Duct to duct biliary reconstruction during major hepatectomy with limited resection of the biliary confluence

In major hepatectomies, biliary reconstruction may be necessary due to oncological reasons or intraoperative events. Duct-to-duct biliary reconstruction (DDBR) may be an alternative to the classical Roux-en-Y bilioenteric (RYBE) anastomosis in well selected cases. This study aims to evaluate the outcomes of DDBR in our institution. Between 2014 and 2023, 14 patients underwent major hepato-biliary resection with subsequent DDBR. Ten were planned preoperatively and classified as intentional and 4 were dictated by intraoperative events and classified as non-intentional. Bile leak occurred in a single patient (7%), requiring reoperation for biliary peritonitis. Five patients (36%) developed intra-abdominal collections, including three abscesses and two bilomas that required percutaneous drainage. During these procedures, routine cholangiography was performed through the trans-anastomotic drain placed at the initial surgery. In all five patients, no anastomotic leakage was demonstrated, indicating that the collections originated from the transection margin of the liver rather than the anastomosis. Clinically relevant anastomotic stricture occurred in four patients (28.5%): three (75%) were successfully managed endoscopically, while one (25%) required conversion to RYBE. An additional patient was diagnosed with a stricture on follow-up imaging without biochemical or clinical consequences and was managed conservatively. DDBR, when performed under optimal conditions, yields satisfactory functional outcomes and long-term results. The ability to manage complications effectively further supports DDBR as a viable reconstructive technique in major hepatectomy in well selected cases.