Novel Anastomosis Technique Offers Potential Benefit for Living-Donor Liver Transplant Recipients

A novel duct-to-duct anastomosis technique was associated with a reduction in posttransplant biliary complications for living-donor liver transplant recipients.

Living-donor liver transplant offers many potential benefits to transcript recipients, including faster recovery times and increased likelihood of long-term survival, when compared with deceased-donor liver transplant. But living-donor liver transplant is also associated with a higher risk of posttransplant biliary complications than deceased-donor liver transplant. This higher risk may be in part due to a mismatch between living donor and recipient anatomy and bile duct size.

Coauthors include Sabin Subedi, MBBS, MD, Godwin Devadhas Packiaraj, MD, Vikraman Gunabushanam, MD, director, organ procurement, UPMC Liver Transplant Program, Christopher Hughes, MD, surgical director, UPMC Liver Transplant Program, and Abhinav Humar, MD, chief, UPMC Division of Transplantation Surgery and clinical director, Thomas E. Starzl Transplantation Institute.

The living-donor liver transplant surgical procedure may include one or more biliary anastomoses, connecting the recipient’s bile ducts and the liver graft’s bile ducts. This reconstruction of the biliary system can lead to the narrowing or blockage of bile ducts or bile leakage into the abdominal cavity. Biliary strictures and bile leaks are common complications in living-donor liver transplantation and can lead to graft dysfunction, graft loss, or transplant recipient death.

Living-donor liver transplant recipients at UPMC whose surgeries incorporated the traditional duct-to-duct technique had variable rates of biliary complications at 1-year posttransplant:

• Biliary strictures: 15-20%
• Bile leaks: 10-15%

This study explored the impact of an updated anastomosis technique on biliary complications during the first year after living-donor liver transplant.

Participants

Study participants were 42 living-donor liver transplant recipients whose surgeries were completed between 03/20/2023 and 11/15/2024. Collected participant data included underlying liver disease, anastomosis type, immunosuppressant regimen, and post-surgery outcomes.

Participant liver disease etiology included nonalcoholic steatohepatitis, now known as metabolic dysfunction-associated steatotic hepatitis (35.7%), alcohol-associated liver disease (28.6%), and hepatocellular carcinoma (19%).

1D/1A (one duct/one anastomosis) was the most common anastomosis configuration type (57.1%) among participants. The second most common anastomosis configuration type was 2D/1A (28.6%). All participants had internal biliary stents placed during transplant surgery.

All participants underwent a duct-to-duct anastomosis using an eversion technique. This technique incorporated aligning recipient and graft ducts, identifying and bringing together tissues with better blood supply, and stenting. “In the traditional technique, the anastomosis is made to the very end of the recipient duct. Theoretically, this region has relatively poorer blood supply than the remainder of the duct. That blood supply is crucial for appropriate healing,” Dr. Hughes explains. “In the eversion technique, the end of the bile duct is rolled outward, and the connection is made 2-3 millimeters from the end, where the blood supply is better, leading to better healing.”

Results

At 6-month follow-up of 42 patients

• 3/42 (7.1%) experienced bile strictures
• 4/42 (9.5%) experienced bile leaks

At 12-month follow-up of 28 patients*

*14 of the 42 patients had a <12-month follow-up.

• 2/28 (7.1%) experienced bile strictures
• 0/28 (0%) experienced bile leaks.

Living-donor liver transplant recipients at UPMC who underwent the eversion duct-to-duct anastomosis technique had significantly lower rates of biliary complications (p<0.05) than recipients at UPMC who underwent the traditional duct-to-duct anastomosis technique.

Posttransplant biliary complications that did occur in this participant group were treated with interventions such as endoscopic retrograde cholangiopancreatography (ERCP) with stenting.

Next Steps

Multicenter research is needed to further explore the association between the eversion duct-to-duct technique and lower rates of biliary complications among living-donor liver transplant recipients.