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Predicting Biliary Complications in Right Lobe Liver Transplant Recipients according to Distance between Donor's Bile Duct and Corresponding Hepatic Artery¹

¹ From the Departments of Radiology (B.M.Y., F.V.C., A.C.W., B.N.J., A.Q.) and Surgery (C.E.F., R.A.M., J.P.R.), University of California San Francisco, Box 0628, C-324C, 505 Parnassus Ave, San Francisco, CA 94143-0628. From the 2005 RSNA Annual Meeting. Received December 21, 2005; revision requested February 20, 2006; revision received March 30; accepted May 3; final version accepted May 9. Address correspondence to B.M.Y. (e-mail: ben.yeh{at}radiology.ucsf.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 
Purpose: To retrospectively determine whether biliary complications in recipients of living-donor right lobe liver grafts can be predicted at pretransplantation donor computed tomography (CT).

Materials and Methods: The human research committee approved this study. The requirement for informed consent was waived. Multi–detector row CT cholangiography and CT angiography were performed in 44 consecutive right lobe liver donors (25 men, 19 women; mean age, 37 years). When CT cholangiography in the donor demonstrated the right biliary anatomy (conventional or variant), the shortest distance between the right main (or second-order) hepatic artery and the corresponding right main (or second-order) bile duct was measured and compared with posttransplantation biliary complications in the transplant recipient by using generalized estimating equations.

Results: In 22 transplant recipients with one right main duct–to–common duct anastomosis (ie, conventional donor anatomy), the distance between the donor's right main bile duct and hepatic artery generally was small (mean distance, 3.8 mm; range, 1–14 mm) and unrelated (P = .46) to biliary complications (n = 6). In 22 recipients who required two second-order right duct anastomoses (ie, with variant donor anatomy), the distance between the donor's second-order duct and corresponding hepatic artery was more variable (mean distance, 6.6 mm; range, 1–32.5 mm), and biliary complications were significantly more common when this distance was 10 mm or greater (in eight of 13 ducts with conventional anatomy and four of 31 ducts with variant anatomy, P < .05).

Conclusion: Right lobe liver graft recipients who have variant right biliary anatomy and a second-order bile duct 10 mm or farther from the corresponding hepatic artery are at high risk for biliary complications, possibly because of a predisposition to ischemic injury.

© RSNA, 2007

	INTRODUCTION

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A primary goal of imaging living potential right lobe liver donors is to determine the suitability of the donor liver for transplantation. The ideal liver graft has a sufficiently large right lobe relative to the body mass of the graft recipient, minimal hepatic steatosis, and favorable vascular and biliary anatomy. However, despite careful preoperative evaluation, surgical complications are common: In particular, biliary leaks and strictures occur in up to 30% of liver transplant recipients (1). Biliary complications in liver transplant recipients are more common after living-donor right lobe transplantation than after cadaveric donor liver transplantation (2,3), and they decrease patient and graft survivals (4).

The increased risk of biliary complications related to living-donor right liver lobe transplantation may be due to leaks caused by the division of the liver at retrieval. During surgical recovery of the right lobe, variant biliary anatomy results in more than one bile duct orifice in as many as 40%–60% of patients (4,5). The presence of more than one duct, coupled with the small diameters of the ducts, presumably contributes to the increased frequency of complications (4). Another contributing factor may be ischemia in the right biliary tract. It is possible that the blood supply to some right bile ducts is from small perforating arteries branching from the main or left hepatic arteries and that this supply is compromised when the arterial inflow is isolated to the right artery after right liver lobe retrieval. Prior study investigators have evaluated the relationship between biliary and vascular variants (6,7), but they have not evaluated whether such relationships affect the outcome of surgery in transplant recipients.

Several investigators have found computed tomographic (CT) cholangiography and CT angiography to be accurate for evaluating both the biliary tract anatomy (8,9) and the hepatic artery anatomy (9,10) in living potential liver donors. We hypothesized that the farther the distance of the bile ducts from the hepatic artery, the greater the risk of complications. Thus, the purpose of our study was to retrospectively determine whether biliary complications in recipients of living-donor right lobe liver grafts can be predicted at pretransplantation donor CT imaging.

