Different Knots, Same Outcome: Evaluating the Role of Surgical Technique on Biliary Anastomotic Strictures After
Samith Minu Alwis1, Robert Torode1, Michael Anthony Fink1,2
1Department of Surgery (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia.
Background:
Biliary anastomotic strictures (BAS) after liver transplant (LT) are a significant contributor to post-transplant morbidity. Although surgical technique has been proposed as a risk factor, accurate evaluation of technique has been limited by inherent bias in conventional definitions for BAS. This study aimed to evaluate the incidence of clinically significant BAS (csBAS) with absorbable suture material and variable anastomotic suture technique in patients undergoing LT with duct-to-duct (DD) anastomosis.
Methods:
A retrospective medical record review was conducted of adult patients undergoing LT at a single center between January 1st, 2000 and December 31st, 2023. Suture technique included continuous or interrupted alone, or a combined technique (continuous to posterior wall, interrupted anteriorly), while suture material was either absorbable or non-absorbable suture. Primary endpoint was the incidence of csBAS using a previously introduced surrogate marker, extended biliary dilatation programs (EBDP). Secondary endpoints included time to csBAS, incidence of bile leak, intervention rates with csBAS, and graft failure. Univariable and multivariable analyses were performed to identify independent associations with csBAS. Graft survival with csBAS was assessed using a Kaplan-Meier curve.
Results:
A total of 842 patients underwent 864 LTs with DD anastomosis, of which 123 LTs (14.2%) developed csBAS. The mean age and follow up time were 53.3 ± 11.3 years and 7.0 ± 5.0 years, respectively. Year of transplant (p < 0.01), donor age (p = 0.01), suture material (p = 0.05) and suture technique (p = 0.01) were associated with csBAS on univariable analysis. On multivariable analysis, only donor age (adjusted OR 1.01, 95% CI 1.00-1.03, p = 0.03) was found to be independently associated, while absorbable suture material, suture technique and year of transplant were not associated. No difference was seen in bile leaks or graft failure with absorbable suture material nor anastomotic technique. No significant association was observed with time to csBAS, nor between csBAS and graft failure.
Conclusion:
Variable suture technique and suture material during DD reconstruction are associated with comparable outcomes following LT.
