An Innovative Surgical Management of Complicated Bile Duct Variant in Emergency Living Donor Adult Liver Transplantation: Initial Experience

Background: The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the dile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high MELD score patients. Methods: The common hepatic duct (CHD) and the LHD of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed. Results: Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (Four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up, significant differences (P<0.05) were found when two stages were compared. Conclusions: Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant RHDs in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.