title: Clinicopathological review of 18 cases of liver allografts lost due to bile duct necrosis.
abstract: Clinical, radiographic, and pathological features of 18 patients with biliary necrosis in their explanted liver allografts were reviewed. Twelve patients were men and ages ranged from 27 to 72 years. Indications for initial liver transplant (LT) were viral hepatitis (n = 7), steatohepatitic cirrhosis (n = 3), cryptogenic cirrhosis (n = 3), secondary sclerosing cholangitis (n = 2), primary sclerosing cholangitis (n = 1), biliary atresia (n = 1), and nodular regenerative hyperplasia (n = 1). Donor age ranged from 16 to 75 years. Duct-to-duct biliary anastomoses were fashioned in 13 cases; warm and cold ischemia times were not significantly different from general LT population. Seventeen allograft biopsies after recirculation had no significant findings. Post-LT, clinical and radiographic evaluation indicated biliary strictures (n = 7), bile leak (n = 7), intrahepatic abscess (n = 1), and duodenal perforation (n = 1). Radiographic vascular studies suggested hepatic arterial thrombosis or stenosis in 11 cases. Biopsies prior to retransplantation were performed on 17 patients and showed acute rejection (n = 10), biliary outflow impairment (n = 4), normal histology (n = 2), and centrilobular necrosis (n = 1). Retransplantation was performed 14 to 334 days after initial LT. Pathological examination of explants revealed perihilar duct necrosis in all cases, with bacterial colonies (n = 10) and fungal organisms (n = 2). Arterial thrombi were seen in 10 cases, and two had prominent arteriosclerosis. Infarction and centrilobular necrosis were seen in 9 and 13 cases, respectively. Four explants showed features of biliary outflow impairment. Twelve patients were alive 6 to 18 months following retransplantation. We conclude that post-LT biliary necrosis is associated with ischemia, and such a complication is rarely evident in allograft biopsies. Biliary and vascular imaging studies are essential in evaluating patients for this complication.
authors.affiliation: Mayo Clinic, Jacksonville, Florida, USA. krishna.murli@mayo.edu
authors.forename: M
authors.initials: M
authors.lastname: Krishna
authors.forename: A P
authors.initials: AP
authors.lastname: Keaveny
authors.forename: P V
authors.initials: PV
authors.lastname: Genco
authors.forename: B G
authors.initials: BG
authors.lastname: Rosser
authors.forename: R C
authors.initials: RC
authors.lastname: Dickson
authors.forename: J H
authors.initials: JH
authors.lastname: Nguyen
authors.forename: J L
authors.initials: JL
authors.lastname: Steers
authors.forename: R E
authors.initials: RE
authors.lastname: Nakhleh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D001652:Bile Ducts / Q000473:pathology* / Q000601:surgery; D005705:Gallbladder Diseases / Q000473:pathology; D006801:Humans; D008107:Liver Diseases / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects / Q000473:pathology*; D008875:Middle Aged; D009336:Necrosis; D011183:Postoperative Complications / Q000473:pathology*; D012189:Retrospective Studies