	MATERIALS AND METHODS

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Patients and Medical Record Review
Our retrospective single-institution study was approved by our human research committee and was compliant with requirements of the Health Insurance Portability and Accountability Act. The requirement for informed consent was waived. One author (J.P.R.) identified 114 patients who underwent CT angiography of the liver and CT cholangiography, both with intravenous contrast material enhancement, for evaluation of possible right lobe liver donation between November 1, 2001, and March 10, 2005. At our center, intravenous contrast material–enhanced CT cholangiography is routinely performed in conjunction with intravenous contrast-enhanced CT angiography of the liver for evaluation of living potential right liver lobe donors.

Five patients did not donate their liver because unfavorable biliary anatomic variants were seen at CT cholangiography, and 65 others did not donate owing to nonbiliary reasons. The remaining 44 patients underwent right lobe liver donation and comprised our study group. The patients were 25 men with a mean age of 36 years (range, 22–50 years) and 19 women with a mean age of 39 years (range, 23–53 years). There was no significant difference in age between the men and women at unpaired t testing (P = .17). All patients were healthy: They had normal serum bilirubin levels and no known liver disease.

Two other authors (A.C.W., R.A.M.) reviewed all of the medical records of the corresponding right liver lobe transplant recipients and recorded the age, sex, and number of biliary anastomoses required at transplantation. These authors also identified all biliary complications that occurred after liver transplantation and required surgical, endoscopic, or interventional radiology management. Biliary complications were categorized as leak, stricture, or both. For the recipients who required multiple bile duct anastomoses, biliary complications were recorded for each duct segment separately. For each complication, the type of intervention and outcome was recorded. The mean length of clinical follow-up of the transplant recipients was 684 days (range, 50–1428 days).

CT Techniques
All CT examinations were performed by using a four-section (high-speed mode, LightSpeed LX/i; GE Medical Systems, Milwaukee, Wis) (n = 5, performed before February 2002) or 16-section (LightSpeed; GE Medical Systems) (n = 39, performed in or after February 2002) multi–detector row scanner. Contrast-enhanced CT angiography was performed 20 seconds after the intravenous injection of 150 mL of iohexol (Omnipaque 350; GE Healthcare, Princeton, NJ) through a power injector (Stellant D; Medrad, Indianola, Pa) at a rate of 4–5 mL/sec. No oral contrast material was administered. The abdomen was imaged from the dome of the diaphragm to the iliac crests at a section thickness of 1.25 mm and a tabletop speed of 27.5 mm/sec with the 16-section scanner and at a section thickness of 2.50 mm and a tabletop speed of 27.0 mm/sec with the four-section scanner. The tube potential was set to 120 kVp, and the tube current was modulated automatically to attain a noise level of 11.57 HU, with a maximum tube current of 440 mA.

CT cholangiography was performed on the same day, within 1 hour after contrast-enhanced CT angiography of the abdomen. Before administration of the cholangiographic contrast material, each donor received 25 mg of diphenhydramine (Benadryl; Pfizer, New York, NY) intravenously. Then, 20 mL of iodipamide meglumine 52% (Cholografin; Bracco Diagnostics, Princeton, NJ) diluted in 80 mL of normal saline solution was infused for 30 minutes. The liver was imaged during a single breath hold 15 minutes after completion of the infusion. The abdomen was imaged from the dome of the diaphragm to the iliac crests with the same technique used to perform CT angiography, with the exception that for eight CT cholangiographic examinations performed between August 3, 2004, and March 10, 2005, a fixed amperage of 200 mA was used as part of a different study (not published).

For both CT angiography and CT cholangiography, CT technologists created volume-rendered (40-mm-thick sections at 3-mm intervals) and maximum intensity projection (20-mm-thick sections at 3-mm intervals) reformations in the coronal and transverse planes by using a dedicated three-dimensional workstation (Advantage Windows 4.0; GE Healthcare). Full-volume bone-subtracted rotational volume-rendered reformations with a small field of view also were created, and all images were downloaded to our institutional picture archiving and communication system (IMPAX, version 4.5; Agfa, Mortsel, Belgium). For the volume-rendered image acquisitions, the technologist adjusted the window level and width settings visually for each CT scan to reduce background noise and maximize visualization of the structures of interest.

