Living Donor Hepatectomies with Procedures to Prevent Biliary Complications

Living Donor Hepatectomies withProcedures to Prevent Biliary ComplicationsAkinobu Taketomi,MD ,PhD ,FACS ,Kazutoyo Morita,MD ,Takeo Toshima,MD ,Kazuki Takeishi,MD ,Hiroto Kayashima,MD ,Mizuki Ninomiya,MD ,PhD ,Hideaki Uchiyama,MD ,PhD ,Yuji Soejima,MD ,PhD ,FACS ,Ken Shirabe,MD ,PhD ,FACS ,Yoshihko Maehara,MD ,PhD ,FACSBACKGROUND:Biliary complications in donor hepatectomies are still common,and occur in approximately 5%of the procedures.STUDY DESIGN:T o evaluate the usefulness of the management and surgical procedures to prevent the biliarycomplications in donor hepatectomies,a total of 343donors were retrospectively studied.The clinical and surgical parameters of the donors and the postoperative biliary complications were evaluated.RESULTS:Fourteen donors had biliary complication (BC)during the follow-up period (4.1%).Donorswere divided into 2groups;donors without BC (non-BC group;n ϭ329)and donors with BC (BC group;n ϭ14).Mean peak level of total bilirubin,mean duration of hospital stay after surgery,and medical cost in the BC group were significantly higher than in the non-BC group (p Ͻ0.01).As improved procedures to prevent the BC were established at 2005,including the use of a real-time cholangiography by the C-arm,a minimized dissection of the hepatic vessels,the meticulous closure of the bile duct,and/or the use of Pringle maneuver during the paren-chymal transection,the donors were divided into 2groups before and after these establishments (the early period,n ϭ173;the later period,n ϭ170).Refinements in the management and surgical procedures reduced the occurrence of biliary complications from 6.4%during the early period to 1.8%during the later period (p Ͻ0.01),and no biliary complications in the last 69consecutive donors were observed.CONCLUSIONS:T echnical refinements described in this study might be useful to prevent the occurrence ofbiliary complications in a donor hepatectomy.It is particularly important to preserve the blood supply for the biliary tract of both the graft and the remnant liver.(J Am Coll Surg 2010;211:456–464.©2010by the American College of Surgeons)Nearly 4,000adult-to-child living donor liver transplan-tations (LDLTs)have been performed worldwide 1since the introduction of LDLT in 1989,with the first report of a successful series of pediatric recipients.2The indica-tions for this modality have been actively extended to adult recipients since the first successful report on adult-to-adult LDLT was published in 1994.3LDLT is often the only means of saving patients with end-stage liverdisease in countries where organ donation from de-ceased donors is scarce,such as most Asian countries including Japan.On the other hand,in the United States,since the death of a donor in January 2002,the number of centers performing LDLT and the number of procedures performed has declined,although it appears to have stabilized at ϳ250cases per year,about half of the peak in 2001in US centers.4Donor safety is a critical issue in LDLT,and one of the most important complications during donor surgery is biliary complication (BC).A previous study reported that the overall complication rate is 34.0%,including BCs in 5.3%.5A Korean group reported major donor complications,including bile duct stricture and bile leakage,to occur in 37of 1,162donors,with most of them occurring in right lobe donors.6Other groups also reported the rate of BC ranging from 2.4%to 5.3%.7,8BCs affect the patients and their families psychologi-Disclosure Information:Nothing to disclose.This study was supported in part by a grant from the Scientific Research Fund of the Ministry of Education of Japan.Received March 17,2010;Revised April 22,2010;Accepted April 27,2010.From the Department of Surgery and Science,Graduate School of Medical Sciences,Kyushu University,Fukuoka,Japan.Correspondence address:AkinobuT aketomi,MD,PhD,Department of Surgery and Science,Graduate School of Medicine,Kyushu University,3-1-1Maidashi,Higashi-ku,Fukuoka 812-8582,Japan.Email:taketomi@surg2.med.kyushu-u.ac.jp456©2010by the American College of Surgeons ISSN 1072-7515/10/$36.00Published by Elsevier Inc.doi:10.1016/j.jamcollsurg.2010.04.018cally,physically,and economically.Therefore,the occur-rence of BCs should be avoided.Graft procurement must be done meticulously and safely to prevent such complications in a healthy donor.It is responsibility of the donor surgeon to minimize