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
Authors: Elmesiny Mohamed , Behairy Gad M , Zaky Khaled , Aal Amr Abdel , Abdo Mostafa 
Published: July 2024

Abstract

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. Most of the patients indicated for LDLT do not have the luxury of having an ideal living donor although we have big families in Egypt. 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% to 21.9% while strictures occur in 3.7% to 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 to August 2021. During this study, 40 patients candidate for LDLT was divided into two groups according to type of biliary anastomosis, group A included 20 recipients who had stentless duct-to-duct biliary anastomosis compared to group B including 20 recipients underwent Roux-en-Y hepaticojejunostmy.

Results
A total of 40 recipients were divided into two equal groups according to biliary reocstruction into group A duct-to-duct biliary anastomosis, and group B Roux-en-Y hepaticojejunostmy. The incidence of biliary related complications was higher in group A reaching 30%, double that recorded in group B (15%, p = 0.262). Upon stratification of those complications, the incidence of biliary leakage was reversed being doubled in group B 10% versus 5% in group A (p = 0.553). After exclusion of seven mortalities (one in group A and 6 in group B) who did not complete the 6 months follow-up period necessary for complete observation of BAS, there was insignificant difference between the two groups. The overall mortality was 17.5% (7 out of 8 recipients), and all died from non-biliary complication related causes. The only recipient died from biliary sepsis following ERCP and stenting for BAS, 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 (Table 8), we found that there was a higher frequency of complications in both 1x1 and 2x2 technique in group A (33% each). In contrast, all complication happened in group B was in 1x1 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 2 ducts grafts represent 66.7% of complications in group A compared to 100% in single duct graft in group B.

Conclusion
BC is a bottleneck along the path of a successful LDLT as it 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 ERCP in management of complications, are buffered by the higher incidence of biliary complication that is involved with D2D. Therefore, we think that surgeons should master both reconstruction techniques and weight the risk-and-benefit case by case.