The right may not be always right: Biliary anatomy contraindicates right lobe live donor liver transplantation

Abstract

A 56-year-old woman presented with acute-on-chronic hepatitis B liver failure and was put on a high-urgency list for liver transplantation. She was cared for in the intensive care unit and rapidly lapsed into a coma because of hepatic encephalopathy. She had endotracheal intubation and was supported with mechanical ventilation. Her brother, 40 years old, volunteered to be the liver donor after detailed counseling. The preoperative donor evaluation including independent psychological assessment to confirm true voluntarism, blood biochemistry, computed tomography with volumetric measurement to show that he was suitable to be the liver donor. Hepatic angiography showed no vascular abnormality. Emergent operation was then arranged for live donor liver transplantation using the right lobe liver graft. Both laparotomies of the donor and the recipient started simultaneously. Operative cholangiography of the donor was performed under fluoroscopy after cholecystectomy and cannulation of the cystic duct with a French 3.5 catheter. It demonstrated several segmental branches of the right biliary tree joining the hepatic confluence (Fig. 1). Harvesting of the right lobe of the liver might result in 5 ductal openings in the graft, rendering it unsuitable for transplantation. It was then decided intraoperatively that the left lobe with a single left hepatic duct opening should be harvested together with the middle hepatic vein. The graft weighed 405 grams, which corresponded to 38% of the estimated standard liver weight of the recipient.1 The recipient operation was uneventful. Roux-en-Y hepaticojejunostomy was employed for biliary reconstruction, using 6-O polydioxanone sutures (PDS II, Ethicon, Edinburgh, United Kingdom). The postoperative courses of both the donor and recipient were uneventful. The postoperative hospital stay of the donor and the recipient were 4 days and 24 days, respectively. Operative cholangiogram of the donor with an anterior-oblique view, demonstrating several segmental branches of the right biliary tree joining the hepatic confluence. A metal clip (white arrow) was placed at the liver hilum to mark the confluence of hepatic ducts. A catheter was placed through cystic duct (C) into the common bile duct for injection of contrast. Segmental branches of hepatic ducts are labeled (1r = right caudate bile duct; 1ls= superior branch of left caudate bile duct; 1li = inferior branch of left caudate bile duct). Biliary complications remain the Achilles' heels of right-lobe live donor liver transplantation,2 contribute significantly to the postoperative morbidity, and are occasionally the causes of graft loss.3 The risks of biliary complications increase with the number of bile duct openings in the graft. Routine preoperative assessment of the anatomy of the biliary tree of the potential donors has been recommended as the standard practice, including the use of magnetic resonance cholangiography4 and computed tomographic cholangiography with intravenous biliary contrast.5 However, intraoperative cholangiography remains the gold standard of mapping the biliary anatomy of the donors. Biliary anatomy has rarely been a contraindication for right lobe liver donation in the authors' experience. The donor in the present report was the first in the 143 right lobe liver donors of the authors' experience who demonstrated significant biliary anomaly that contraindicated the use of the right lobe for transplantation. Satisfactory operative outcomes were fortunately achieved using the left lobe liver graft for transplantation.