Where Is the Optimal Site for Division of Donor and Recipient Bile Duct for Duct-to-duct Anastomosis During Liver Transplantation?

Abstract

Background: The blood supply of the bile duct (BD) is a key to minimizing biliary complications (BC) after liver transplantation (LT). Method: A literature review was performed. Results: The retroportal artery (RPA) and 3 and 9 o'clock arteries were first reported by Northover and Terblanche in 1979. They found the RPA in all 21 human resin casts and classified it into two variants; type I RPA arising from the superior mesenteric artery or the Coeliac trunk, and crossing the back of the portal vein to join the posterior superior pancreaticoduodenal artery: and type II RPA which crosses the posterior surface of the supraduodenal BD, and ascends to join the right hepatic artery. They recommended making the donor BD as short as possible. Rath et al described 6 types of marginal arteries of the BD. They suggested dividing both donor and recipient BD just below the confluence of the cystic duct. According to anatomical descriptions of the RPA, which should be included in any description of connective tissue related to the pancreatic head, and contains the BD innervation from the coeliac and superior mesenteric nerve plexuses. Higher division is preferable in order to avoid injury to the recipient RPA and accompanying nerves, which may cause ampullary dysfunction on the recipient. Conclusion: The focus has always been on the donor, but we identify preservation of arterial inflow and innervation of the recipient BD as being important. Deeper consideration and modification of techniques for these small structures may reduce BC after LT.