Biliary complications (BC) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of “all knots outside technique” (AKOT) of biliary reconstruction (BR) and its impact on BC. Retrospective analysis of prospectively collected data of consecutive 330 adult patients undergoing LDLT from July 2011 to February 2018 with minimal follow up of 24 months was performed. Only 2.8% required Hepatico-jejunostomy and were excluded. In initial 122 patients BR was performed with standard technique (ST) and subsequent 208 were performed with AKOT. In AKOT group; single anastomosis was attempted even for multiple ducts whenever feasible. Major BC was defined as requiring endoscopic, percutaneous or surgical interventions. In the AKOT group, significantly more patient’s received left lobe graft (5.7% versus 18.2%; p=0.001), shorter warm ischemia time (44.6 versus 27 minutes; p <0.001) and left hepatic artery (LHA) in right lobe (48 versus 122; p= 0.003) was used for arterial reconstruction. The incidence of BC in the entire cohort was 47 (14.2%). The overall (ST – 27/122 (22.1%) v AKOT – 20/208 (9.6%) (p= 0.003) and major BC (ST- 20.8% versus AKOT 6.9%; p <0.001) decreased significantly. On multivariate analysis; number of bile ducts (p= 0.003; hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78), number of anastomosis (p= 0.04; HR, 2.03; 95%CI, 1.03-4.02) and technique of anastomosis (p=0.002; HR, 0.36; 95% CI, 0.19-0.68) predicted BC. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomosis and AKOT for BR significantly decreased the incidence of BC.
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