Background : Multiple graft bile ducts (BDs) are related to higher incidence of biliary complications (BCs) and biliary reconstruction for multiple BDs still remain a technical challenge during living donor liver transplantation (LDLT). Especially, biliary reconstruction using high biliary radicals of recipients for multiple BDs has very high probability of BCs secondary to devascularization and ischemia.

Methods : Herein, we analyzed clinical outcomes through retrospective reviews 281 patients receiving DDA for right lobe grafts LDLT from January 2013 to September 2019. 104 LDLT using grafts with multiple BDs have been performed under our strategy; In cases with two close ducts or the two orifices were located in the same hilar plate, we have recently performed dunking with mucosal eversion technique instead of ductoplasty. In the cases of two orifices far located, we tried to perform 2 separate duct to duct anastomosis (DDA) using high biliary radicals of the recipient with minimal hilar dissection, external biliary stents and mucosal eversion technique to reduce BCs.

Results : Among mutiple BDs group, 20 underwent unification ductoplasty , 45 were treated using dunking with mucosal eversion technique and 39 patients underwent 2 DDAs separately using high biliary radicals (HBR group). The incidence of biliary leakage and stricture were 11.5% and 10.6% in multiple BDs group and these outcomes were not different to those in one BD group. Neither overall patient survival nor graft survival differed significantly between the two groups. In subgroup analysis, we compared clinical outcomes between HBR group and one BD group and the incidence of biliary complications in HBR group was 10.3%, which was comparable to that in one BD group.

Conclusions : LDLT using multiple graft BDs could be a safely without negative impacts on posttransplant outcomes. Furthermore, biliary reconstruction using high biliary radicals could be a safe option for multiple graft BDs during LDLT.