Risk factor analysis and procedural modifications for biliary stricture after adult living donor liver transplantation

Background: We undertook a retrospective assessment of risk factors for biliary stricture after adult living donor liver transplantation (LDLT) and evaluated risk reduction following the implementation of modified surgical procedures. Methods: Between June 1997 and December 2009, 85 adult patients underwent LDLT. Up to September 2006, we performed duct-to-duct hepaticocholedochostomy (D-D) in 38 patients and Roux-en-Y hepaticojejunostomy (R-Y) in 24 patients. Risk factors for biliary stricture were analyzed for these patients. We then performed D-D in 23 patients using modified procedures and assessed the resultant outcomes. Results: D-D was a significant risk factor in the 62 patients who underwent LDLT before September 2006. Despite this result, we decided to employ only D-D for subsequent cases. Since the presence of multiple graft bile duct orifices was a significant risk factor in the 38 patients who underwent D-D, we used modified procedures after October 2006 to address grafts with multiple bile duct orifices. The procedures included:1) inserting a biliary tube from the common bile duct;2) placing the tip of tube beyond the anastomosis;3) inserting the tubes in all the anastomoses if multiple; and 4) maintaining the tube for 6 months postoperatively. The incidence of biliary stricture after D-D was significantly less frequent with the use of these procedures (before:36%; after:13%). Conclusions: In our early experience, D-D was a significant risk factor for biliary stricture after adult LDLT. Although we are now employing only D-D, our procedural modifications seem promising for preventing biliary stricture after D-D.