We are aware that intravenous biliary contrast materials are reportedly associated with a high rate of adverse reactions. This has not been our experience (8), and in several studies of CT cholangiography, minor contrast agent reactions have occurred in only 1%–3% of patients—a rate similar to that associated with conventional intravenous contrast-enhanced CT (11–14). Nonetheless, all patients were observed for contrast agent reactions. One patient developed mild transient facial urticaria, and another experienced mild self-limiting wheezing; neither of these conditions required treatment. CT cholangiography has been used extensively in Asia (15–18) and Europe (9,19–21) and has been described in a few studies in the United States (8,22–24). The United States Food and Drug Administration has approved iodipamide meglumine for intravenous cholangiography.

Image Interpretation
All donor transverse and three-dimensional reformation CT angiograms and CT cholangiograms were evaluated by one abdominal imaging attending radiologist (B.M.Y.), who had 4 years subspecialty experience in liver CT and was unaware of the biliary complication histories of the transplant recipients. The images were viewed at the picture archiving and communications system workstation. The images were evaluated for quality of visualization of the second-order bile duct anatomy and the hepatic artery anatomy and were rated as diagnostic or nondiagnostic. CT cholangiograms were considered to be diagnostic if the right and left main ducts and both right second-order bile ducts were visualized on transverse images. CT angiograms were considered to be diagnostic if the right main and second-order right hepatic arteries were visualized on transverse images. For the cases rated as diagnostic, the reader recorded the right hepatic artery anatomy and the right biliary branching anatomy of the biliary tract (25) as conventional or variant. Three patients had undergone intraoperative cholangiography at the time of liver graft retrieval, and the findings were concordant with those of CT cholangiography. These three patients previously had been included in a separate report (8). Intraoperative cholangiograms were not assessed further in this study because the three-dimensional distances between bile ducts and arteries cannot be readily assessed at conventional cholangiography.

Conventional right hepatic artery anatomy was defined as anatomy with the common hepatic artery arising from the celiac artery and branching into the left and right main hepatic arteries, which in turn branch into the anterior and right posterior hepatic arteries. All other right hepatic artery branching patterns were considered to be variant. Conventional right biliary tract anatomy was defined as anatomy with the right posterior second-order duct (which drains from Couinaud liver segments VI and VII) draining into the right anterior second-order duct (which drains from Couinaud liver segments V and VIII) to form a right main first-order bile duct. All other right bile duct branching patterns were considered to be variant because these branches do not have a common right main bile duct and thus require multiple bile duct anastomoses for right lobe liver transplantation.

The reader recorded the shortest distance between the donor's right main hepatic artery and right main bile duct, as well as the shortest distance between each of the two second-order right hepatic arteries and the origin of the corresponding right second-order bile duct. Origin of a second-order bile duct was defined as the segment of the bile duct within 1 cm of its insertion into the downstream bile duct. For patients with a variant right biliary tract branching anatomy, only the shortest distance between each of the two second-order right hepatic arteries and the corresponding right second-order bile duct was recorded because such patients lack a common trunk for the right-sided bile ducts.

Because the CT angiograms and CT cholangiograms were obtained during different acquisitions, the reader cross-referenced the transverse CT angiographic images with the corresponding CT cholangiographic images to identify the location of the bile ducts for measurement purposes (Figs 1, 2). On these transverse CT images, the z-axis and in-plane distances between the bile ducts and the hepatic arteries were recorded. The Pythagorean theorem was then used to calculate the distance between the two structures. The z-axis distance was determined by counting the number of contiguous CT sections between one structure and the other and multiplying this number by the section thickness. The three-dimensional reformations (Figs 1, 2) were used for reference only—not for actual distance measurements; all distance measurements were made on the transverse images.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: Images obtained in 26-year-old male liver donor with conventional biliary and hepatic artery anatomy. (a) CT cholangiogram (coronal volume-rendered reformation) shows conventional right biliary anatomy with a single right main bile duct (arrow). (b) CT angiogram (coronal volume-rendered reformation) shows conventional right hepatic artery anatomy (arrow). (c) Fused CT angiogram and CT cholangiogram confirm similar craniocaudal position of right hepatic artery (small arrow) and corresponding right main bile duct (large arrow). (d) Transverse CT cholangiogram shows right main bile duct (arrow) as opacified structure. (e) Corresponding transverse CT angiogram shows opacified branch of right hepatic artery (black arrow) 1.0 mm lateral to nonopacified right main bile duct (white arrow).

