Abstracts

BILIARY COMPLICATIONS AFTER COMPOSITE VISCERAL TRANSPLANTATION WITH PRESERVATION OF THE DONOR DUODENUM

Geoffrey Bond, Kyle Soltys, Guillherme Costa, Adam Slivka, Rakesh Sindhi, George Mazariegos, Kareem Abu-Elmagd. University of Pittsburgh Medical Center, Thomas E Starzl Transplantation Institute, Pittsburgh, PA.

Background: Originally, combined liver and intestinal allografts(L/I) were transplanted separately, utilizing a Roux-en-Y intestinal loop to drain the biliary system. To avoid biliary complications and loss of bowel length, modifications in donor retrieval led to the duodenal sparing en-bloc L/I technique to maintain continuity of the biliary system. Full multivisceral allografts(MVTx) were retrieved as en-bloc organs. We report a series of biliary complications seen with maintenance of this duodenal c-loop.

Materials: Since 1990, 127 composite L/I were transplanted, 82(65%) since 1997 utilizing the duodenal sparing technique. 68% were children. Over the entire period 67 MVTx(72% adults) were transplanted.

Results: 9 patients(6 adult, 3 children) with preservation of the duodenal c-loop have had biliary complications(6%) requiring intervention. Presentation was with elevated liver function tests(LFTs), recurrent pancreatitis, abnormal imaging studies and/or histopathologic biliary changes.All children had L/I transplants. Onset of complication was between 1 month and 3 years. All were managed by percutaneous transhepatic cholangiogram (PTC) with biliary balloon dilatation and stenting/drainage. All are alive. 12 procedures were required until the drain was removed in one patient. 2 recent cases still have drains in-situ. The adult patients underwent MVTx(n=4) and L/I(n=2). Onset of biliary complication was between 3 months and 3 years (average 1.3 yrs). All underwent endoscopic retrograde cholangiopancreaticogram (ERCP) and sphincterotomy, removal of debris, and stenting in 2. One also had multiple PTC and dilatation/drainage procedures. All have had resolution of the biliary complication. Imaging studies and /or clinical responses were consistent with distal bile duct obstruction presumed to be Ampulla of Vater dysfunction, with some also suggestive of concurrent disease in the more proximal biliary tree.

Discussion: Although technically easier from an allogratft recovery and implantation view point, this duodenal preserving method has potential complications. Etiology of the biliary complication is unclear, but may be due to extrinsic denervation or related to ischemia and reperfusion injury. It is important to recognize this potential complication as a distinct entity causing elevated LFTs, necessitating different modalities of treatment.