Internal hernia of the small intestine around biliary catheter after living-donor liver transplantation: A case report.

INTRODUCTION: Biliary reconstruction is a cornerstone of living-donor liver transplantation (LDLT). The routine uses of trans-anastomotic biliary catheters in biliary reconstruction had been a controversial issue. We describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter.
PRESENTATION: A 42 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Biliary reconstruction was done by single duct-to-duct anastomosis over trans-anastomotic biliary catheter. The patient was doing well apart from early postoperative ascites that was managed medically. Three weeks after surgery, the patient developed severe agonizing central abdominal pain not responding to anti-spasmodics and analgesics. The decision was to proceed for surgical exploration. Exploration revealed internal herniation of the small bowel loops around the trans-anastomotic biliary catheter without strangulation. Reduction of the internal hernia was done by releasing the fixation of the biliary catheter from the anterior abdominal wall. Small bowel resection was not required. The patient had smooth postoperative course and was discharged 10 days after surgery. DISCUSSION: Awareness regarding this rare complication plus early surgical intervention can prevent the development of postoperative morbidity and mortality. To the best of our knowledge this is the first report to describe such are complication after LDLT.
CONCLUSION: We report the first case of internal herniation of small bowel around biliary catheter early after LDLT.

Introduction

Liver transplantation is considered the only effective treatment for patients with end stage liver disease and selected hepatic malignancies. Nowadays, living-donor liver transplantation (LDLT) is considered an acceptable and safe alternative option to deceased donor liver transplantation [[1], [2], [3]].

Biliary reconstruction is a cornerstone of LDLT. It is performed most commonly by a duct-to-duct anastomosis. Despite the accumulating experience in LDLT, the incidence of biliary complications remains high [4,5].

The routine uses of trans-anastomotic biliary catheters in duct-to-duct biliary reconstruction had been a controversial issue, and most of studies did not prove a real advantage of its routine use [[6], [7], [8]]. In our center, we routinely use trans-anastomotic biliary catheters during duct-to-duct biliary anastomosis [9]. The advantages of its routine use are to facilitate healing of the anastomosis, decrease the incidence of anastomotic biliary leakage, and allows easy evaluation of biliary anastomosis by cholangiogram. However, several disadvantages related to its use had been reported including cholangitis, biliary leakage at the site of its exit, cholangiogram related complications, and the development of non-anastomotic biliary strictures [6].

In this report, we describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter. To the best of our knowledge this is the first report to describe such complication after LDLT. This work has been reported in line with the SCARE criteria [10].

Case presentation

42 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. He was planned for LDLT. His preoperative Child-Pugh score was 10 (class C), and model for end stage liver disease (MELD) was 15. Preoperative triphasic abdominal computed tomography (CT) showed markedly cirrhotic liver, markedly enlarged spleen, and mild pelvic ascites.

He received a right hemi-liver graft without the middle hepatic vein from his nephew (33 years old). The actual graft weight was 1056 g and graft weight to recipient weight ratio (GRWR) was 1.15.

The graft had a single dominant right hepatic vein (30 mm) and was anastomosed to the recipient right hepatic vein with venoplasty (30 mm). The recipient main portal vein stump (14 mm) was anastomosed, in end to end fashion, to the graft portal vein (8 mm). Then arterial reconstruction was done between the graft right hepatic artery (2 mm) and the recipient right hepatic artery (3 mm).

Doppler ultrasound (US) was performed upon completion of all vascular anastomoses and showed sound anastomoses and adequate inflow and outflow without congestion.

Biliary reconstruction was done by duct-to-duct anastomosis between the graft right hepatic duct (4 mm) and the recipient right hepatic duct (4 mm) over trans-anastomotic biliary catheter (4 french) exiting through a separate opening into the common bile duct. Completion cholangiogram showed adequate biliary anastomosis with no leakage.

Postoperatively, the patient was transferred to the intensive care unit. Extubation was done in the first postoperative day. The patient has smooth postoperative course and was transferred to the ward on the fifth postoperative day.

In the ward, the patient was doing well apart from early postoperative ascites that was managed by intravenous albumin 4% infusion daily and monitoring of serum electrolytes. Doppler US was performed daily to check patency of all vascular anastomoses and adequate inflow and outflow to the graft.

On the 25th postoperative day, the patient developed severe agonizing central abdominal pain. There was no vomiting or constipation. Abdominal examination was free. Serum total leucocytic count was normal. The patient received intravenous anti-spasmodics and analgesics with no improvement of the abdominal pain.

Plain abdominal radiograph was ordered and showed gas shadow inside the stomach and dilated small bowel loop at the right hypochondrial region (Fig. 1). Non-contrast abdominal CT confirmed the presence of the dilated jejunal loop with no definite obstructing cause (Fig. 2). Doppler US was done and confirmed patency of all vascular anastomoses. The decision was to proceed for surgical exploration.