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: Images obtained in 26-year-old male liver donor with conventional biliary and hepatic artery anatomy. (a) CT cholangiogram (coronal volume-rendered reformation) shows conventional right biliary anatomy with a single right main bile duct (arrow). (b) CT angiogram (coronal volume-rendered reformation) shows conventional right hepatic artery anatomy (arrow). (c) Fused CT angiogram and CT cholangiogram confirm similar craniocaudal position of right hepatic artery (small arrow) and corresponding right main bile duct (large arrow). (d) Transverse CT cholangiogram shows right main bile duct (arrow) as opacified structure. (e) Corresponding transverse CT angiogram shows opacified branch of right hepatic artery (black arrow) 1.0 mm lateral to nonopacified right main bile duct (white arrow).

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: Images obtained in 26-year-old male liver donor with conventional biliary and hepatic artery anatomy. (a) CT cholangiogram (coronal volume-rendered reformation) shows conventional right biliary anatomy with a single right main bile duct (arrow). (b) CT angiogram (coronal volume-rendered reformation) shows conventional right hepatic artery anatomy (arrow). (c) Fused CT angiogram and CT cholangiogram confirm similar craniocaudal position of right hepatic artery (small arrow) and corresponding right main bile duct (large arrow). (d) Transverse CT cholangiogram shows right main bile duct (arrow) as opacified structure. (e) Corresponding transverse CT angiogram shows opacified branch of right hepatic artery (black arrow) 1.0 mm lateral to nonopacified right main bile duct (white arrow).

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 1d: Images obtained in 26-year-old male liver donor with conventional biliary and hepatic artery anatomy. (a) CT cholangiogram (coronal volume-rendered reformation) shows conventional right biliary anatomy with a single right main bile duct (arrow). (b) CT angiogram (coronal volume-rendered reformation) shows conventional right hepatic artery anatomy (arrow). (c) Fused CT angiogram and CT cholangiogram confirm similar craniocaudal position of right hepatic artery (small arrow) and corresponding right main bile duct (large arrow). (d) Transverse CT cholangiogram shows right main bile duct (arrow) as opacified structure. (e) Corresponding transverse CT angiogram shows opacified branch of right hepatic artery (black arrow) 1.0 mm lateral to nonopacified right main bile duct (white arrow).

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 1e: Images obtained in 26-year-old male liver donor with conventional biliary and hepatic artery anatomy. (a) CT cholangiogram (coronal volume-rendered reformation) shows conventional right biliary anatomy with a single right main bile duct (arrow). (b) CT angiogram (coronal volume-rendered reformation) shows conventional right hepatic artery anatomy (arrow). (c) Fused CT angiogram and CT cholangiogram confirm similar craniocaudal position of right hepatic artery (small arrow) and corresponding right main bile duct (large arrow). (d) Transverse CT cholangiogram shows right main bile duct (arrow) as opacified structure. (e) Corresponding transverse CT angiogram shows opacified branch of right hepatic artery (black arrow) 1.0 mm lateral to nonopacified right main bile duct (white arrow).