or eradicate complica-tions.We have reported that right lobe procurement is an independent predictor for the occurrence of BC after donor hepatectomy.5Based on our early experiences with206donors,we established the management and surgical procedures to prevent BC.This study prospectively reviewed outcomes in343do-nors who underwent graft procurement and evaluated the usefulness of the managements and surgical procedures to prevent BCs.METHODSPatientsThree-hundred and forty-two LDLT operations,including 1dual-graft case,were performed at Kyushu University Hospital,Fukuoka,Japan from October1996to October 2009,after prior approval from the Ethics and Indications Committee of Kyushu University.Therefore,343donor hepatectomies for LDLT were retrospectively reviewed in this study.Donor evaluation and selectionPotential donors undergo blood tests,including complete cell count,liver function tests,serum electrolytes,blood type,hepatitis C antibody,hepatitis B surface antigen,and hepatitis B core antibody.If these screening tests are accept-able,the potential donor will be evaluated by chest x-ray, electrocardiogram,and CT.Preoperative multidetector he-lical CT images were obtained using2-mm-thick slices with an intravenous bolus of contrast medium.Three-dimensional reconstructions of both the liver and the graft were rendered using the3-dimensional CT software(Re-gion Grow;Hitachi Medical Corporation,Zio M900;Zio Software Inc.),which calculated the total liver volume (TLV).9The actual graft volume(GV)was measured on the back table after flushing with University of Wisconsin so-lution(ViaSapan;Bristol-Myers Squibb).The remnant liver volume(RV)ratio was calculated as:RV ratioϭ[(TLVϪGV)/TLV]ϫ100.CT cholangiography is also performed to detect any variation in the biliary tree.The general selection criteria for grafts in adult-to-adult LDLT based on volumetric analysis have been described previous-ly.5,9Briefly,a left-lobe graft is initially considered for the graft and is generally used.A right lobe is chosen if the estimated left lobe with caudate lobe volume of the donor isϽ35%of the standard liver volume of the recipient.If the RV isϽ35%of the TLV,the person will be excluded as a donor candidate.Biopsy of the donor liver is performed if the CT or ultrasonographic study shows possibility of ste-atosis or if the donor’s body mass index(calculated as kg/ m2)isϾ25.A marginal donor is given a short-term(2to8 weeks)combination therapy of diet,exercise,and drugs to improve hepatic steatosis.10If the RV isϽ35%of TLV after this diet protocol,the donor will be excluded.Autologous blood was collected from the donor1week before opera-tion,with400mL blood at a time.The blood was stored in a liquid state without freezing.Differences of surgical procedures between the early and later periodsThe donor hepatectomy was performed as described previ-ously.5Management and surgical procedures to prevent BCs were changed in2005.1.Pre-or intraoperative cholangiography is one of theimportant issues.The donor surgeons first evaluate the distribution and anatomical variation of the biliary tree using3-dimensional CT cholangiography.Intraopera-tive cholangiography was performed using the static x-ray film unit until2004(the early period).High-resolution cameras and television monitors led to high-definition intraoperative fluorocholangiography with a C-arm unit(ARCADIS Avantic;SIEMENS)has been used since2005(the later period)to clarify the ana-tomic details in the biliary duct(Fig.1).This unit easily identified bile duct injury and bile duct anatomy.In addition,cholecystocholangiography,which was per-formed by inserting a catheter into the neck of the gall-bladder,is preferred because the cystic duct is some-times too small to insert the cholangiocatheter.This procedure can prevent cystic duct injury and common bile duct injury.2.It is important to preserve the blood supply for thebiliary tract of both the graft and the remnant liver.It is necessary to harvest a sufficient length of the hepatic artery and portal vein during the donor hepatectomy for the reconstruction of vessels in the recipient.These vessels are susceptible to excessive dissection from the surrounding tissues,resulting in an ischemic change in the biliary tract and the occurrence of BCs.Since2005,Abbreviations and AcronymsBCϭbiliary complicationBMIϭbody mass indexGVϭgraft volumeLDLTϭliving donor liver transplantation RVϭremnant liver volumeTLVϭtotal liver volume 