Effect of arterial reconstruction using recipient’s left hepatic artery on postoperative biliary complications in right lobe liver graft in living donor liver transplantation

Background
Biliary complications are still considered the Achilles’ heel of living donor liver transplantation (LDLT), with recorded complication rates for right lobe LDLT as high as 20–34%. Anatomically, it seems more appropriate to use the recipient’s right hepatic artery (RHA) over the left hepatic artery (LHA) for arterial reconstruction in right lobe LDLT. The course of the recipient’s RHA usually runs just behind the common hepatic duct and gives small nourishing branches to the biliary tree. Dissecting this tissue between the common hepatic duct and the RHA to increase the later flexibility can cause ischemia of the recipient’s extrahepatic bile duct and cause further biliary complication, especially biliary anastomosis stricture (BAS). The aim of this study was to determine if the use of recipient’s LHA as inflow in arterial reconstruction lowers the risk of postoperative biliary complication.
Patients and methods
A prospective cohort study was conducted at the Liver Transplantation Unit in Air Forces Specialized Hospital, Cairo, Egypt, between July 2020 and the end of April 2022. It included all patients who underwent LDLT with stentless duct-to-duct biliary reconstruction. They were divided into two group: group A included 40 recipients who had LHA for arterial reconstruction and group B (historical control) included 40 recipients who underwent LDLT using RHA for arterial reconstruction.
Results
A total of 80 patients were divided into two equal groups: group A, LHA reconstruction group, and group B, RHA reconstruction group. On stratifying the technique of biliary reconstruction used in both groups regarding the number of graft ducts and the way they were anastomosed to the recipient biliary tree, we found no significant difference regarding incidence on statistical analysis. The incidence of biliary leakage was higher in group A (22.5%) versus group B (15%). Moreover, the number of patients who experienced both leakage and BAS was also higher in group A (7.5 vs. 2.5%) but both did not achieve statistical significance. BAS alone showed no statistically significance difference regarding the incidence. On analyzing the factor influencing biliary leakage other than arterial reconstruction, such as number of graft ducts and the effect of biliary reconstruction technique in the context of minimal dissection of the CBD, all the patients who had biliary leakage in group B had two graft ducts, but there was no statistically significant difference when compared with group A. The same factors were studied for the BAS. There was no increase in incidence, and the difference was not statistically significant for both number of graft ducts and reconstruction techniques.
Conclusion
The use of either RHA or LHA in arterial reconstruction in right lobe LDLTs does not reduce the incidence of duct-to-duct biliary complications which is a multifactorial risk that needs to be approached systematically to reduce all risk factors such as number of graft ducts, ductoplasty, cold ischemia, and arterial reconstruction. In addition, further prospective multicenter studies are needed to definitively identify the multivariate risk factors and improve the outcome of these complications.