Untangling biliary reconstruction in liver transplants for primary sclerosing cholangitis

Abstract

Aim: Primary sclerosing cholangitis (PSC) is characterised by fibro-obliterative inflammation of the biliary tree. In patients with PSC, biliary reconstruction technique during liver transplant (LT) remains controversial. We aimed to evaluate the incidence of biliary complications in patients with PSC receiving a duct-to-duct (DD) anastomosis or Roux-en-Y hepaticojejunostomy (HJ). Methods: A retrospective cohort analysis was performed for 101 patients with PSC who underwent LT at Austin Health between June 1st 2000 and December 31st 2022. Primary and secondary endpoints were the incidence of biliary anastomotic (BAS) and non-anastomotic (NAS) strictures, and non-stricture complications, respectively. A novel definition, extended biliary dilatation programs (EBDP), was introduced to assess clinically significant BAS. Results: In 105 transplants performed, BAS was more common (48.1% vs 27.5%, OR 2.45, p=0.03) and occurred earlier (4.8 vs 41.8 months, p=0.001) in the DD group. On multivariable analysis, only type of anastomosis was associated with BAS (DD adjusted OR 3.00, p=0.02). Anastomotic revision was exclusively seen following HJ (p=0.02). No difference was seen in frequency of EBDP, bile leaks, cholangiocarcinoma, graft failure, and the incidence and time to NAS (p>0.05). Cumulative survival rates between cohorts were also comparable. Conclusion: DD anastomosis conferred greater risk of BAS in patients with PSC undergoing LT. However, non-inferiority in clinically significant BAS coupled with the complexity of HJ, emphasise the ongoing need for strict patient selection for HJ. Impact: Bile duct narrowing, especially in PSC, increases the risk of developing gallstones, life-threatening infections and requiring subsequent invasive procedures. We found a greater risk of bile duct narrowing following LT with a “duct-to-duct” reconstruction of the biliary tract in patients with PSC. A lower risk of narrowing was associated with a more surgically complex reconstructive technique, “Roux-en-Y hepaticojejunostomy”. Our findings will help guide risk assessment with each reconstructive technique during LT for patients with PSC.