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Biliary complications in the setting of liver transplant are common, ranging from 5% to 32% (5% to 15% in deceased donors to 28% to 32% in living donors), and are associated with significant morbidity and mortality.1 Biliary complications include leaks, strictures, and sequelae including choledocholithiasis and biliary casts.2 Technical problems often predispose the patient to complications in the majority of cases; hence, a meticulous methodology in biliary reconstruction is the key to avoiding them. Biliary ischemia either from hepatic artery thrombosis or after receiving an organ from a cardiac death donor can increase the rate of biliary complications and poor posttransplant graft prognosis.3 Recognition of the importance of an adequate blood supply is fundamental for achieving technical success.3


The bile duct’s blood supply is dependent upon anatomic location and can be divided as follows:4

  • Supraduodenal bile duct: Supplied by the branches of the gastroduodenal (including the retroduodenal), right hepatic, and cystic arteries. The main vessels run upward along the lateral borders of the bile duct (3 o’clock and 9 o’clock position), while some branches run downward (38%).

  • Hilar bile duct: Supplied by a rich arterial plexus receiving blood from its surroundings, which then connect with the vessels from the supraduodenal duct. An arcade vessel that communicates the left and right hepatic arteries can be located within the hilar plate (Fig. 86-1).


Blood supply of the biliary tree.


Several different anastomotic techniques can be utilized during liver transplantation. The types and their selection criteria are discussed here. In general, they can be classified into 2 general categories:

  • Duct-to-duct

    • Choledochocholedochostomy/hepaticocholedochostomy

  • Duct to intestine

    • Choledochoduodenostomy/hepaticoduodenostomy

  • Choledochojejunostomy/hepaticojejunostomy

Selection of Anastomotic Technique Based on Etiology

Choledochocholedochostomy/Hepaticocholedochostomy (Duct-to-Duct)

This is the method of choice for reconstruction in liver transplantation when the native duct is healthy and suitable in terms of caliber. Etiologic examples of liver transplant recipients who should undergo this approach include cirrhosis from viral hepatitis, alcoholic or nonalcoholic steatohepatitis (NASH), autoimmune hepatitis, and primary biliary cirrhosis. Patients with hepatocellular carcinoma who have one of the aforementioned etiologies for liver disease are also candidates for this type of anastomosis. Some degree of size discrepancy between donor and recipient ducts is commonly encountered using this type of anastomosis. Maneuvers to overcome a significant duct size mismatch include spatulating the bile duct or incorporating the cystic duct, and these are described later. In recent literature, a duct-to-duct anastomosis has been advocated in patients with primary sclerosing cholangitis (PSC) because of equivalent results when compared to Roux-en-Y reconstruction, provided that the native distal duct is normal and there is no suspicion of cancer.5

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