A jejunal Roux limb is required for anastomosis of the other graft duct. (iv) The two graft ducts are connected to one single large recipient duct in two anastomoses.

The recipient duct is partially sutured in its middle part and specifically fashioned to accommodate two graft ducts separately. This “2-to-1 reconstruction” is used when the distance between the two graft ducts is bigger than the diameter of the smaller duct opening and when there is only one recipient duct opening, with a size big enough for two graft ducts. Technical flaw has been considered a factor in the formation of BAS. A study reported a 2.5-time reduction of the rate of BAS after LDLT to 7% (with only 2.5% of the BAS cases requiring intervention) with the routine use of microsurgical BR.[24, 43] This reflects that technical flaw may be a contributing factor in the formation of http://www.selleckchem.com/products/abt-199.html BAS. The involvement of microvascular surgeons may also be beneficial. In addition, choice of suture for anastomosis could be another factor but research is needed to verify see more which suture material is better.[43, 44] However, not all transplant centers have the same availability of expertise. Endoscopic retrograde cholangiography (ERC) with balloon dilatation

is the most common treatment for BAS after DDA.[22, 45] The success rate of the treatment can be as high as 73.2%.[22] Among various factors that decide success of treatment, morphology of stricture is the most influential

one, and pouched strictures are the most difficult type. Hsieh et al.[23] reported that ERC with balloon dilatation followed by maximal stent placement resulted in a 100% success rate in the treatment of BAS after DDA on an intention-to-treat analysis. However, this result is not reproducible and is not applicable in certain situations. Sometimes the graft bile 上海皓元 duct above the stricture is not distended enough or the stricture is too tight for stent insertion. In fact, the endoscopic means cannot produce a good result for a long and tight stricture.[3] It has been suggested that ERC should be performed by the operating surgeon since the surgeon has a better understanding of the biliary systems of the graft and the recipient[22] (Fig. 3). Careful study of the donor cholangiograms at the time of endoscopy is also very useful in detecting biliary anomalies. Percutaneous transhepatic biliary drainage (PTBD) with dilatation is often adopted after endoscopic treatment fails.[5] This invasive treatment carries some risk. If the intrahepatic ducts are not distended enough, cannulation will be difficult and the risk of vascular injury is higher. A 2.2% risk of hepatic artery injury has been reported.[46] The rendezvous technique is an approach combining PTBD and ERC. This technique has the advantage of getting rid of the external draining catheter.