Roux-en-Y Bleeding After Living Donor Liver Transplantation: A Novel Technique for Surgical Treatment G. Icoz, M. Kilic, M. Zeytunlu, O. Yaprak, C. Arikan, Y. Yuzer, and Y. Tokat ABSTRACT Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications following liver transplantation. The aim of this study is to define the prevalence of GIB due to Roux- en Y (R-Y) enteral anastomoses after living donor liver transplantation (LDLT) and recommend an anastomotic technique for easy surgical intervention. Ninety-five patients underwent 96 LDLT from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients. Anastomoses were end-to-side (ES) in the first 25 patients and side-to-side (SS) type in the last 18 patients. GIB occurred in 13 patients (30%). The R-Y anastomotic line was shown to be the bleeding site in 10 patients. Anastomoses were in ES fashion in 7 of 10 patients (70%). In other words 28% of ES and 17% of SS anastomoses displayed a bleeding episode after LDLT. Four patients required surgical intervention (Three ES, one SS), namely an operative rate of 9%. The type of the jejunojejunostomy, the UNOS or Child-Pugh scores, the presence of preexisting portal hypertension, the duration of portal vein clamping, the GRWR of patients, revealed no statistical significant difference between bleeding and non- bleeding patients. Although statistical analyses did not reveal any significant difference (P = .47), GIB was higher among patients with an ES type of anastomoses. As a result we recommend a jejunojejunostomy in SS fashion on the antimesenteric borders of the jejunal segments with a 3– 4 cm blind intestinal segment. The surgical procedure for R-Y bleeding may then be performed without disrupting the jejunojejunostomy. L IVER TRANSPLANTATION (LT) is the treatment of choice for patients with acute and chronic liver failure and with certain metabolic disorders. The dramatic increase waiting times and death rates has been a stimulus to use living donors during the last decade. Despite advances in surgical technique, complications are still not infrequent. Upper gastrointestinal bleeding (GIB) is one of the most common gastroenterologic complications after orthotopic LT 1 , as well as living-related donor liver transplantation (LDLT). Moreover, LDLT may not resolve hemodynamic changes due to portal hypertension as may be obtained with a full-size cadaver donor graft. 2 The aim of the present study was to assess the prevalence of GIB due to Roux- en-Y (R-Y) enteral anastomoses after LDLT and to rec- ommend an anastomotic technique for easy surgical inter- vention. PATIENTS AND METHODS Ninety-five patients (65 males, 30 females) underwent 96 LDLTs at the Ege University Organ Transplantation Center from June 1999 through January 2003. R-Y biliary reconstruction was employed in 43 patients, which included 18 right lobe (Couinaud segments V through VIII) and 25 left lateral segments (Couinaud segments II and III). Eighteen patients were adults and 25 were children. The median age was 13 years (range 6 months to 57 years). Recipients’ UNOS classification was as follows: 5 patients in UNOS 1; 13, UNOS 2A; 21, UNOS 2B; and 4, UNOS 3. Classification of patients according to the Child–Pugh score was similar: class A, 2 patients; class B, 7 patients; and class C, 31 patients. Three patients with fulminant hepatic failure could not be assessed by the Child–Pugh classification. The common indications for LDLT were cholestatic disease (n = 14), chronic active viral hepatitis with liver cirrhosis (n = 11), including hepatitis B in 9 patients and hepatitis C in 2 patients; metabolic disorders (n = 5); cryptogenic cirrhosis and autoimmune hepatitis (n = 5); fulminant hepatic failure (n = From the Ege University Medical School, Department of Organ Transplantation and Research Center, Izmir, Turkey. Address reprint requests to Dr Gokhan Icoz, Department of Surgery, Ege University Medical School, 35100 Izmir, Turkey. E-mail: gicoz@med.ege.edu.tr © 2003 by Elsevier Inc. All rights reserved. 0041-1345/03/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/S0041-1345(03)00484-6 Transplantation Proceedings, 35, 1463-1465 (2003) 1463