Graft Steatosis as a Risk Factor of Ischemic-Type Biliary Lesions in Liver Transplantation F. Frongillo*, M.C. Lirosi, G. Sganga, U. Grossi, E. Nure, A.W. Avolio, G. Bianco, G. Mariano, and S. Agnes Department of Surgery, Transplantation Service, Catholic University of the Sacred Heart, Rome, Italy ABSTRACT Ischemic-type biliary lesions (ITBLs) are now a discussed cause of morbidity and mortality in liver transplant recipients, even if not definitively characterized. We reviewed 13 years of donor and recipient data between April 2001 and April 2013. We evaluated the incidence of ITBL occurrence, exploring the possible predisposing factors, focusing on the rela- tionship between severe macrovesicular steatosis of the graft and incidence of ITBL. A total of 445 grafts were harvested: 416 of them were transplanted at our institution, the remaining 29 were discarded by our donor team as showing more than 40% macrovesicular steatosis. Mild-moderate (20% to 40%) macrovesicular steatosis (P < .001) and cold ischemia time (P ¼ .048) significantly increased the risk of ITBLs, also resulting in inde- pendent risk factors at multivariate analysis. B ILIARY tract complications remain the Achilles heel of orthotopic liver transplantation, with a reported incidence ranging from 10% to 30% in large series [1]. Biliary leaks and strictures are the most common biliary complications. Ischemic-type biliary lesions (ITBL) have been identified as a new pathological entity [2], character- ized by intrahepatic strictures and dilatations in the absence of other conditions such as hepatic artery stenosis or thrombosis, portal thrombosis, chronic ductopenic rejection, and primary sclerosing cholangitis. In this article we analyze a 13-year experience of orthotopic liver transplantation, focusing on the occurrence of ITBL in order to clearly define macrovesicular steatosis as a predisposing factor. PATIENTS AND METHODS From April 2000 to April 2013, 324 livers referred to our institution were considered potentially transplantable. Twenty-nine showed more than 40% macrovesicular steatosis on biopsy, and thus were discarded by our donor team. The specimens were obtained by 1 wedge biopsy and 1 needle biopsy. Macrovesicular steatosis was defined as a single vacuole, larger than the nucleus, replacing most of the hepatocyte’s cytoplasm and displacing the nucleus toward the cytoplasmic border [3,4]. Among 295 harvested and full-size trans- planted grafts, 47 (15.9%) showed mild-moderate (25% to 40%) (Fig 1) macrovesicular steatosis. These grafts were not allocated to recipients with portal thrombosis, diabetes, or renal failure, but were transplanted only into recipients under 65 years old and with Model for End-Stage Liver Disease scores up to 27. The median cold ischemia time (CIT) of this cohort was 490 minutes. In all cases, biliary reconstruction was performed using duct-to-duct choledochocholedochostomy through a double running suture and included a T-tube splint of the anastomosis successively removed 3 months after transplantation. Outcomes of patients with vs without ITBL were compared in respect to demographic, biochemical, surgical, and pathological variables. Statistical analysis was per- formed using the SPSS statistical package (version 16.0; SPSS Inc., Chicago, IL). RESULTS Forty-two patients developed biliary complications. Bile leakage occurred in 13 patients (5.9%), anastomotic stricture in 4 patients (1.8%). All were successfully treated with endoscopic sphincterotomy, stenting, or dilatation and/or percutaneous transhepatic cholangiography-guided drainage. Nonanastomotic strictures developed in 25 patients (11.2%), mostly due to ITBL (21 patients, 9.4%). In the remaining 4 patients (1.8%), the strictures resulted from hepatic artery thrombosis and chronic ductopenic rejection in 2 cases each. Among those with ITBL, 8 patients showed changes located primarily in the extrahepatic bile duct and underwent resection of the stenotic tract with Roux-en-Y hepaticojejunostomy; 6 patients required retransplantation; 7 patients were treated conservatively with permanent percutaneous transhepatic drainage. Univariate analysis between patients with vs without *Address correspondence to Francesco Frongillo, Department of Surgery, Transplantation Service, Policlinico “A. Gemelli”, Largo A. Gemelli 8, 00168 Rome, Italy. E-mail: ffrongillo@yahoo.it ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 0041-1345/14 http://dx.doi.org/10.1016/j.transproceed.2014.07.057 Transplantation Proceedings, 46, 2293e2294 (2014) 2293