Managing Multiple Bile Ducts in LDLT- Liver Transplant Feb.26

Multiple bile ducts (MBDs) in living donor liver transplantation (LDLT) remain a major technical challenge, particularly in right lobe grafts. This large retrospective study analysed 1,780 microsurgical biliary reconstructions over 16 years to determine optimal reconstruction strategies and outcomes.

Approximately 23% of grafts had multiple bile ducts. Overall, biliary complications were higher in MBD grafts compared with single-duct grafts (14.7% vs 11.2%), driven mainly by increased bile leak rates (6.1% vs 2.1%), while stricture rates were similar. Among adult LDLT recipients with right lobe grafts, 2-to-2 duct-to-duct reconstructions had the highest complication rate (16.6%). In contrast, 2-to-2 duct-to-jejunum anastomoses showed no biliary complications in this cohort. Overall, duct-to-duct reconstruction was associated with significantly higher biliary complications than duct-to-jejunum anastomosis (12.5% vs 2.6%).

The study emphasises the importance of individualised surgical planning. Technical refinements—such as biliary stenting, ipsilateral duct alignment, figure-of-8 suturing at junctions, and centralisation techniques for size mismatch—may reduce complications.

For transplant surgeons, the key message is that duct-to-jejunum reconstruction should be strongly considered in grafts with multiple bile ducts, particularly in complex 2-to-2 configurations, as it may lower leak risk and improve early biliary outcomes.