Transhepatic Biliary Catheterization Before Graft Implant in Living Donor Liver Transplantation J.C. Wiederkehr, I.M. Coelho Lemos, S.G. Avilla, C. Schulz, M. Moreira, M. Ekerman, and J.C. Pereira ABSTRACT Aim. Despite the evolution in surgical technique, the biliary anastomosis remains the technical Achilles’ heel of liver transplantation, especially in living donor liver transplan- tation. Interventional radiology or endoscopic procedures constitute the most common options to treat complications from the biliary anastomosis. We report a novel technique to prevent biliary complications following the transplant. Methods. During the donor procedure a wire guide was introduced in the severed duct, left or right, in retrograde fashion. The liver surface was then perforated and the wire guide exposed. A 4F catheter was then attached to the wire guide and pulled into the bile duct passing through the end-to-end duct-to-duct anastomosis or hepaticojejunostomy. Results. This technique was performed in six living donor grafts: one right lobe, two left lobes, and three left lateral segments. All patients had no complications from the stent placement, biliary strictures, or leaks. One developed a hepatic artery thrombosis on the posttransplant day 14 with no major biliary complications. B ILIARY COMPLICATIONS of liver transplants pro- duce significant morbidity and mortality despite the evolution in surgical, immunological, and in interventional radiology and endoscopic techniques. Biliary complications remain the Achilles’ heel of transplantation with an inci- dence of 10% to 38%. 1–3 Prolonged cold ischemia, chronic rejection, intrapulmonary shunting, critically ill patients, and arterial thrombosis have been shown to be important etiologic factors for posttransplant biliary complications. 1 Among pediatric patients, reduced size and split liver transplantations have been major advances to expand the donor pool. The development of living donor liver trans- plantation (LDLT), the recent usage of the right lobe graft in LDLT, and split-liver transplantation have further in- creased donor availability for adult patients. 1,4 In particular, bile leaks and anastomotic strictures may be considered to be the most common complications. 1 A novel technique to reduce the incidence of such complications is introduced here. PATIENTS AND METHODS In six consecutive cases we performed biliary catheterization during the donor procedure, including five pediatric transplants three boys and two girls and one adult (man), all from living donors. The main indication for LDLT was biliary atresia (n = 4). Other indications included fulminant hepatic failure and liver cirrhosis due to hepatitis C. Recipient age ranged from 4 months to 47 years and body weight from 4.2 kg to 72 kg. All patients received ABO- identical or compatible grafts. The donor evaluation and surgery were performed according to protocols that include an intraoper- ative cholangiogram. We used two left lobes and three left lateral segment for the pediatric group, and one right lobe for the adult recipient. During the donor operation, after the parenchyma had been sectioned, the bile duct was severed. A wire guide was introduced into the bile duct (right or left) in a retrograde fashion until it perforated the liver surface exposing the wire. A 4F catheter was then attached to the wire guide and carefully pulled into the bile duct. During the recipient procedure the catheter was placed through the duct-to-duct anastomosis (n = 3) or hepaticojejunos- tomy (n = 3) before being exteriorized from the graft surface through the abdominal wall. The catheter was maintained as an external drainage for 7 to 14 days, and then used for a postopera- tive cholangiogram. If there was no evidence of stricture or leakage, the catheter was closed and kept in place until satisfactory postoperative recovery, ranging from 30 to 90 days posttransplan- From the Division of Liver Transplantation, Santa Casa de Curitiba, and Hospital Pequeno Principe, Catholic University of Parana, Parana, Brazil. Address reprint requests to Dr. Julio Cesar Wiederkehr, Divi- sion of Liver Transplantation, Catholic University of Parana, Alameda das Buganvilias, 754, Curitiba, Parana 81210-190, Brazil. 0041-1345/05/$–see front matter © 2005 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2004.12.264 360 Park Avenue South, New York, NY 10010-1710 1124 Transplantation Proceedings, 37, 1124 –1125 (2005)