Biliary anastomotic stenosis has been the most intractable problem after living-donor liver transplantation (LDLT) (1, 2). We first applied the side-to-side intrahepatic cholangiojejunostomy to biliary obstruction after LDLT. We here report our surgical techniques and the successful outcome of the procedure after 34 months. A 49-year-old woman was diagnosed with primary biliary cirrhosis 15 years ago. She developed liver failure with gastrointestinal bleeding caused by esophageal varices and subsequently underwent LDLT. The donor was the patient’s brother. The left lobe of the liver was harvested. Biliary reconstruction included a duct-to-duct anastomosis between the left hepatic duct of the donor and the common hepatic duct of the recipient. After anastomosis, a 5 F stenting tube was inserted toward the graft hepatic duct from the stump of the cystic duct. LDLT was successfully completed, and the patient postoperatively recovered without biliary complications. However, 3 months later, the patient occasionally experienced delayed bile leakage when the stenting tube was removed. Immediately, continuous drainage for the leak space was started. Subsequently, complete obstruction of the biliary anastomosis remained. Therefore, the percutaneous transhepatic bile drainage (PTBD) tube was inserted. Recanalization by radiologic interventions was attempted several times without success. In this case, cholangiography showed no anatomical anomaly and communication between the bile ducts of segment II, III, and IV at the occurrence of biliary obstruction as well as at the first transplant operation. Thus, the bile duct of the segment III was reconstructed by intrahepatic cholangiojejunostomy 6 months after LDLT. For this technique, which has been described previously, the bile duct is exposed by dissecting the umbilical fissure, and the division of liver tissue is not required (3). However, in the present patient, the bile duct of segment III was not markedly dilated (5 mm in diameter), and thus the process of its sufficient expo- sure for anastomosis posed some technical challenges. First, we confirmed the glisson of segment III by using intraoperative ultrasonography and inserted the marking needle toward its proximal site. Along this needle, the liver parenchyma was transected to the left of the round ligament. After the glisson was exposed sufficiently, the bile duct was identified by examining its bulge when the PTBD tube was pressurized. The bile duct was incised approximately 3 cm longitudinally and anastomosed side-to-side to the Roux-en-Y limb of the jejunum with a 6–0 PDS suture in an interrupted fashion. A 5 F biliary stenting tube was introduced toward the graft hepatic duct from the Roux-en-Y limb of the jejunum (Fig. 1, A and B). The patient remained well without biliary complications during the follow-up period of 34 months (Fig. 1C).FIGURE 1.: Successful treatment of delayed-onset biliary obstruction after left-lobe living-donor liver transplantation (LDLT) by side-to-side intrahepatic segment III cholangiojejunostomy. (A) Schematic view of the procedure. The bile duct of segment III is exposed and incised approximately 3 cm longitudinally. It is anastomosed side-to-side to the Roux-en-Y limb of the jejunum with a 6–0 PDS suture in an interrupted fashion. A 5 F biliary stenting tube is introduced toward the graft hepatic duct from the Roux-en-Y limb of the jejunum. (B) Operative field photograph after completion of the procedure. (C) Magnetic resonance cholangiopancreatography 32 months after the reoperation showing patency of the anastomosis.Originally, this technique was used as a palliative treatment for obstructive jaundice caused by tumor involvement of the hepatic hilum (4). Although conversion to Roux-en-Y hepaticojejunostomy is usually used in the management of biliary obstruction after duct-to-duct anastomo-sis, it is always accompanied by the risk of injury to the important hilus structures. As for the intrahepatic cholangiojejunostomy, the Longmire technique has been widely recognized. However, it requires partial hepatectomy and is sometimes followed by anastomotic stenosis, especially when a small intrahepatic bile duct is anastomosed end-to-side to the jejunum (5). In contrast, this technique has the following advantages. First, it avoids manipulation of the hepatic hilum. Second, the bile duct of segment III is superficially located and easily accessible, and thus the reoperation can be performed at the minimal expense and without hepatic sacrifice. Finally, side-to-side reconstruction offered a sufficient anastomotic size. However, further investigation is necessary to substantiate the value of this technique. Motohide Shimazu Tomotaka Akatsu Go Wakabayashi Minoru Tanabe Shigeyuki Kawachi Ken Hoshino Masaki Kitajima Department of Surgery Keio University School of Medicine Tokyo, Japan