457Vol.211,No.4,October2010Taketomi et al Donor Hepatectomy without Biliary Complicationswe have emphasized minimizing the dissection of the hepatic artery and portal vein to keep the surrounding tissues attached to the common hepatic duct (Fig.2),resulting in the preserved blood supply for the biliary tree.In particular,the right hepatic artery,which passes immediately posterior to the proximal portion of the common hepatic duct should not be touched.3.The cutting orifice of the hepatic duct has been metic-ulously closed by 6-0PDS (Ethicon)continuous suture since 2005.The orifice should be closed with transverse choledochoplasty if the bifurcation of hepatic duct is too close to prevent biliary stenosis.4.Pringle maneuver has been partly applied during the parenchymal transaction even if the excessive hemor-rhage was recognized until 2004,and it has been rou-tinely applied since 2005because its safety for donor hepatectomies has been reported.11Pringle maneuver helps not only in reducing bleeding but also in identi-fication of certain hepatic vessels,resulting in avoidance of a biliary tract injury.Management after donor hepatectomyDonors were managed on a regular surgical ward.Antibi-otics were continued for 24hours postoperatively.Oral intake was started 1day after the plete blood counts,coagulation profile,and serum liver enzymes were monitored 1,2,3,5,and 7days after the surgery.Prophy-laxis for deep-vein thrombosis continued with sequential compression stockings and graduated compression devices until restoration of walking.Drains were usually removed within 3days after the surgery if no abnormality was ob-served.All patients underwent routine CT on day 7after the surgery to assess their vessel and parenchymal integrity.The follow-up of donors was carried out with routine lab-oratory investigations and abdominal ultrasound at 1month,3months,6months,and then annually after the surgery.Complications and clinical dataThe surveillance of donors for complications was pro-spectively performed by physicians.BCs were defined as any complication related to biliary injury—bile leakage or biliary stenosis.Non-BCs were defined as any abnor-mal finding during the postoperative course requiring surgical or radiological intervention,pharmacological treatment,or readmission after discharge—nerve paral-ysis,gastric stasis,peptic ulcer,hoarseness,pneumotho-rax,depression,or wound problems.All complications after donor hepatectomies recognized during the follow-up period were categorized according to Cla-vien’s classification of surgical complications.12The medical expenditures were expressed in US dollars (100Japanese yen ϭ1.08US dollars,according to foreign exchange rates on April 16,2010).Figure 1.Intraoperative procedures for the cutting the biliary tree.(A)The right hilar plate was isolated from the portal vein or right hepatic artery.Three surgical clips were placed at the position of the expected cutting line.(B)Real-time intraoperative cholangiography with a C-arm was performed to ensure the cutting line of the right hepatic duct.458Taketomi et al Donor Hepatectomy without Biliary Complications J Am Coll SurgStatistical analysisAll statistical analyses were performed using the StatView 5.0software package(Abacus Concepts).Continuous vari-ables were compared using the Mann-Whitney U test.All variables are expressed as the meanϮSD.Categorical data were compared using the chi-square test.Logistic regres-sion analysis was performed to identify the independent variables for postoperative complications.Differences were considered to be significant if the p value wasϽ0.05.RESULTSDemographics and complicationsThe343donors included221male and122female pa-tients.Their mean age,body weight,height,and BMI were 35.6Ϯ10.9years,61.6Ϯ10.8kg,165.8Ϯ8.3cm,and 22.3Ϯ2.9,respectively.The living donors included sons (nϭ126),daughters(nϭ45),spouses(nϭ42),mothers (nϭ38),brothers(nϭ35),fathers(nϭ24),others(nϭ17),and sisters(nϭ16).T wo-hundred and ten of the 343 Figure2.Isolation of the hepatic hilar plate,hepatic artery and portal vein.It is important to preserve the blood supply for the biliary tract.(A)For right lobe graft procurement,dissection was performed at only the right side of common hepatic duct.In particular,the part of the right hepatic artery that passes immediately posterior to the common hepatic duct should not be touched.