5 Fr) is used to loop around the whole right hilar plate and a metal clip is applied just beside the catheter to mark the site of transection. A third operative cholangiography is performed to ascertain the patency of the left ductal system (Fig. 2c). The routine use of methylene blue solution to check for bile leakage at the end of operation has been advocated,[29] but its efficacy has not been confirmed.[30] Besides the operation station, find more the back table is another location where intensive attention must be exercised. Clamping
of the right hepatic duct must be avoided at all time to avoid crushing injury. The graft is flushed with University of Wisconsin solution or histidine-tryptophan-ketoglutarate solution. It has been reported that the former may be associated with a higher incidence of BAS after LDLT,[13] but a recent meta-analysis failed to conclude that there is superiority of one over the other.[31]
Duct-to-duct anastomosis (DDA) and hepaticojejunostomy (HJ) are the two most common methods of BR. With DDA, the simpler one among the two, the normal physiological bilioenteric integrity can be maintained and future endoscopic access to the bile duct is possible.[32, 33] However, if the bile duct available for anastomosis is diseased or not long enough, DDA will not be feasible and HJ is the option.[5] At most centers,[30-32] DDA is preferred unless the native bile duct is not suitable for it or should not be used (e.g. with primary sclerosing cholangitis). In HJ, an intestinal segment is used as a component of the anastomosis. The adoption of HJ means that an additional anastomosis
Atezolizumab datasheet has to be made. Usually a jejuno-jejunostomy is then made 40 cm from the anastomosis, but a recent report suggested that a short Y-limb (20 cm) is sufficient.[34] Besides the need for an additional anastomosis, other disadvantages of HJ include longer operation time, possible contamination during enterotomy, and the risk of ascending cholangitis due to loss of function of the sphincter. Moreover, future endoscopic access to the bile duct will be difficult,[13, 14] although the rendezvous technique can be used at expert centers.[35] There is not any randomized study in the literature documenting the superiority of Etoposide concentration DDA over HJ or vice versa. Generally, DDA is the choice in adult RLDLT if there is no contraindication. Choledochoduodenostomy, an alternative to DDA, has been proposed to cope with hostile abdomens and to preserve maximal bowel length.[36] One pitfall in recipient total hepatectomy is preserving a common hepatic duct that is “too long”, with the fear that not enough length is left for a tension-free DDA. An excessively long common hepatic duct would leave an ischemic segment, causing ischemic anastomotic stricture or even bile leakage. Caudal shifting of the hepatic vein anastomosis helps when the gap between the hilum of the graft and the hepatoduodenal ligament of the recipient is too wide (e.g.
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