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Biliary reconstruction in right lobe living donor liver transplantation

We read with interest the article by Yan et al., which presented the decreased incidence of biliary complications in their right lobe living donor liver transplantation (LDLT) series. They reported that their technical refinements decreased the post-LDLT biliary complication rate down to less than 5%. Those included intraoperative cholangiogram, careful bile duct dissection, high hilar dissection technique in recipients, continuous sutures for the posterior wall and interrupted for the anterior wall, and a specialized single surgeon with the application of microsurgery. Although their refinements are appraised positively, we have several questions and comments. One of the points of concern in their report might be the short observation period. The mean follow-up period in their article was around a year, and this may still be too short for discussing bile duct complications. Over half of bile duct stenosis occurs after 1-year period from LDLT according to the majority of previous reports. Another concern is the uniform patient background; most of their cases were hepatitis B associated. Recently, it has been well known that the incidence of bile duct stenosis following LDLD for hepatitis C was more frequent than that for other indications, and visa versa; bile duct complication is among the significant determinant factor for aggressive recurrent hepatitis C. For microsurgical biliary reconstruction, they performed this in only four cases, and another 20 cases probably underwent reconstruction under surgical telescope. Therefore, it might be difficult to conclude that their methods had the advantages in bile duct reconstruction in LDLT at this moment with insufficient observation periods, extremely small patient numbers, and uniform patient backgrounds. Nevertheless, the new application of microsurgery in biliary reconstruction is appreciated. Most of their techniques might have been practiced widely in most LDLT centers, resulting in post-LDLT bile duct stenosis rates around 20–30% in the previously reported major series. This means that bile duct stenosis in LDLT might occur at such a rate, because of the tiny ducts, immunological, virological and/or preservation insults. Bile duct stenosis is a kind of different complication from other surgical or technical complications. The superiority of duct–duct reconstruction is its easy endoscopic access in the event of actual complications. It is a surprise that Yan et al. applied continuous sutures for tiny bile duct anastomosis. They were the techniques previously applied but abandoned because of the increased incidence of bile duct stenosis with incorporation of continuous sutures and T-tube use. The tight continuous sutures might have not only squeezed up the anastomoses, but also jeopardized the peri-biliary vascular plexus, as Kasahara et al. reported. In order to clarify the usefulness of their technique, we ask several questions. How much would be the complication rate at the present time with the current follow-up periods? How could we confirm the superiority of their techniques, including microsurgical reconstruction and the use of continuous sutures?