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Anatomy of segment I with the biliary drainage. Segment I includes Spiegel's lobe (SPG); paracaval portion (PC) and the caudate process (CP). Spiegel's lobe may drain into the left hepatic duct (LHD) (1), into one of its branches (2) or into the right biliary system (3). The paracaval portion may drain into the right posterior sectoral duct (RPD) (4), right hepatic duct (RHD) (5) or into the left biliary system (6). IVC = inferior vena cava.
Source publication
Bile leak in split and living donor liver transplantation is not an uncommon postoperative complication with significant morbidity to both donor and recipients. Nonanastomotic bile leaks in these transplants are less well characterized and generally described as cut-surface leaks. A proportion of these leaks may derive from biliary radicles drainin...
Citations
... The retained S4 parenchyma often undergoes silent atrophy but retained S4-associated complications such as ischemic parenchymal necrosis and biliary leak can develop. These complications increase morbidity and can sometimes lead to graft loss [9,14,15]. Consequently, some authors have proposed systematic removal of the retained S4 during SLT [16][17][18]. We previously reported a case of retained S4 resection due to intractable bile leak after donation of an LLS graft in a living donor [13]. ...
... Biliary leak from the graft liver cut surface has also been reported to be one of the retained S4-associated major complications [14,15,25]. If the blood supply to the retained S4 parenchyma partially remains, it can induce bile production in the retained S4 parenchyma. ...
Purpose:
When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft.
Methods:
This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts.
Results:
The mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes.
Conclusion:
The amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.
... It usually occurs at the biliary anastomosis but could also occur at the liver cut surface or at the T-tube insertion site. Bile leakage from the liver cut surface may occur in LDLT or split DDLT, and a proportion of this type of leak may be derived from biliary radicles draining the caudate lobe [105]. In a systemic review, the incidence of bile leak was not significantly different between DDLT and LDLT (7.8% vs. 9.5%) [85]. ...
Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.
... Anastomotic leaks are the more common type and occur more frequently with Roux-en-Y anastomosis than with duct to duct anastomosis [7]. Cut surface bile leaks usually originate from small bile ducts in the caudate lobe that are transected during surgery and are usually detected incidentally at reoperation [8]. ...
... The early experience of SLT and LDLT saw a high incidence of biliary complications attributed to cut surface leaks. In 2008, based on their extensive experience in SLT, the senior author of this communication from Kings college hospital, London, proposed an explanation for the high incidence of bile leaks in segmental liver transplantation based on the biliary anatomy of caudate lobe [2]. The authors, Makki et al., have taken this one step further and analysed the detailed biliary anatomy of caudate lobe in 500 LDLT donors using intraoperative cholangiogram (IOC) and suggest this as key to the low rates of biliary complications in both their donors and recipients. ...
We read with interest the article by Makki et al[1], in which they have analysed the caudate lobe biliary anatomy in 500 living liver donors and stressed its importance in reducing post‐operative bile leaks. A clear understanding of liver anatomy and improvements in cross‐sectional imaging have contributed extensively to the success of split liver transplantation (SLT) and living donor liver transplantation (LDLT). The early experience of SLT and LDLT saw a high incidence of bile leaks attributed to cut surface leaks. In 2008, based on a vast experience in SLT, the senior author of this communication, from Kings college hospital, London proposed an explanation for the high incidence of bile leaks in segmental liver transplantation based on an understanding of the biliary anatomy of caudate lobe.
This article is protected by copyright. All rights reserved.
... Biliary anatomy of the caudate lobe has important implications in major liver surgeries involving the hilum. Caudate duct leaks are an important cause of nonanastomotic bile leak in recipients and cut surface leaks in donors [10,11]. Caudate duct leaks tend to be refractory. ...
Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post‐operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage.
This single centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on IOCs with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left to right cross over drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and recipients was 2.2%.
Proper intra‐operative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.
This article is protected by copyright. All rights reserved.
... Anastomotic leaks are the more common type and occur more frequently with Roux-en-Y anastomosis than with duct to duct anastomosis [7]. Cut surface bile leaks usually originate from small bile ducts in the caudate lobe that are transected during surgery and are usually detected incidentally at reoperation [8]. ...
... However, the B1 branch is the primary cause of "cutsurface bile leak" in LDLT. 27 The anastomosis site bile leak is relatively straightforward and is usually controlled by percutaneous drainage, but this kind of non-anastomosis site "cut-surface bile leak" is hard to identify and more difficult to manage. 27,28 Additionally, the caudate lobe has a variable number of IHDs, ranging from one to five, with a broad spectrum of anatomical variations. ...
... 27 The anastomosis site bile leak is relatively straightforward and is usually controlled by percutaneous drainage, but this kind of non-anastomosis site "cut-surface bile leak" is hard to identify and more difficult to manage. 27,28 Additionally, the caudate lobe has a variable number of IHDs, ranging from one to five, with a broad spectrum of anatomical variations. 29 Therefore, the precise prediction of B1 branch anatomy is crucial to reducing postoperative BD complications. ...