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Images obtained in 31-year-old male liver donor with conventional hepatic artery anatomy and right posterior duct draining into left main duct. (a) CT cholangiogram (coronal volume-rendered reformation) shows right anterior bile duct (arrowhead) and separate posterior bile duct (arrow) draining into left main duct. (b) CT angiogram (coronal volume-rendered reformation) shows right anterior (arrowhead) and right posterior (arrow) hepatic artery branches. (c) Fused coronal volume-rendered CT cholangiogram and CT angiogram show similar craniocaudal position of right anterior hepatic artery (small arrowhead) and corresponding bile duct (large arrowhead) but a longer distance between right posterior hepatic artery (small arrow) and corresponding bile duct (large arrow). At transverse CT (not shown), right anterior bile duct was 2.5 mm more inferior on z-axis and 2.0 mm anteromedial to origin of right anterior hepatic artery. This duct was calculated (with use of Pythagorean theorem) to be 3 mm from right anterior bile duct. Right posterior bile duct was 10 mm inferior on z-axis and 7.5 mm anteromedial to right posterior hepatic artery. This artery was calculated (with use of Pythagorean theorem) to be 12.5 mm from that duct.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Images obtained in 31-year-old male liver donor with conventional hepatic artery anatomy and right posterior duct draining into left main duct. (a) CT cholangiogram (coronal volume-rendered reformation) shows right anterior bile duct (arrowhead) and separate posterior bile duct (arrow) draining into left main duct. (b) CT angiogram (coronal volume-rendered reformation) shows right anterior (arrowhead) and right posterior (arrow) hepatic artery branches. (c) Fused coronal volume-rendered CT cholangiogram and CT angiogram show similar craniocaudal position of right anterior hepatic artery (small arrowhead) and corresponding bile duct (large arrowhead) but a longer distance between right posterior hepatic artery (small arrow) and corresponding bile duct (large arrow). At transverse CT (not shown), right anterior bile duct was 2.5 mm more inferior on z-axis and 2.0 mm anteromedial to origin of right anterior hepatic artery. This duct was calculated (with use of Pythagorean theorem) to be 3 mm from right anterior bile duct. Right posterior bile duct was 10 mm inferior on z-axis and 7.5 mm anteromedial to right posterior hepatic artery. This artery was calculated (with use of Pythagorean theorem) to be 12.5 mm from that duct.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 2c: Images obtained in 31-year-old male liver donor with conventional hepatic artery anatomy and right posterior duct draining into left main duct. (a) CT cholangiogram (coronal volume-rendered reformation) shows right anterior bile duct (arrowhead) and separate posterior bile duct (arrow) draining into left main duct. (b) CT angiogram (coronal volume-rendered reformation) shows right anterior (arrowhead) and right posterior (arrow) hepatic artery branches. (c) Fused coronal volume-rendered CT cholangiogram and CT angiogram show similar craniocaudal position of right anterior hepatic artery (small arrowhead) and corresponding bile duct (large arrowhead) but a longer distance between right posterior hepatic artery (small arrow) and corresponding bile duct (large arrow). At transverse CT (not shown), right anterior bile duct was 2.5 mm more inferior on z-axis and 2.0 mm anteromedial to origin of right anterior hepatic artery. This duct was calculated (with use of Pythagorean theorem) to be 3 mm from right anterior bile duct. Right posterior bile duct was 10 mm inferior on z-axis and 7.5 mm anteromedial to right posterior hepatic artery. This artery was calculated (with use of Pythagorean theorem) to be 12.5 mm from that duct.

	RESULTS

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Complications and Anatomic Variants
Preoperative CT angiograms and CT cholangiograms were rated as diagnostic in all 44 (100%) donors. A single duct-to-duct anastomosis was performed in 22 right lobe liver transplant recipients, and owing to variant second-order biliary anatomy in the donor, separate second-order bile duct anastomoses were performed in the 22 remaining recipients. Thirteen (30%) of 44 donors had conventional anatomy of both the right biliary tract and the hepatic artery, and 10 (23%) had variant anatomy of both the right biliary tract and the hepatic artery. Nine (20%) of 44 donors had conventional right biliary tract anatomy and variant right hepatic artery anatomy, whereas 12 (27%) had variant right biliary tract anatomy and conventional right hepatic artery anatomy. Biliary complications (Table) occurred in 16 (36%) of the 44 recipients: six requiring single duct-to-duct anastomosis, eight requiring one second-order duct anastomosis, and two requiring anastomoses of both second-order ducts. There was no significant difference in the incidence of biliary complications between the recipients with a single duct-to-duct anastomosis (six [27%] of 22 patients) and those with a separate second-order bile duct anastomosis (10 [45%] of 22 patients, P = .35).

View larger version (29K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Graph illustrates distances between second-order right bile duct and corresponding hepatic artery branch at donor CT cholangiography and CT angiography and subsequent development of biliary complication in the right liver lobe recipient. For both right anterior and right posterior bile ducts, the mean distance between the second-order bile duct and the corresponding hepatic artery was greater in the ducts with complications than in those without complications (P < .05 for both). Generalized estimating equations revealed a 5.6-fold greater likelihood of bile duct complication for a given second-order bile duct for each centimeter of increased distance between the bile duct and the corresponding hepatic artery, as well as a significantly increased incidence of biliary complications for second-order ducts that were 10 mm or farther from the corresponding hepatic artery compared with second-order ducts that were closer to the artery (in eight of 13 ducts without and four of 31 ducts with variant anatomy, P < .05).

