Endoscopic management of postoperative biliary complications in donors for living donor liver transplantation  Kazunori Hasegawa*, Shujiro Yazumi*, Hiroto Egawa‡, Hiroyuki Tamaki*, Masanori Asada*, Yuzo Kodama*, Hiroshi Hisatsune*, Kazuichi Okazaki*, Koichi Tanaka‡, Tsutomu Chiba*  Clinical Gastroenterology and Hepatology  Volume 1, Issue 3, Pages 183-188 (May 2003) DOI: 10.1016/S1542-3565(03)70034-2 Copyright © 2003 American Gastroenterological Association Terms and Conditions

Fig. 1 Retrograde cholangiograms demonstrating biliary leakage (patient 4). (A) Biliary leakage (arrowhead) was confirmed at the closure portion of right hepatic duct. (B) The leakage resolved within 18 days after an ENBD tube was placed. Asterisk identifies a surgical drain for biliary fluid collection. Arrow identifies the ENBD tube. Clinical Gastroenterology and Hepatology 2003 1, 183-188DOI: (10.1016/S1542-3565(03)70034-2) Copyright © 2003 American Gastroenterological Association Terms and Conditions

Fig. 2 Cholangiograms showing 2 cases of biliary stricture (A-C, patient 5; D-F, patient 7). (A) Biliary leakage (arrowhead) relapsed within 194 days after donation. (B) The leakage was resolved after PTBD (asterisk), but the contorted stricture remained. (C) The stricture relaxed within 147 days after the endoscopic biliary stent had been placed (arrow). (D) An intraoperative cholangiogram demonstrated that the angle between the common hepatic duct and the left hepatic duct was markedly obtuse. (E) Biliary leakage (arrowhead) was confirmed at 78 days after donation. (F) The angle between the common hepatic duct and the left hepatic duct became slightly larger within 123 days after endoscopic biliary stent placement. Clinical Gastroenterology and Hepatology 2003 1, 183-188DOI: (10.1016/S1542-3565(03)70034-2) Copyright © 2003 American Gastroenterological Association Terms and Conditions

Fig. 3 Cholangiograms of all the patients showing biliary leakage. The maximum angle between the common hepatic duct and the left hepatic duct was measured by using fluoroscopy. Biliary leakage disappeared in patients 1, 2, 3, and 4 (A-D, respectively), but a contorted stricture remained in patients 5, 6, and 7 (E-G, respectively) even after the biliary leakage resolved. The angles between the ducts in patients who had a contorted stricture (E-G) were more acute than those in patients who did not have a stricture (A-D) (median angle, 62 degrees vs. 119 degrees). Clinical Gastroenterology and Hepatology 2003 1, 183-188DOI: (10.1016/S1542-3565(03)70034-2) Copyright © 2003 American Gastroenterological Association Terms and Conditions

Fig. 4 Mechanism for the development of recurrent biliary leakage or biliary stricture. (A) The residual biliary system after the right lobe has been resected. (B) With the compensatory hypertrophy of the residual left lobe, the hilum shifts into the vacant right subdiaphragmatic space. The angle between the left hepatic duct and the common hepatic duct consequently becomes smaller than it would immediately after left lobe resection. In addition, inflammation and infection around bifurcation due to biliary leakage immediately after donation would cause thickening of the bile duct wall and stenosis of the bile duct. Eventually, relapse of biliary leakage or biliary stricture would develop. F, the falciform ligament; P, pancreas. Arrows indicate the thickening of the bile duct wall and stenosis of the bile duct. Clinical Gastroenterology and Hepatology 2003 1, 183-188DOI: (10.1016/S1542-3565(03)70034-2) Copyright © 2003 American Gastroenterological Association Terms and Conditions