Strategies and outcomes of multiple bile duct reconstruction in living donor liver transplantation

Background: Multiple bile ducts in liver grafts presents a significant risk for biliary complications following living donor liver transplantation. However, a standardized approach for managing these cases remains unclear. We aim to evaluate various biliary reconstruction procedures and identify most effective strategies for minimizing complications. Materials and Methods: We conducted a retrospective analysis of 1780 microsurgical biliary reconstructions in living donor liver transplantation between 2006 and 2022. Outcomes were assessed based on the conduit used and anastomotic techniques focusing on duct-to-duct reconstructions, and duct-to-jejunum anastomoses. Technical refinements including biliary stent insertion, ipsilateral bile duct anastomosis, figure-of-8 suturing over junction of anastomosis, centralization anastomosis for size discrepancies were applied. Results: Among the 1780 living donor liver transplantations, 23.1% have multiple bile ducts. The biliary complication rate for single bile ducts was 11.2% (131/1169), while multiple bile ducts had 14.7% (58/394). Bile leaks were significantly higher in multiple bile duct grafts compared to single bile ducts (6.1% vs. 2.1%, p =0.001), with no significant difference in stricture formation ( p =0.76). In adult LDLT using right lobe graft, the 2-to-2 duct-to-duct reconstructions had the highest biliary complication rate of 16.6% (25/150), while duct-to-jejunum anastomoses with 2-to-2 configuration had the lowest biliary complication rate of 0% (0/21). Overall, there were significantly higher biliary complications among duct-to-duct than duct-to-jejunum anastomoses (12.5% vs 2.6%, p =0.001) in adult LDLT using right lobe graft. Conclusions: Duct-to-jejunum anastomoses offer a viable alternative with fewer complications for MBDs. Tailored strategies and technical refinements can mitigate the complications associated with MBD reconstruction.