TO THE EDITOR: We are pleased that the authors read our article with great interest. We strongly disagree with the authors' comment that corner‐sparing and mucosal eversion is essentially the same as the Hilar plate and Glissonian sheath (HPGS) method. The approach previously described by the authors is essentially the method of donor duct division.1 In other words, they have ascribed the improvement of biliary complications essentially to the way they divide the donor duct. There are many ways a donor duct can be divided, and it varies from center to center. The basic principle of duct division is to preserve the hilar plate along with its vascular plexus in periductal tissue. As described in our article, we believe in a precise and sharp division of the donor duct without disturbing the hilar plate. The end result of this method is the same as the HPGS approach. Unlike HPGS, which is one of the methods of donor duct division, our article focuses on anastomosis rather than on donor duct division.2 The high hilar division described in our article is essentially for the recipient duct, with the aim being to get the second‐ or third‐order biliary orifices. These orifices can be tailored and joined together to yield a funnel‐shaped recipient bile duct, which can be easily everted. The authors have further raised anatomic and practical reservations with our concepts. The first issue raised is regarding the eversion of the donor duct. If read carefully, the authors will notice that we have not mentioned donor duct eversion in our article because we are aware that it cannot be everted due to the short stump.2 Mucosal eversion is for the recipient duct. Eversion of the recipient duct is a very important component of our technique in many ways. First, it allows us to anastomose with healthy and well‐vascularized mucosa because the end of the cut stump may be of doubtful vascularity. Second, adventitial tissue does not pop in‐between the sutures, giving us a near perfect mucosal apposition. Third, the overhanging part of the duct forms a supporting cuff around the anastomosis. The second issue raised is about the corner‐sparing component of our technique. Corner‐sparing sutures in our article are mainly for the donor duct rather than for the recipient duct as perceived by the authors. Corner‐sparing sutures in the recipient duct are placed just to match and correspond to the corner‐sparing sutures in the donor duct. Corner‐sparing of the donor duct (avoiding sutures at 3 and 9 o'clock) is a very crucial and important part of our technique for 2 reasons. First, corners are the weakest part of the donor duct because the hilar plate splits at the corners. We have learned from our experience (re‐explorations and endoscopic retrograde cholangiography) that most posttransplant bile leaks are from the corners. Sparing of the corners avoids any cut‐through or necrosis of the donor duct at the corners during or after tying knots. Second, the natural shape of the donor duct is like a slit with 2 ends as corners (to be avoided in sutures). Corner‐sparing anterior and posterior sutures in the donor duct actually convert the slit into a square or rectangle (which further simplifies anterior suturing). On the contrary, if corners are included in the sutures, it further accentuates the slit and makes suturing difficult. This concept of squaring is beautifully shown in the photograph presented in our original article. As mentioned in the original article, we refute the component of a learning curve because we had had significant experience before modifying our technique. At our center, we do not reject or select the donor based on biliary anatomy. We have stopped doing preoperative magnetic resonance cholangiopancreatography in our protocol for selecting a donor for the last 350 patients. The corner‐sparing and mucosal eversion technique is very promising and significantly reduces the overall biliary complications to <4%. We have further used this technique for more than 200 patients since our original publication with a similar low incidence of biliary complications.
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