A comparative study of the biliary outcome in Roux-en-Y hepaticojejunostomy versus duct-to-duct biliary anastomosis in right-lobe living-donor liver transplantation in adults

Background
Recently, liver transplantation settled to be a real breakthrough in surgery as the only curable treatment to deal with fatal liver diseases. Living-donor liver transplantation (LDLT) is the only available option in Egypt owing to the inactive deceased-donor program. Surgeons of recipient’s operation should occupy refined surgical skills and experience to reduce the risk of complications. The incidence of biliary complications (BCs) ranges from 5.3 to 40.6%. Leaks occur in 0–21.9%, while strictures occur in 3.7–25.3%. Duct-to-duct anastomosis (D2D) and hepaticojejunostomy (HJ) are the two most common techniques of bile-duct anastomosis in LDLT. D2D is gaining popularity over HJ, because of shorter operative time, fewer septic complications, a better physiologic gastrointestinal function, and rapid recovery, beside easier endoscopic approach to the reconstructed biliary tract.
Patients and methods
The current surgical methodology is a prospective study with nonrandomized convenient sampling that was conducted at Liver Transplantation Unit in Air Forces Specialized Hospital and Nasser Institute for Research and Treatment, Cairo, Egypt, between August 2019 and August 2021. During this study, 40 patients candidate for LDLT were divided into two groups according to type of biliary anastomosis, group A included 20 recipients who had stentless D2D biliary anastomosis compared with group B, including 20 recipients who underwent Roux-en-Y HJ.
Results
A total of 40 recipients were divided into two equal groups according to biliary reconstruction into group A D2D biliary anastomosis, and group B Roux-en-Y HJ. The incidence of biliary-related complications was higher in group A reaching 30%, double that recorded in group B (15%, =0.262). The incidence of biliary leakage was reversed being doubled in group B 10 versus 5% in group A (=0.553). After exclusion of seven mortalities (one in group A and six in group B) who did not complete the 6-month follow-up period necessary for complete observation of biliary anastomotic stricture, there was insignificant difference between the two groups. The overall mortality was 17.5% (seven out of 40 recipients), and all died from non-BC-related causes. The only recipient who died from biliary sepsis following endoscopic retrograde cholangiopancreatography and stenting for biliary anastomotic stricture, was included in the results as he died after 5 months from the operation. In a trial to understand the relation between the biliary reconstruction and the complication rate, we found that there was a higher frequency of complications in both 1 × 1 and 2 × 2 technique in group A (33% each). In contrast, all that complications happened in group B were in 1 × 1 technique. In addition, we could not apply the statement that the higher the number of ducts, the higher the rate of complications in the study as two duct grafts represent 66.7% of complications in group A compared with 100% in single-duct graft in group B.
Conclusion
BC is multifactorial, making it impossible to specify a single predictable risk factor to avoid. The advantages of D2D over HJ, especially the beneficial use of endoscopic retrograde cholangiopancreatography in management of complications, are buffered by the higher incidence of BC that is involved with D2D. Therefore, we think that surgeons should master both reconstruction techniques and weight the risk-and-benefit case-by-case.