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

Abstract

Background: Biliary complications after pediatric living donor liver transplantation (LDLT) remain a significant causeof morbidity and graft loss. Because of the predominance of biliary atresia and the small size of donor ducts, Roux-en-Yhepaticojejunostomy 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, wecompare 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 December2022. In all, 107 cases were divided into two groups according to the type of biliary anastomosis: group A included 53recipients who had stentless D2D biliary anastomosis compared with group B including 54 recipients, who underwentRoux-en-Y hepaticojejunostomy.Results: The incidence of biliary-related complications was higher in the D2D group reaching 44.4%, double that recordedin the H-J group (22.8%, P=0.011). The incidence of biliary leakage alone was significantly higher (61.5%, n=8/13) inthe 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 wasaccompanied 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 proceededby 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-Jgroup were diagnosed early (<3 months), while in the D2D group, the incidence was nearly equally distributed betweenearly and late presentations (56.5 vs. 43.5%, respectively) (P=0.030). Biliary-related mortality was nearly similar in bothgroups (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 LDLTand 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 postoperativeBCs, which was the most among patients who had undergone D2D biliary reconstruction. As these complications canbe managed safely and effectively, D2D biliary reconstruction can be the method of choice for pediatric patients withsuitable bile ducts for reconstruction and surgeons should master both techniques.