As a consequence of bile duct anatomic variations, Ixazomib Ki SLT requires a precise knowledge of the liver anatomy [3, 4]. The challenge of this procedure is represented by a preoperative radiological assessment of the biliary anatomy often unavailable at the donor’s hospital. Thus the risk of biliary duct injury during the splitting procedure is usually considered higher than during living donor procedure. In this report we describe an uncommon late biliary complication that occurred after SLT and was successfully treated by a multidisciplinary approach. 2. Case Report A 63-year-old male with hepatitis C-related cirrhosis was referred for liver transplantation to our institution. We performed a conventional A/P SLT with in situ technique providing the left lateral segment for a child (segments II-III) and leaving the right lobe graft (segment I-IV-V-VI-VII-VIII) for an adult recipient.

The celiac trunk was left on the left graft while the right hepatic artery remained on the right graft. The common hepatic bile duct was left on the right graft. The patient was transplanted using the piggy-back technique without a veno-venous bypass. The biliary tract was reconstructed performing a duct-to-duct anastomosis using a T-tube by our standard technique previously described [5]. A cholangiography through the T-tube was performed on postoperative day 14, and the T-tube was clamped before patient discharge. Three months after A/PSLT the T-tube was removed after a cholangiography with normal findings.

One year after transplant the patient showed abnormal liver function tests, hyperbilirubinemia, leukocytosis, and elevated g-glutamyl transpeptidase (GGT), and mild elevation in alanine transaminase (ALT). The patient underwent a doppler ultrasound that showed (a patent hepatic artery) an intrahepatic bile duct dilatation and an anastomotic biliary stricture. These findings were confirmed by a magnetic resonance cholangiography (MRC). The anastomotic stricture was treated by stenting the main biliary duct during an endoscopic retrograde cholangiopancreatoghaphy (ERCP) without any evidence of intrahepatic biliary dilatation. After this procedure the patient was submitted to a percutaneous transhepatic cholangiography (PTC) showing a complete obstruction of segments VI and VII biliary branches near the duct-to-duct biliary anastomosis (Figure 1).

A percutaneous biliary drain was left inside the distended biliary branches. The patient was discharged leaving the external biliary drain open allowing bile drainage and an easy access for repeated radiologic treatment and an internal Entinostat stent in the common bile duct. Three months later the patient underwent a surgical revision because of repeated episodes of cholangitis. During surgery an intraoperative cholangiography was performed through the biliary drain confirming a bile duct dilatation at the level of segments VI and VII.