S. Chanthongthip1, C. A. Kubal1, B. Ekser1, J. A. Fridell1, R. S. Mangus1 1Indiana University School Of Medicine,Transplant,Indianapolis, IN, USA
Introduction:
Reconstruction of the bile duct after liver transplantation in patients with primary sclerosing cholangitis (PSC) is controversial. Historically, these patients have all undergone Roux-en-Y choledochojejunostomy (RY). More recently, several centers have published results suggesting equivalent outcomes using duct-to-duct reconstruction (DD). Recently, a meta-analysis of 10 single center studies demonstrated similar post-transplant incidence of bile duct complications, and similar 1-year graft survival. This study presents a similar single center analysis comparing RY and DD reconstruction of the bile duct, with 10-year Cox regression analysis of graft survival.
Methods:
The records of all liver transplants at a single center between 2001 and 2015 were reviewed. Patient with primary sclerosing cholangitis were identified. The primary operative reports for these patients were reviewed and reconstruction of the bile duct was coded as RY or DD. The decision to perform DD was based upon the appearance of the remaining bile duct after hepatectomy, with a healthy appearing native duct being reconstructed with DD and a diseased duct with RY. All bile duct imaging and interventions were recorded to assess for strictures and leaks. Survival data was extracted from the transplant database, which is compared on a regular basis with national death databases to assure accuracy. Cox regression analysis was performed with a direct entry method.
Results:
There were 1722 liver transplants during the study period, with 164 patients having a diagnosis of PSC (10%). Bile duct reconstruction included 93 RY and 71 DD. The DD patients had a higher MELD and older age, while RY patients were more likely to be a retransplant and have a longer warm ischemia time. Among the PSC patients, 8% had a bile duct leak (13% RY and 3% DD, p=0.03). Strictures were seen in 29% of patients (5% RY and 39% DD, p<0.001), though this is a result of nearly all patients undergoing ERCP receiving a diagnosis of stricture and having a stent placed. Only one patient in either group require operative intervention for stricture, and another patient required operative intervention for leak. Length of hospital stay was equivalent in both group (10 days, p=0.51). Cox regression 10-year graft survival showed no difference between RY and DD (p=0.47).
Conclusion:
DD reconstruction of the bile duct after liver transplantation for PSC results in similar post-operative outcomes, and equivalent long-term survival, compared to RY. These results were achieved using surgeon judgement of bile duct quality to determine the method of reconstruction.
