Roux-en-Y Choledochojejunostomy Versus Duct-to-Duct Biliary Anastomosis in Liver Transplantation for Primary Sclerosing Cholangitis: A Meta-Analysis

Biliary tract complications and its prevention

“…Some studies are in favor of the systematic use of biliary stenting, although some studies are not. Because of the increasing use of extended criteria allografts, more evidence comes up that biliary stenting may reduce the incidence of biliary stenosis …”

“…Because of the increasing use of extended criteria allografts, more evidence comes up that biliary stenting may reduce the incidence of biliary stenosis. 7 The importance of a systematic search for biliary problems has been clearly shown by the "shocking" Sanchez-Urdazpal et al report from the Mayo clinic, which described a surprisingly high incidence (approximately 20%) of ischemic-type biliary tract lesions (ITBLs), later on also termed as nonanastomotic strictures (NASs) or ischemic cholangiopathy. 8 These lesions are identical to those seen after hepatic artery thrombosis pointing therefore in the direction of a compromised (micro)vascularization of the intrahepatic bile ducts.…”

“…The 2 overview reports of the Groningen group by Buis and Verhoeven in relation to NAS or ITBL give a very comprehensive insight into the diagnostic and/or therapeutic complexity. 6,7 NAS can be present centrally usually in the form of a destruction of the main biliary bifurcation; if peripheral (or intrahepatic), both hemilivers are usually involved. Such conditions will need multiple, many times unsuc-cessful, nonsurgical interventions.…”

Hepaticojejunostomy Anastomotic Strictures

“…In these situations, the incidence of HJ strictures ranges from 2 %, in the case of liver retransplantation [23], to 21 % in patients with PSC [24]. In this latter setting, it has been recently suggested that duct-to-duct anastomosis (DDA) provided better long-term functional results than HJ [24] without increasing the risk of disease recurrence [25,26], supporting that it should be probably preferred [27,28]. In this latter setting, biliary anastomotic strictures represent the Achilles heel of these procedures with reported rates ranging from 6 to 22 % [29,30].…”

Can we avoid primary sclerosing cholangitis recurrence?

“…Several centers, however, have revisited to duct‐to‐duct anastomosis; no consensus exists regarding the best approach. Wells et al conducted a meta‐analysis including 692 patients transplanted for PSC and found no differences in rates of biliary complications, recurrent PSC, or 1‐year patient or graft survival. Another more recent meta‐analysis including 910 patients confirmed comparable outcomes between the 2 types of biliary reconstruction, the only difference being an increased rate of ascending cholangitis among patients getting a Roux‐en‐Y (odds ratio, 2.9; 95% confidence interval, 1.2‐7.2) .…”