Living Donor Liver Transplantation Using Selected Grafts With 2 Bile Ducts Compared With 1 Bile Duct Does Not Impact Patient Outcome.

Abstract

Potential conflict of interest: Nothing to report. TO THE EDITOR: We read with great interest the article from the Toronto group showing similar results with grafts with 1 or more bile ducts in living donor liver transplantation (LDLT).1 However, one should take this message cautiously because intuitively a graft with 1 duct is preferred by most surgeons. Previous studies have demonstrated that having multiple bile ducts was a significant independent risk factor for the development of biliary complications with no difference in patient survival when compared with patients with a single duct in pediatric liver transplantation.2 From the data presented in the article, the graft‐to‐recipient weight ratio in the single‐duct recipient group was lower than 0.8% compared with that of the double‐duct group, which might have impacted the outcome. Furthermore, a greater proportion of the patients in the double‐duct group underwent hepaticojejunostomy, and therefore, it becomes a comparison between duct‐to‐duct anastomosis versus hepaticojejunostomy. The authors have also suggested that biliary complications were more difficult to manage in the group with 2 ducts. One reason why grafts with multiple ducts may have a similar outcome as grafts with a single duct is that the combined diameter of the ducts would be greater than when the duct is single. This factor would negate the difficulty associated with multiple duct anastomosis. Thus, the measurement of the diameter of the bile ducts should have been a very important parameter in this study. Interestingly, in our own series of over 2500 LDLTs over 10 years, what we experienced was that the number of biliary strictures was quite lower with multiple‐duct patients. Sometimes a single duct with type 3a anatomy may actually result in posterior duct narrowing if the lateral wall is not divided. In conclusion, even though the presence of multiple ducts had comparable complications and survival to that of a single duct, once a biliary leak occurred, the multiple‐duct group had worse graft survival. Therefore, it should be a careful decision to choose a multiple duct over single duct procedure.