partial venous congestion of part of the graft, but
not to graft loss. Other centers report comparable low incidences of venous outfl ow
complications with side-to-side cavocavostomy [ 2 ]. When venous outfl ow obstruc-
tions after liver transplantation develop however, symptoms can vary from mild
ascites to acute failure of the graft. Especially if the latter is the case, a prompt
intervention is mandatory. Surgical correction of the venous outfl ow can be very
challenging because the liver will be congested, and swollen, and consequently very
fragile, hampering easy handling particularly of the most dorsally located anastomosis: the site-to-site cavocavostomy. Percutaneous correction of the stenosis via
placement of a covered stent as in a transjugular portosystemic shunt or TIPSS
procedure in cirrhotic patients is the preferred technique in those patients as is
shown in this case (Illustration 29.1 ).
References
1. Darcy MD. Management of venous outfl ow complications after liver transplantation. Tech
Vasc Interv Radiol. 2003;10:240–5.
2. Navarro F, Le Moine MC, Fabre JM, et al. Specifi c vascular complications of orthotopic liver
transplantation with preservation of the retrohepatic vena cava: review of 1361 cases.
Transplantation. 1999;68:646–50.
Chapter 30
https://t.me/med1917
Case on CBD Lesion During Laparoscopic
Cholecystectomy
Oliver R.C. Busch , Klaske A.C. Booij , Dirk J. Gouma ,
and Thomas M. van Gulik
Keywords Common bile duct • CBD lesion • Laparoscopic cholecystectomy •
Symptomatic cholecystolithiasis • Bile duct injury
Diagnosis and Indication for Surgery
A 71-year-old female patient underwent a laparoscopic cholecystectomy because of
symptomatic cholecystolithiasis.
Operation Description, Identifi cation,
and Treatment of Complication
During operation, the surgeon noticed a bile duct injury, possibly a complete transection of the common bile duct (CBD). The surgeon contacted our center for advice
from the operating room. We recommended to leave a catheter in the proximal part
of the divided bile duct and the patient was referred to our center. One day after
operation the patient arrived in our hospital. Cholangiography using the catheter
which was left in the bile duct showed a normal intrahepatic biliary anatomy, no
absence of any segmental bile duct. Furthermore, a proximal CBD without a connection with the distal CBD was seen (Fig.
was suspected of having a type D bile duct injury. The patient was in a good condition without signs of abdominal sepsis. Therefore, a direct reconstruction was performed 2 days after initial operation. The hepatoduodenal ligament was explored by
O. R.C. Busch , M.D., Ph.D. (*) • K. A.C. Booij • D. J. Gouma • T. M. van Gulik
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: o.r.busch@amc.uva.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_30,
© Springer International Publishing Switzerland 2014
30.1 ). Based upon these fi ndings, patient
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Fig. 30.1 Cholangiography
by a drain in the proximal
CBD which shows a
complete transection of the
CBD
O.R.C. Busch et al.
a subcostal incision. Besides a complete divided CBD a complete transection of the
right hepatic artery was seen. At fi rst, a venous reconstruction of the right hepatic
artery was performed. Secondly, a bile duct reconstruction was done by using a
Roux-en-Y hepaticojejunostomy (Illustration 30.1 ). The patient had an uncompli-
cated postoperative course and left the hospital on day 7. One year after
reconstruction, patient did not have any complaints.
Discussion
The most devastating complication after cholecystectomy is Bile Duct Injury (BDI),
with a reported incidence of 0–1.5 %. The key issue in the management of BDI is
prevention. Prevention is only adequate with the awareness of pre- and intraoperative
risk factors, the use of CVS, experience in performing cholecystectomy and knowledge of the different escape strategies in the case of a diffi cult cholecystectomy. BDI
can be diagnosed either peroperatively or in the direct or late postoperative phase. In
case BDI occurs, the severity of the injury should be classifi ed thoroughly before a
proper treatment can be chosen. The treatment of BDI should be performed by a
multidisciplinary team and only if suffi cient experience in dealing with this complication is present. If not, the patients should be referred to a tertiary center. Even after
an objectively excellent outcome of treatment, the reported QoL is still reduced [ 1 ].
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