(B)It is important to minimize the dissection of the hepatic artery and portal vein and not to damage the surrounding tissues attached to the common hepatic duct and the arterial plexus from the3or9o’clock marginal arteries.(C)Gastroduodenal ligament after the graft procurement. The surrounding tissues attached to the common hepatic duct and branched duct of the remnant liver were maintained to avoid dam-age to the arterial plexus for them.459Vol.211,No.4,October2010Taketomi et al Donor Hepatectomy without Biliary Complicationsdonors underwent a left lobectomy(61.2%),106donors received a right lobectomy(30.9%),and1donor received a right posterior segmentectomy.In addition,26left lateral liver grafts were procured for child recipients.Mean op-eration time,intraoperative blood loss,GV,and RV were 442Ϯ74minutes,452Ϯ430mL,457Ϯ119g,and 59.7%Ϯ12.3%,respectively.Mean number of hepatic duct orifice at the stump was1.20Ϯ0.45(range1to4). None of the343donors received an allogenic blood trans-fusion during or after the surgery.According to the Cla-vien’s classification,the postoperative complication were recognized in44for grade I(12.8%),24for grade II (7.0%),17for grade IIIa(5.0%),and8for grade IIIb (2.3%).There were no life-threatening complications, such as Clavien’s grade IV or V.The mean duration of the postoperative hospital stay and medical cost were14.7Ϯ9.4days and$20,138Ϯ$4,490,respectively. Comparison of donors with or without BC Fourteen donors had BC during follow-up period(4.1%). The clinical courses of the patients with BC are summa-rized in Table1.Mean time from donor hepatectomy to the occurrence of BC was24.6days(range0to193days).T wo of14donors had BCs that were repaired during the initial surgery;the insertion of biliary drainage tube for biliary stricture and choledochojejunostomy for biliary injury. T wo donors underwent a reoperation;1with choledocho-plasty with a T tube for biliary stenosis and1with biliary tract drainage and irrigation for an abdominal abscess due to bile leakage.Six of14donors were percutaneously treated with abscess drainage for bile leakage with or with-out an endoscopic nasobiliary drainage tube.Three donors with BC complications were conservatively followed up. Donors were divided into2groups;donors without BC (non-BC group;nϭ329)and donors with BC(BC group; nϭ14).The clinical parameters of the patients were com-pared between2groups(Table2).No difference was found in the age,gender,BMI,TLV,graft type,GV,RV ratio, duration of operation,intraoperative blood loss,incidence of multiple hepatic duct at the stump,and peak postoper-ative alanine aminotransferase level between the2groups. Mean peak level of total bilirubin in the BC group(4.0Ϯ2.7mg/dL)was significantly higher than that in the non-BC group(2.5Ϯ1.4mg/dL;pϽ0.01).In addition, mean duration of hospital stay after surgery(33.4Ϯ20.9 days)and medical cost($26,137Ϯ$8,937)in the BC group were significantly higher than those in the non-BC group(13.1Ϯ4.2days and$19,844Ϯ$3,954;pϽ0.01). Comparison of donors by the period of surgery Managements and surgical procedures were established in 2005to prevent the donor complication.Therefore,do-nors were divided into2groups before the establishment of management and surgical procedures to prevent BCs(the early period;from October1996to December2004,nϭ173)and after(the later period;from January2005to October2009,nϭ170).The clinical parameters of the donors were compared between the2groups(Table3). Mean BMI and TLV of the patients during the later period were considerably lower than those of the patients during the early period.However,no difference was found in age, gender,graft type,GV,RV ratio,duration of operation, and peak postoperative total bilirubin level between the groups.Although mean peak alanine aminotransferaseTable1.Clinical Parameters and Treatment of Donors with Biliary ComplicationPatient no.Period Type of BC Type of treatment BC occurrence Hospital stay,d 1Early Stenosis PTCD,reoperated with choledochoplasty1243 2Early Stenosis PTCD,balloon dilatation1442 3Early Bile leak Conservatively followed up322 4Early Bile leak Conservatively followed up321 5Early Bile leak PAD2711,80* 6Early Injury Choledochojejunostomy063 7Early Stenosis Conservatively followed up19331 8Early Stenosis RTBD026 9Early Bile leak PAD1271 10Early Bile leak PAD1041 11Early Stenosis RTBD,ENBD,balloon dilatation062,20* 12Later Bile leak PAD,ENBD,reoperation2813,63* 13Later Bile leak PAD,ENBD228,59* 14Later Bile leak PAD2113,71* BC,biliary complication;ENBD,endoscopic nasobiliary drainage;PAD,percutaneous abdominal drainage;POD,postoperative days;PTCD,percutaneous transhepatic cholangiodrainage;RTBD,retrograde transhepatic biliary drainage.