Biliary Reconstruction in Liver Transplantation for Primary Sclerosing Cholangitis: Outcomes of an Anatomy-Driven Shift Towards Duct-to-Duct Anastomosis.

Background/Objectives: Selecting the optimal biliary reconstruction technique for liver transplantation (LT) in primary sclerosing cholangitis (PSC) remains challenging. Many centers have historically favored Roux-en-Y hepaticojejunostomy (RYHJ) to bypass potentially diseased recipient ducts, whereas duct-to-duct (D-D) anastomosis preserves endoscopic access and decreases cholangitis rates. We evaluated outcomes during an institutional, anatomy-driven transition toward D-D reconstruction. Methods: We retrospectively analyzed primary LTs for PSC performed at Münster University Hospital between January 2008 and February 2021. Patients were stratified by biliary reconstruction technique into a RYHJ and D-D group. The reconstruction strategy was based on the recipient's bile duct anatomy (D-D when distal extrahepatic duct pathology was absent and duct quality was deemed suitable; RYHJ otherwise). Postoperative complications within 12 months, biliary complications, and long-term patient and graft survival were assessed. Results: Forty-six patients were included (RYHJ n = 24; D-D n = 22). Overall biliary complication rates and patient and graft survival were comparable between the groups. Anastomotic strictures occurred more frequently after D-D reconstruction, whereas the rates of bile leakage, cholangitis, and revision surgery were similar between the two groups. In exploratory multivariable analyses, reconstruction type was not associated with mortality or overall biliary complications, whereas recipient age and male donor sex were associated with biliary complications. Conclusions: In selected patients with PSC undergoing LT with an anatomy-driven reconstruction strategy, D-D anastomosis achieved outcomes comparable to those of RYHJ, with a higher rate of anastomotic strictures but preserved potential for endoscopic management.