Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

Zhihao Li; Ashwin Rammohan; Vasanthakumar Gunasekaran; Suyoung Hong; Itsuko Chih-Yi Chen; Jongman Kim; Kris Ann Hervera Marquez; Shih-Chao Hsu; Elvan Onur Kirimker; Nobuhisa Akamatsu; Oren Shaked; Michele Finotti; Marcus Yeow; Lara Genedy; Philipp Dutkowski; Silvio Nadalin; Markus U Boehnert; Wojciech G Polak; Glenn K Bonney; Abhishek Mathur; Benjamin Samstein; Jean C Emond; Giuliano Testa; Kim M Olthoff; Charles B Rosen; Julie K Heimbach; Timucin Taner; Tiffany Cl Wong; Chung-Mau Lo; Kiyoshi Hasegawa; Deniz Balci; Mark Cattral; Gonzalo Sapisochin; Nazia Selzner; Long-Bin Jeng; Dieter Broering; Jae-Won Joh; Chao-Long Chen; Kyung-Suk Suh; Mohamed Rela; Pierre-Alain Clavien

doi:10.1016/j.ajt.2024.02.023

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

Am J Transplant. 2024 Feb 28:S1600-6135(24)00165-5. doi: 10.1016/j.ajt.2024.02.023. Online ahead of print.

Authors

Zhihao Li¹, Ashwin Rammohan², Vasanthakumar Gunasekaran², Suyoung Hong³, Itsuko Chih-Yi Chen⁴, Jongman Kim⁵, Kris Ann Hervera Marquez⁶, Shih-Chao Hsu⁷, Elvan Onur Kirimker⁸, Nobuhisa Akamatsu⁹, Oren Shaked¹⁰, Michele Finotti¹¹, Marcus Yeow¹², Lara Genedy¹³, Philipp Dutkowski¹⁴, Silvio Nadalin¹³, Markus U Boehnert¹⁵, Wojciech G Polak¹⁵, Glenn K Bonney¹², Abhishek Mathur¹⁶, Benjamin Samstein¹⁶, Jean C Emond¹⁶, Giuliano Testa¹¹, Kim M Olthoff¹⁰, Charles B Rosen¹⁷, Julie K Heimbach¹⁷, Timucin Taner¹⁷, Tiffany Cl Wong¹⁸, Chung-Mau Lo¹⁸, Kiyoshi Hasegawa⁹, Deniz Balci⁸, Mark Cattral¹⁹, Gonzalo Sapisochin¹⁹, Nazia Selzner¹⁹, Long-Bin Jeng⁷, Dieter Broering⁶, Jae-Won Joh⁵, Chao-Long Chen⁴, Kyung-Suk Suh³, Mohamed Rela², Pierre-Alain Clavien²⁰

Affiliations

¹ Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada.
² The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India.
³ Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
⁴ Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
⁵ Department of Surgery, Samsung Medical Center, Seoul, South Korea.
⁶ Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
⁷ Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.
⁸ Department of Surgery, Ankara University School of Medicine, Ankara, Turkey.
⁹ Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan.
¹⁰ Division of Transplantation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹¹ Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA.
¹² Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore.
¹³ Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany.
¹⁴ Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
¹⁵ Department of Surgery, Division of HPB & Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands.
¹⁶ Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA.
¹⁷ Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
¹⁸ Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China.
¹⁹ Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada.
²⁰ Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland. Electronic address: clavien@access.uzh.ch.

PMID: 38428639
DOI: 10.1016/j.ajt.2024.02.023

Abstract

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Keywords: bile leak; biliary anastomotic stricture; biliary complications; liver transplantation; living-donor liver transplantation.