Bilateral Duct-to-Duct Reconstruction in Dual Left Graft LDLT: Liver Transplantation | July 2026

Introduction:

In dual left graft living donor liver transplantation (LDLT), reconstruction of the bile ducts is technically demanding because rotation of the right-sided graft alters the anatomical relationship between the bile duct and portal vein. This study evaluated a structured intraoperative strategy to optimize bilateral duct-to-duct (D-D) reconstruction while minimizing biliary and vascular complications.

Why was this study needed?

• Biliary reconstruction remains one of the most challenging aspects of dual left graft LDLT.
• Bilateral duct-to-duct reconstruction preserves future endoscopic access but is technically difficult after graft rotation.
• No standardized intraoperative algorithm has been available for selecting D-D reconstruction versus hepaticojejunostomy.
• Portal vein compression or narrowing may occur after reconstruction and compromise graft function.
• Practical surgical guidance is needed to improve technical success and long-term outcomes.

Results:

• Bilateral duct-to-duct reconstruction was successfully performed in 72% of patients without any bile leak, demonstrating that this approach is feasible when guided by careful intraoperative anatomical assessment.
• Most biliary strictures were successfully managed endoscopically, preserving one of the major advantages of duct-to-duct reconstruction and avoiding surgical revision in the vast majority of patients.
• Portal vein narrowing occurred predominantly when the rotated right graft bile duct was positioned deeply behind the portal vein. Intraoperative portal vein stenting prevented subsequent graft atrophy in affected patients, whereas conservatively managed patients frequently developed right graft atrophy.

Clinical Impact:

This study proposes a practical intraoperative decision-making algorithm based on the bile duct–portal vein relationship after graft rotation. Surgeons should proceed with bilateral duct-to-duct reconstruction when anatomy is favorable, convert to hepaticojejunostomy when anatomical alignment is unfavorable, and consider intraoperative portal vein stenting if portal vein narrowing is identified.

Bottom Line:

Bilateral duct-to-duct reconstruction is feasible and safe in carefully selected dual left graft LDLT recipients. Success depends on meticulous intraoperative assessment of biliary and portal vein anatomy, with selective use of hepaticojejunostomy or portal vein stenting to optimize long-term graft outcomes.