Bilateral duct-to-duct anastomosis in dual left graft living donor liver transplantation: Bile duct position assessment after graft procurement and perfusion — a retrospective cohort study

In adult dual left liver graft living donor liver transplantation (LDLT), composite rotation of the right-sided graft alters the bile duct-portal vein relationship, making bilateral duct-to-duct (D-D) reconstruction technically challenging. Although bilateral D-D preserves endoscopic access and avoids enteric reconstruction, no structured intraoperative strategy has been established. From 36 consecutive dual left graft LDLT procedures, we propose a practical approach based on bile duct-portal vein positional patterns and a two-stage intraoperative assessment. Bilateral D-D was achieved in 26 patients (72.2%) without bile leak. Biliary stricture occurred in 38.5% and was managed endoscopically in 88.9% without surgical reintervention. Portal vein narrowing developed in 8 patients (22.2%), most often when the right graft bile duct lay deeply posterior to the portal vein after rotation (55.6% vs. 11.1-12.5% in other patterns). Among patients with narrowing and long-term follow-up, all 4 conservatively managed grafts developed right graft atrophy, whereas none of the 3 managed with intraoperative portal vein stenting did; no mortality was attributable to narrowing. Bilateral D-D is therefore achievable when guided by intraoperative assessment of the bile duct-portal vein relationship after composite rotation: hepaticojejunostomy should be performed without hesitation in unfavorable configurations, and intraoperative portal vein stenting considered selectively when narrowing is detected. In carefully selected patients, bilateral D-D is a feasible strategy that preserves endoscopic access; these single-center observations are exploratory and warrant prospective validation.