Longmire Type I in a Transplant Liver Graft: A Salvage Solution for Complex Hepaticojejunostomy Stricture

Liver transplantation using a left lateral segment (LLS) graft is a lifesaving procedure for pediatric recipients. While long-term graft function may remain well preserved, biliary complications can arise over time, threatening both graft viability and patient well-being. In some cases, endoscopic or radiological interventions may be infeasible or fail to provide durable relief. We present a case of a biliary anastomotic stricture following pediatric LLS transplantation, successfully managed using a rarely performed but technically valuable surgical approach, that of intrahepatic hepaticojejunostomy known as Longmire type I procedure.

A 21-year-old female, who underwent LLS liver transplantation at 8 months of age for acute liver failure, presented with recurrent episodes of cholangitis. She had previously undergone complex biliary revision with 2 separate hepaticojejunostomies, but subsequently developed a stricture mainly involving the segment II bilio-enteric anastomosis. Radiological intervention failed to traverse the stricture. A segmental intrahepatic cholangio-jejunostomy, commonly referred to as the Longmire type I procedure, was performed successfully, relieving the obstruction and preserving graft function.

Biliary complications remain the Achilles' heel of long-term liver transplant outcomes. While endoscopic and radiological interventions are typically first-line, surgical revision of hepaticojejunostomy is sometimes required. However, re-operative biliary surgery carries significant risks, especially in the context of previous revisions. Intrahepatic cholangio-jejunostomy offers a viable alternative in selected patients, as demonstrated in this case, which is the first of its kind reported in the literature following pediatric living donor liver transplantation.