	DISCUSSION

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In our study involving right lobe liver transplant recipients, we found that biliary complications were more common in recipients of right liver lobes with variant right biliary anatomy and a second-order right bile duct that was 10 mm or farther from the corresponding hepatic artery. The risk of biliary complications increased 5.6 fold for every centimeter of increased distance between a variant-anatomy second-order right biliary branch and the corresponding hepatic artery. To our knowledge, our study is the first in which a relationship between bile duct–hepatic artery anatomy in the donor and liver transplantation complications in the recipient was reported. The finding of a 10-mm or greater distance between the second-order biliary branch and the corresponding hepatic artery and the need for multiple biliary anastomoses may prompt modifications in biliary anastomotic technique or exclusion of the donor for liver transplantation.

Our findings support the idea that right lobe second-order biliary complications are often due to an inadequate blood supply. It is likely that increased distances between second-order bile ducts and corresponding hepatic arteries predispose such ducts to ischemia at liver retrieval and transplantation owing to injury of small delicate feeding arteries or to separation of the biliary branch from an alternate blood supply, such as the proper or left hepatic artery.

Preoperative measurement of distances between second-order bile ducts and hepatic artery branches demands high-spatial-resolution imaging of these small branching structures. A particular benefit of performing both preoperative CT angiography and preoperative CT cholangiography is the relative ease with which the biliary anatomy and vascular anatomy can be cross-correlated by using easily identifiable local landmarks on transverse images. A more direct means of evaluating the distance between the hepatic artery and the bile duct is to perform CT cholangiography concurrently with CT angiography during the same acquisition (19). With this method, the bile ducts and hepatic arteries are simultaneously opacified. Owing to concerns regarding possible reactions to intravenous CT cholangiographic contrast material, to minimize any possible loss of data in the event of a severe reaction, we performed CT cholangiography after acquiring the CT angiogram. However, we did not experience this limiting phenomenon. We did not evaluate the usefulness of magnetic resonance (MR) angiography and MR cholangiography in determining bile duct–to–hepatic artery distances, and further work to assess MR imaging for this indication is needed (9,26).

Our study had limitations. First, the CT cholangiograms and CT angiograms were obtained during different acquisitions. This necessitated the use of local anatomic landmarks to determine the distances between the hepatic arteries and the bile ducts and thus possibly limited the accuracy of measurements in some patients. However, since the range of relevant distances between the biliary branches and the hepatic arteries was on the order of 1–32.5 mm, it is unlikely that more accurate measurements of biliary-to-vascular distances would yield an incremental benefit. Second, the data were acquired from a single institution offering living-donor right lobe liver transplantation and thus from a limited number of patients. Because surgical techniques may vary between institutions, corroboration by means of multiinstitutional assessment would be beneficial for determining the generalizability of our findings. Third, we examined right lobe liver transplant recipients only. Further examinations of other patient groups, such as those requiring left hepatectomy, may be useful in determining the value of similar bile duct–to–hepatic artery distance measurements for risk stratification in larger patient populations.

In conclusion, recipients of right lobe liver grafts from donors with variant right biliary anatomy and a second-order bile duct 10 mm or farther from the corresponding hepatic artery may be at high risk for biliary complications, possibly because of a predisposition to ischemic injury. Further investigation to define the relationship between biliary and arterial anatomy with regard to surgical risk is warranted.

	ADVANCES IN KNOWLEDGE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 

• In right lobe liver transplantations that require separate second-order right bile duct anastomoses, biliary complications are more common when the donor's second-order bile duct is 10 mm or farther from the corresponding hepatic artery.
  
• When a single right main duct–to–common duct anastomosis is performed at right liver lobe transplantation, the distance between the donor's right main bile duct and hepatic artery is not predictive of subsequent biliary complication in the transplant recipient.
  

	FOOTNOTES

 
Authors stated no financial relationship to disclose.

Author contributions: Guarantor of integrity of entire study, B.M.Y.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, B.M.Y., J.P.R.; clinical studies, B.M.Y., A.C.W., B.N.J., C.E.F., J.P.R.; statistical analysis, B.M.Y.; and manuscript editing, all authors

	References

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE References

 

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