*Hospital stay at second administration.460Taketomi et al Donor Hepatectomy without Biliary Complications J Am Coll Surglevel during the later period (575Ϯ294IU/mL)was con-siderably higher than that during the early period (471Ϯ253IU/mL),intraoperative blood loss during the later pe-riod (390Ϯ205mL)was significantly lower than that during the early period (515Ϯ570mL;p Ͻ0.01).The incidence of multiple hepatic duct at the stump during the later period (25.6%)was significantly higher than that dur-ing the early period (11.0%;p Ͻ0.01).Mean medical cost during hospitalization during the later period ($17,373Ϯ$2,125)was significantly lower than that during the early period ($22,580Ϯ$4,614;p Ͻ0.01).Although the post-operative complication ratio (percent of Clavien’s classifi-cation for II,IIIa,and IIIb)during the later period was comparable with that in the early period,the occurrence of BCs during the later period (1.8%)was significantly lower than that during the early period (6.4%;Fig.3,p Ͻ0.01).In addition,no BCs were observed in the last 69consecu-tive donors.Occurrence of BCs in the recipientsBCs of the recipient are also influenced by donor factors,including the donor bile duct anatomy and quality,and the techniques of donor hepatectomy,so the occurrence of the BC in the recipients was compared.The ratio of BCs dur-Table parison of Donors by Surgical PeriodsVariablesEarly period (n ؍173)Later period (n ؍170)p ValueAge (y),mean ϮSD 36.6Ϯ11.234.5Ϯ10.6NS Gender (male/female)118/55103/67NS BMI,mean ϮSD 22.6Ϯ3.022.0Ϯ2.7Ͻ0.05TLV (g),mean ϮSD 1237Ϯ2311109Ϯ210Ͻ0.01Graft type,RL/LL/LLS 45/113/1562/97/11NS GV (g),mean ϮSD470Ϯ124445Ϯ113NS RV ratio (%),mean ϮSD60.9Ϯ11.858.4Ϯ12.7NS Duration of operation (min),mean ϮSD 448Ϯ74438Ϯ75NS Intraoperative blood loss (mL),mean ϮSD 515Ϯ570390Ϯ205Ͻ0.01Multiple hepatic duct,%11.625.6Ͻ0.01Peak ALT (IU/L),mean ϮSD 471Ϯ253575Ϯ294Ͻ0.01Peak TB (mg/dL),mean ϮSD 2.5Ϯ1.7 2.7Ϯ1.2NS Hospital stay (d),mean ϮSD 14.4Ϯ9.413.6Ϯ3.9NS Medical costs ($),mean ϮSD22,580Ϯ4,61417,373Ϯ2,125Ͻ0.01Postoperative complication (%of Clavien’s classification of II,IIIa,IIIb)13.312.4NSALT,alanine aminotransferase;BC,biliary complication;BMI,body mass index (calculated as kg/m 2);GV,graft volume;LL,left lobe;LLS,left lateral segment;NS,not significant;RL,right lobe;RV ,remnant liver volume;TB,total bilirubin;TLV,total liver volume.Table parison of Donors with or without Biliary ComplicationVariablesWithout BC (n ؍329)With BC (n ؍14)p ValueAge (y),mean ϮSD 35.4Ϯ10.840.1Ϯ12.4NS Gender (male/female)213/1168/6NS BMI (kg/m 2),mean ϮSD 22.4Ϯ2.921.7Ϯ2.9NS TLV (g),mean ϮSD 1,173Ϯ2301,185Ϯ217NS Graft type RL/LL/LLS 99/204/268/6/0NS GV (g),mean ϮSD456Ϯ120501Ϯ105NS RV ratio (%),mean ϮSD59.8Ϯ12.856.5Ϯ11.6NS Duration of operation (min),mean ϮSD 441Ϯ75468Ϯ53NS Intraoperative blood loss (mL),mean ϮSD 451Ϯ402490Ϯ883NS Multiple hepatic duct,%17.814.3NS Peak ALT (IU/L),mean ϮSD 516Ϯ279510Ϯ185NS Peak TB (mg/dL),mean ϮSD 2.5Ϯ1.4 4.0Ϯ2.7Ͻ0.01Hospital stay (d),mean ϮSD 13.1Ϯ4.233.4Ϯ20.9Ͻ0.01Medical costs ($),mean ϮSD 19,844Ϯ3,95426,137Ϯ8,937Ͻ0.01ALT,alanine aminotransferase;BC,biliary complication;BMI,body mass index;GV,graft volume;LL,left lobe;LLS,left lateral segment;NS,not significant;RL,right lobe;RV,remnant liver volume;TB,total bilirubin;TLV ,total liver volume.461Vol.211,No.4,October 2010Taketomi et al Donor Hepatectomy without Biliary Complicationsing the early period was 25.9%,and that during the later period was 10.5%(p Ͻ0.01).DISCUSSIONBCs affect the donors and their families psychologically and physically.Therefore,the occurrence of BC should be avoided.This report evaluated the usefulness of the current management and surgical procedures for preventing the occurrence of BCs during a donor hepatectomy.Technical refinements have reduced the occurrence of BCs 6.4%dur-ing the early period to 1.8%during the later period.In addition,no BC was observed in the last 69consecutive donors.The rate of postoperative complications in donor hepa-tectomies is expected to be reduced in comparison with that of hepatectomies for liver tumors because of its normal liver function and the anatomical resection.Rates of BCs after a donor hepatectomy (5.3%to 9.3%)5,13,14are com-parable to that after hepatectomy for liver tumors (3.7%to 8.1%).15,16Preserving the blood supply for the biliary tract of the