Strategies and outcomes of multiple bile duct reconstructions in living donor liver transplantation.

Multiple bile ducts (MBDs) in liver grafts present a significant risk for biliary complications (BCs) following living donor liver transplantation (LDLT). However, a standardized approach for managing these cases remains unclear. We aim to evaluate various biliary reconstruction procedures and identify the most effective strategies for minimizing complications. We conducted a retrospective analysis of 1780 microsurgical biliary reconstructions in LDLT between 2006 and 2022. Outcomes were assessed based on the conduit used and anastomotic techniques, focusing on duct-to-duct reconstructions and duct-to-jejunum (D-J) anastomoses. Technical refinements, including biliary stent insertion, ipsilateral bile duct anastomosis, figure-of-8 suturing over the junction of anastomosis, and centralization anastomosis for size discrepancies, were applied. Among the 1780 LDLTs, 23.1% have MBDs. The BC rate for single bile ducts was 11.2% (131/1169), while MBDs had 14.7% (58/394). BLs were significantly higher in MBD grafts compared with single bile ducts (6.1% vs. 2.1%, p =0.001), with no significant difference in stricture formation ( p =0.76). In adult LDLT using right lobe graft, the 2-to-2 duct-to-duct reconstructions had the highest BC rate of 16.6% (25/150), while D-J anastomoses with 2-to-2 configuration had the lowest BC rate of 0% (0/21). Overall, there were significantly higher BCs among duct-to-duct than D-J anastomoses (12.5% vs 2.6%, p =0.001) in adult LDLT using right lobe graft. D-J anastomoses offer a viable alternative with fewer complications for MBDs. Tailored strategies and technical refinements can mitigate the complications associated with MBD reconstruction.