Biliary reconstruction and complications after living-donor liver transplantation

The technique of biliary reconstruction remains controversial in living-donor liver transplantation (LDLT). The objective of this study was to assess the incidence of biliary complications after LDLT based on the reconstruction technique.

Between 1997 and 2007, 30 patients underwent LDLT. The type of allograft was the right lobe in 15, left lobe in 4 and left lateral sector in 11 patients. There were 18 adult and 12 paediatric recipients. The mean follow-up was 48 months (range 18-120 months). Biliary complications were defined as leak or stricture requiring intervention.

Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy (RYCJ) in 17 patients and duct-to-duct (DD) anastomosis in 13 patients. An external biliary stent was placed in all patients (except one) in the RYCJ group and reconstruction over a T-tube was done in 6 out of 13 patients in the DD Group. Twenty-five (83.3%) patients had one biliary anastomosis and the remaining five (16.7%) had multiple anastomoses (one in the RYCJ group and four in the DD group). The overall incidence of biliary complications was 30%.; 29.4% in the RYCJ group and 38.4% in the DD group (P = 0.6). Biliary complications occurred equally in patients with and without an external stent or T-tube stenting (12.5% vs. 18.8%). The incidence of biliary leakage was 23.5% for RYCJ and 15.3% for DD (P = 0.4). Although the incidence of biliary stricture was significantly higher in the DD (23.1%) compared with the RYCY group (5.9 %) (P < 0.01), all DDCC strictures were successfully managed endoscopically. Need for operative revision of biliary anastomoses was significantly higher in patients with RYCY compared with DD reconstruction; 17.7% vs. 7.7% (P < 0.01).

Although there was a higher rate of biliary stricture formation in the DDCC group, we feel that because of physiological bilioenteric continuity, comparable incidence of leakage and easy endoscopic access, DD reconstruction is the preferred approach for biliary drainage in LDLT. After LDLT, the endoscopic approach has been shown to provide effective treatment of most biliary complications.