remnant liver is crucial in preventing BCs.The ves-sels reconstruction in recipient would be easy and safe if a sufficient length of the hepatic artery,the portal vein,or the bile duct with a graft is harvested.These vessels are suscep-tible to excessive dissection from the surround tissues,re-sulting in ischemic changes in the biliary tract.This is why the rate of BCs in the donor hepatectomy remained high.Based on our early experiences,surgical procedures were established to minimize the dissection of the hepatic artery,portal vein,and bile duct and to keep the surrounding tissues attached to the biliary tract (Fig.2).In particular,the right hepatic artery that passes immediately posterior tothe proximal portion of the common hepatic duct should not be touched.These technical refinements reduced the occurrence of BC,resulting in no BCs in the last 69con-secutive donor hepatectomies.Blood supply to the common bile duct has been thor-oughly analyzed and consists of the ascending axial branches of the gastroduodenal artery (the so-called 3o’clock and 9’o’clock marginal arteries 17).The hilar duct receives a copious supply of arterial blood from its sur-roundings,forming a rich arterial plexus on the surface of the duct in continuity with the vessels around the su-praduodenal duct.In addition,a communication arcade between the right and left arterial system is located within the hilar plate.18On the left side,55%of the communicat-ing arcade originates from a segment IV artery and,on the right side,73%of the communicating arcade originated from the right anterior hepatic artery.17Gunji and col-leagues 17reported that the mean distance between the communicating arcade branching points and the origin of the right hepatic artery is 2.52Ϯ0.83cm,but the distance to the origin of the left hepatic artery is 1.76Ϯ0.86cm.Consequently,the dissection of the hilar plate and hepatic artery in a donor hepatectomy can easily destroy the com-municating arcade of the hilar bile duct,so the blood sup-ply of the remnant side depends on only the arterial plexus from the 3or 9o’clock marginal arteries or from its sur-rounding tissues.It important to minimize the dissection of hepatic artery and portal vein to avoid damage to the arterial plexus and to keep the surrounding tissues attached to the common and branched hepatic duct.In addition to the blood supply to the biliary tract,do-nor biliary anatomy might play a role in the development of donor BCs.Our current study showed the incidence of multiple hepatic duct at the stump during the later period was higher than that during the early period.This finding suggested that hepatic duct has been transected at more peripheral site in donor during the later period as compared with during the early period,resulting in the occurrence of BCs decreased.As the multiple bile duct has been reported as one of the risk factors for biliary stricture at the anasto-mosis in recipient,ductoplasty is recommended to reduce the potential chance of stricture if presented with multiple bile ducts.19This technique enables us to perform bile duct reconstructions in a duct-to-duct fashion.20As a result,the occurrence of BCs in the recipient during the later period was low,even though the incidence of multiple hepatic duct was high.Kakos and colleagues 21reported in 1972that most sur-geons (75%)were still slow to incorporate intraoperative cholangiography into surgical practice,because this tech-nique using the static film required an average of 20to30Figure parison of the ratio of the occurrence of biliary com-plications by the period of surgery.The ratio of the occurrence of biliary complication during the early period was 6.4%,and that during the late period was 1.8%(p Ͻ0.0001).462Taketomi et al Donor Hepatectomy without Biliary Complications J Am Coll Surgminutes to obtain3to4images,and it often had to be repeated to be sure of the anatomy.Development of the mobile image intensifier has resolved that problem.Berci and colleagues22reported the intraoperative fluorocholan-giography with a C-arm mobile intensifier was useful to clearly define the anatomy of the extrahepatic bile ducts. The intraoperative fluorocholangiography procedure with the C-arm has decreased the time to between3and5min-utes,minimizing the time argument against the routine performance of this procedure.In addition,the diagnostic accuracy of a static x-ray unit is50%to70%,but the diagnostic accuracy has increased to95%to100%with a