Roux-en-y biliary anastomosis 

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... is technically more challenging. This structure is usually procured with a segment of the superior mesenteric artery (SMA). While several methods have been described, a common technique used is to resect the excess right HA and SMA trunk and subsequently anastomose the lumen directly to the orifice of the donor splenic artery or GDA. Our preference is to use the GDA to minimize the chance of a kink or twist during the reconstruction on the backtable. The replaced right HA orifice is spatulated and the orifice of the GDA is extended onto the common hepatic artery to create for a wider anastomoses and better outflow (Figure 15b). If variations in recipient anatomy result in inadequate inflow from the common hepatic artery, another inflow source can be used. For example, if the celiac is inadequate (as in arcuate ligament syndrome), the gastroduodenal artery may be dominant. Likewise, if a replaced right is dominant, it may be more appropriate as the recipient vessel. If no vessel is adequate, an aorta to donor artery conduit is created using donor iliac artery. Usually, the infrarenal aorta is chosen as the recipient side, although sometimes the supraceliac aorta is chosen as the proximal side. Similar to a portal venous conduit, it is tunneled retrocolic between the stomach and the pancreas. The tunnel location may vary depending on the anatomy. The aortic side is created with 5-0 prolene and the donor side with 6-0 prolene (Figure 16). While the incidence of HA thrombosis is low, both arterial reconstruction of multiple vessels and increased time to arterial reperfusion are risk factors for this complication. (Warner et al., 2011; Oh et al., 2001; Pastacaldi et al., 2001). Therefore, both technique and time are of essence. Once the liver is reperfused, biliary reconstruction is initiated. An end-to-end anastomosis (choledochocholedochostomy) is the most commonly used configuration. Otherwise, a Roux-en-Y is usually chosen as the second choice. Indications for a Roux include technical difficulty apposing the two duct ends (e.g. after removing a large polycystic recipient liver),size discrepancy, and poor condition or blood supply of recipient duct (e.g. during retransplantation). Another indication for a Roux is a diseased recipient duct. This can be related to choledocholithiasis, biliary atresia, secondary biliary cirrhosis, or primary sclerosing cholangitis. Recently, the tradition of using a Roux for a disease such as primary sclerosing cholangitis has been readdressed, and some authors have reported the use of duct-to-duct anastomosis when there is no evidence of extra-hepatic stricturing involving the distal duct and/or the duct appears visually healthy (Distante et al., 1996; Heffron et al., 2003). The use of choledochoduodenostomy has also been reported. Also, duct to duct anastomosis has been used during retransplantation (Sibulesky et al., 2011) Whatever technique is chosen, the goal is to achieve a tension-free anastomosis between two well vascularized structures. To start the end-to-end anastomosis, it is helpful to elevate the liver with several packs placed behind the right lobe. The donor and recipient ends are trimmed to achieve healthy, bleeding surfaces. Bleeders are controlled with suture ligation. Cautery is avoided. If the donor side contains the lumen of the cystic duct, a small septotomy is made between the cystic and common hepatic duct to create a common orifice. If the cystic duct opening is not in continuity with the common duct, it is marsupialized to avoid creating a fluid-filled “sac” that may eventually contort the main duct. The anastomosis is accomplished with 5-0 or 6-0 absorbable, monofilament (PDS) creating the posterior wall first. Although many surgeons interrupt the anastomosis, we run the suture line. If size discrepancies exist, one end may need to be spatulated or partially closed to allow anastomosis. Most of the time, this does not seem necessary. Traditionally, a T-tube is used. It’s purpose is to provide access to the biliary system, to allow monitoring of the quantity and quality of bile, and to “splint” the anastomosis. The current trend, however, is to avoid the use of T-tubes. This is due to the recognition that T- tubes may be associated with biliary leaks as well as other technical problems (Riediger et al., 2010; Sotropoulos et al., 2009). A Roux-en-Y is constructed in a standard fashion, usually dividing the small bowel 15-20 cm distal to the ligament of Treitz, and making a 40cm defunctionalized limb. The bowel anastomosis can be sewn or stapled. The end of the limb is reinforced with a seromuscular imbricating stitch. The limb is brought to the porta through a retro- or antecolic approach. If the colon is present, and the patient has inflammatory bowel disease, a retrocolic position will make subsequent colectomy easier. The donor duct is anastomosed to the Roux limb with absorbable monofilament. Some surgeons use an internal or external stent (Figure 17). Once the biliary reconstruction is complete, systematic inspection of the field is carried out. Mechanical hemostasis is achieved. Non-mechanical bleeding is addressed by the anesthesia team. Generally, two drains are left, one behind the right lobe towards the supahepatic cava, and one near the biliary anastomosis in an infrahepatic position. The midline incision is closed in a single layer, the bilateral subcostal incisions in two layers. Belghiti, J, Fekete F, Gayet B, Panis Y, & Sauvanet A,. (1992) A New technique of Side to Side Caval Anastomoses During Orthotopic HepaticTransplantation Without Caval Occlusion. Surg Gynecol Obstet, Vol 75, No.3 ( Sep 1992) pp. 75:270-2. Belghiti J, Noun R, & Sauvanet A. 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Cavocaval Adult Liver Transplantation and ...