Fig. 1

Plain abdominal radiograph (erect) showing fixed dilated small bowel loop in the right hypochondrial region (arrow).

Fig. 2

Preoperative non-contrast abdominal computed tomography showing fixed dilated small bowel loop (arrow).

Emergency abdominal exploration was done on the 25th postoperative day. Exploration revealed internal herniation of the small bowel loops around the trans-anastomotic biliary catheter without strangulation (Fig. 3, Fig. 4). The herniated bowel loops were markedly congested from obstruction of the small bowel mesenteric vessels. Reduction of the internal hernia was done by releasing the fixation of the biliary catheter from the anterior abdominal wall. The color of the small bowel returned normal indicating its viability, and small bowel resection was not required. No biliary leakage was detected around site of exit of the catheter from the bile duct and check cholangiogram confirmed absence of biliary leakage.

Fig. 3

Operative photo showing herniated small bowel loops through the biliary catheter (arrow) obstructing the bowel mesentry with no signs of strangulation.

Fig. 4

Diagram illustrating internal hernia of the small bowel loops around trans-anastomotic biliary catheter obstructing its mesentry.

The patient had smooth postoperative course. Intestinal sounds were regained on the second postoperative day and allowed oral fluids. Follow up abdominal radiographs and Doppler US were sound. The patient was discharged 10 days after surgery.

Discussion

Intestinal obstruction after LDLT is serious rare complication. Generally, the incidence of intestinal obstruction after different abdominal operations is about 3–5% in previous reports. The development of post-operative intra-abdominal adhesions is the most common reported cause [11,12]. On the other hand, intestinal obstruction after LDLT is a rarely reported post-operative complication, and the incidence increases in pediatric more than adult patients.12]

Different causes are reported for intestinal obstruction after LDLT. Liu et al. and Sakamoto et al. reported intestinal obstruction due to incarcerated Petersen’s hernia following hepaticojejunostomy Roux-en-Y for biliary reconstruction [13,14]. Okajima ey al. reported intestinal obstruction due to diaphragmatic hernia after LDLT [15]. Mukai et al. reported the development of intestinal obstruction after LDLT due to unconjugated ursodeoxycholic acid enterolith [16]. In our case, intestinal obstruction early after LDLT was due to internal herniation of the small bowel around trans-anastomotic biliary catheter.

The routine uses of trans-anastomotic biliary catheters in duct-to-duct biliary reconstruction in LDLT had been a controversial issue. Many studies did not prove a real advantage of its routine use [[6], [7], [8]]. In our center, we routinely use trans-anastomotic biliary catheters that exit through a separate choledochotomy in the common bile duct during duct-to-duct biliary anastomosis [9]. The catheter is passed through the abdominal wall to be fixed to the skin. We maintain the shortest segment of the trans-anastomotic biliary catheter inside the abdomen to avoid such internal herniations. In this case, we think that the presence of early postoperative ascites allowed small bowel loops to move upwards to the supra-colic compartment and become herniated around the catheter.

In absence of the definite signs of intestinal obstruction, the diagnosis of internal hernia of the small bowel is a difficult clinical situation. Symptoms like vague abdominal pain or discomfort are non-specific and are usually attributed to other causes especially in early post-operative period [17]. In our case, the patient presented with severe agonizing abdominal pain in absence of significant clinical findings on examination. The suspicion of ischemic pain or a closed loop syndrome was our first differential diagnosis. The suspicion was confirmed with abdominal radiographs.

In conclusion, small bowel obstruction due to internal hernia of the small bowel around trans-anastomotic biliary catheter is an unusual life-threatening complication after LDLT. Awareness regarding such complication plus early surgical intervention can prevent severe postoperative morbidity and mortality. Also, it should be considered as an important cause in the differential diagnosis of intestinal obstruction in liver transplant recipients.

Conflicts of interest

All authors declared that there are no conflicts of interest.

This work has been reported in line with the scare criteria.

Sources of funding

No external funding resources.

Ethical approval

This case report was accepted by the local ethical committee.

Consent

We obtained a written informed consent from the patient for the publication of this case report and accompanying images. A copy of this written consent is available for review by the editor-in-chief of the international journal of surgery case reports on request.

Author contribution

Conception and design of the study: Shehta A, Wahab MA.

Collection and assembly of the data: Shehta A.

Data analysis and interpretation: Shehta A, Wahab MA.

Drafting the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Final approval of the manuscript: All authors.

Study supervision: Wahab MA.

Registration of research studies

NA

Guarantor

Mohamed Abdel Wahab.

Ahmed Shehta.