Comparative study between duct-to-duct anastomosis versus R-Y hepaticojejunostomy in pediatric living donor liver transplantation: A retrospective cohort study

Background: Biliary complications after pediatric living donor liver transplantation (LDLT) remain a significant cause
of morbidity and graft loss. Because of the predominance of biliary atresia and the small size of donor ducts, Roux-en-Y
hepaticojejunostomy has been the standard procedure for biliary reconstruction in pediatric LDLT. However, duct-to-duct
(D2D) reconstruction is suggested to have less risk of biliary contamination and shorter operative time. In our study, we
compare D2D and Roux-en-Y hepaticojejunostomy as regards biliary outcome.
Patients and Methods: A retrospective cohort study was conducted on pediatric LDLTs between July 2015 and December
2022. In all, 107 cases were divided into two groups according to the type of biliary anastomosis: group A included 53
recipients who had stentless D2D biliary anastomosis compared with group B including 54 recipients, who underwent
Roux-en-Y hepaticojejunostomy.
Results: The incidence of biliary-related complications was higher in the D2D group reaching 44.4%, double that recorded
in the H-J group (22.8%, P=0.011). The incidence of biliary leakage alone was significantly higher (61.5%, n=8/13) in
the H-J group versus 8.7% (n=2/23) in the D2D group (P=0.027). Biliary anastomotic stricture alone represented 39.1%
(n=9/23) of the biliary complications in D2D groups and only 23.1% (n=3/13) in the H-J group (P=0.014), and it was
accompanied by leakage in 26.1% (n=6/23) in the D2D group and 7.7% (n=1/13) in H-J groups and had been proceeded
by leakage in a similar number of cases (P=0.093). Most of the biliary complications (84.6%, n=11) (P=0.050) in the H-J
group were diagnosed early (<3 months), while in the D2D group, the incidence was nearly equally distributed between
early and late presentations (56.5 vs. 43.5%, respectively) (P=0.030). Biliary-related mortality was nearly similar in both
groups (8.7 vs. 7.7%) (P=0.558).
Conclusion: The D2D anastomosis seems to be a safe and feasible method of biliary reconstruction in pediatric LDLT
and harbors multiple advantages over H-J, especially the ability to use Endoscopic retrograde cholangio pancreatography
(ERCP) in the management of Biliary Complications (BCs). Our study showed a relatively high rate of postoperative
BCs, which was the most among patients who had undergone D2D biliary reconstruction. As these complications can
be managed safely and effectively, D2D biliary reconstruction can be the method of choice for pediatric patients with
suitable bile ducts for reconstruction and surgeons should master both techniques.