digitized image intensifier fluoroscopic unit.23Therefore, the static x-ray film unit has been replaced by the real-time intraoperative cholangiography with a C-arm to visualize the extra-and intrahepatic bile duct during surgery. BCs in the recipient are influenced by donor factors as well as recipient factors.Therefore,occurrence of BC in the recipients was also compared in the current study.The ratio of BC of the recipient during the later period(10.5%)was considerably lower than that during the early period (25.9%).Previous reports have demonstrated the useful-ness of a simple bile duct dissection technique preserving maximum vascular integrity during the total hepatectomy of the recipient.24Lee and colleagues25also reported that the high hilar dissection technique during the recipient hepatectomy can contribute to reduce BCs in duct to duct anastomosis by allowing a tension-free anastomosis and preserving adequate blood supply to the bile duct.These findings indicate that the preservation of blood supply and the minimizing the dissection of the surrounding tissues around the bile duct can reduce the occurrence of BC for both the donor and recipient.In this study,we discussed our4technical improvements to avoid the BC,including the use of a real-time cholan-giography by the C-arm instead of static x-rays,a mini-mized dissection of the hepatic vessels,the meticulous clo-sure of the bile duct,and/or the use of Pringle maneuver during the parenchymal transaction.In addition,it is well-known that the team experience can lead to improved out-comes.Lo and colleagues26reported that the hospital mor-tality rate of right lobe LDLT recipients was reduced from 16%of first50cases to0%of the last50cases,and con-cluded there is a learning curve in adult right lobe LDLT. Our better outcomes at the later period in donors might be related with better experiences of our team in addition to the4technical refinements reported here. Percutaneous treatments including6percutaneous ab-dominal drainage and3percutaneous transhepatic cholan-giodrainage were performed to treat BCs in the current series,and endoscopic nasobiliary drainage was performed for3patients.Only2of14cases required a reoperation with choledochoplasty for biliary stenosis and with repair for bile leakage from the stump of hepatic duct.Endo-scopic intervention is considered to be the primary treat-ment for biliary stricture after liver transplantation with duct-to-duct biliary reconstruction.Seo and colleagues27 demonstrated that the overall success rate of endoscopic retrograde cholangiography with balloon dilation for bili-ary stricture was65%.Cantwell and colleagues28reported their30-year experience with percutaneous biliary balloon dilation of benign postoperative biliary strictures.The follow-up revealed that56of75patients(75%)had suc-cessful management with percutaneous biliary balloon di-lation.BC after a donor hepatectomy might be initially treated by a percutaneous or the endoscopic approach be-cause the success rate of these nonsurgical treatments is relatively high.In conclusion,the refinement of management and sur-gical procedures has reduced the occurrence of BC from 6.4%to1.8%.In addition,no BC was observed in the last 69consecutive donors.These managements and surgical procedures might be useful to prevent the occurrence of BCs in a donor hepatectomy.In particular,is important to preserve the blood supply for the biliary tract of both the graft and the remnant liver.Author ContributionsStudy conception and design:Taketomi,Soejima,Shirabe, MaeharaAcquisition of data:Taketomi,Morita,Toshima,Takeishi, Kayashima,NinomiyaAnalysis and interpretation of data:Taketomi,Toshima, Takeishi,Uchiyama,SoejimaDrafting of manuscript:Taketomi,Morita,Shirabe Critical revision:Taketomi,Maehara Acknowledgment:We thank Prof Brian Quinn for his review of this manuscript,and appreciate the important contribution of Prof Mistuo Shimada,University of Tokushima,Japan, during the early phase of the program.We are also grateful to Mr Leon Sakuma for his excellent help in preparing the figures.REFERENCES1.Middleton PF,Duffield M,Lynch SV,et al.Living donor livertransplantation—adult donor outcomes:a systematic review.Liver T ranspl2006;12:24–30.2.Raia S,Nery JR,Mies S.Liver transplantation from live donors.Lancet1989;2:497.3.Hashikura Y,Makuuchi M,Kawasaki S,et al.Successful living-463Vol.211,No.4,October2010Taketomi et al Donor Hepatectomy without Biliary Complications。