Purpose:
To determine the incremental value of small field of view (sFOV) high-resolution (HR) gadoxetic acid-enhanced 3D T1 -weighted (W) magnetic resonance cholangiography (MRC) for evaluating the biliary anatomy of potential living donors by comparing it to T2 W-MRC.
Materials and methods:
In all, 73 living donor candidates underwent gadoxetic acid-enhanced MRI (3.0T) including three kinds of MRCs: 3D multislice T2 W-MRC, regular FOV (rFOV) (380 × 380mm, resolution 1.0 × 1.2 × 3.0 mm) 3D T1 W-MRC, and sFOV (256 × 208 mm, resolution 1.0 × 1.0 × 1.0 mm) HR-T1 W-MRC. Three radiologists reviewed the image sets for the visibility of segmental intrahepatic bile ducts (BDs), biliary anatomy with its confidence level, and expected number of BD openings at right hemihepatectomy.
Results:
Compared to T2 W-MRC alone, the combination of sFOV HR-T1 W-MRC and T2 W-MRC (sT1 W-HR set) yielded significantly improved BD visibility scores (P < 0.01) and confidence levels for biliary anatomy (P < 0.01). Compared to the rT1 W set (rFOV T1 W-MRC with T2 W MRC), the sFOV HR set showed significantly increased caudate duct visibility (P < 0.001). In the case of T2 W-MRC presenting subdiagnostic image quality, the addition of sFOV HRT1 W-MRC provided diagnostically acceptable image visibility (53.8∼90%) to all reviewers. The addition of sFOV HR-T1 W-MRC resulted in a significantly higher consistency with the operative record and expected number of BD openings than did T2 W-MRC alone (P < 0.05 in all reviewers) or rFOV set (P < 0.05 in one reviewer) with excellent interobserver agreement of both T1 W-MRC sets.
Conclusion:
The combination of sFOV HR-T1 W-MRC and T2 W-MRC significantly improved BD visibility and confidence levels for biliary anatomy compared to T2 W-MRC alone, thereby allowing accurate biliary anatomy assessment in most patients with subdiagnostic T2 W-MRC images.
Level of evidence:
3 J. Magn. Reson. Imaging 2017.
... The rates of S4-related complications in each period were 27.8% (10/36) and 29.4% (5/17), respectively, and no significant difference was observed between the two periods (Fig. 5). Considering that the frequency of S4-related complications did not differ according to the period, and that the complication rate in the present study is almost comparable to that seen in previously published reports, [28][29][30][31] S4-related complication rates of around 20%-40% do not seem to be avoidable after SLT in general. In such a situation, the present study proved that there were no retransplantations and no patient deaths in the 17 consecutive cases (Fig. 5), and both the graft and patient overall survival rates were significantly better for patients in the later period ( Fig. 6A and B). ...
Background:
This study is designed to assess the actual mechanism of segment 4 (S4)-related complications after split liver transplantation (SLT), and their impact on graft and overall survival with reference to those of left lateral sectionectomy for pediatric living donor liver transplantation (LLSLD).
Methods:
Clinical data from 53 SLT recipients and 62 LLSLD patients were assessed to determine the mechanism of S4-related complications. The postoperative parameters of SLT and their impact on graft and overall survival were also evaluated.
Results:
Although two biliary leakage was noted (3.2%), no necrosis of S4 developed after LLSLD. S4-related complications were seen in 15 (28.3%) patients after SLT. Radiological volumetry of S4 and the ischemic area after SLT showed no significant difference between those with and without S4-related complications. There were no significant differences between the patients with and without S4-related complications regarding both overall and graft survival rates. Significant better overall and graft survival rates were observed in patients treated during the later period.
Conclusions:
S4-related complications after SLT are totally independent of the S4 volume, and biliary leakage is inherently an actual mechanism. Adequate intervention with early identification leads to better graft and overall survival, which validates SLT as a treatment option. This article is protected by copyright. All rights reserved.
... Other rare causes of bile leak are due to an incorrect suture of the cystic duct stump and may originate from the resection surface in case of living donor or split liver. In particular, caudate lobe biliary branches, which usually drain in the left liver are sometimes drained in the right liver, increasing the risk of leak either in donors or recipients [20,23] . Late bile leaks are related to T tube [24] removal in nearly 1% of cases, with a fistula arising directly from the insertion site. ...
Biliary complications (BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of post-operative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.
... Verdonk et al [41] showed that 75% of AS could be successfully stented by ERCP, with a median of 3 ERCP sessions for diagnosis and to duct anastomoses [23] . Cut surface bile leaks usually originate from small bile ducts in the caudate lobe that are transected during surgery and are usually detected incidentally at reoperation [37] . Bile leaks have been shown to decrease overall survival and graft survival post transplant [23,38] and are also a significant risk for subsequent development of a stricture [23,27,31,38] . ...
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
