Updated Systematic Review and Meta-Analysis of Duct-to-duct Versus Hepaticojejunostomy Reconstruction After Liver Transplantation for Primary Sclerosing Cholangitis

Roux-en-Y (RY) and duct-to-duct (DD) anastomosis are 2 techniques for biliary reconstruction in orthotopic liver transplantation (OLT), but their effectiveness in patients with primary sclerosing cholangitis (PSC) remains debated. This meta-analysis compares outcomes of DD versus RY reconstruction in OLT for PSC. A systematic review identified studies comparing these surgical approaches. Primary outcomes were postoperative biliary complications, while secondary outcomes included graft and patient survival, cholangitis, cholangiocarcinoma, recurrent PSC, hepatic artery thrombosis, and need for retransplantation. Risk of bias was assessed using the Risk Of Bias In Nonrandomized Studies—of Interventions tool. Binary outcomes were analyzed using odds ratios (ORs) with 95% confidence intervals (CIs), whereas patient and graft survival were evaluated by estimating hazard ratios (HRs) from reconstructed Kaplan-Meier data. Twelve studies with 1418 patients were included, 891 (62.8%) undergoing RY and 527 (37.2%) DD reconstruction. Biliary strictures (OR, 1.18; 95% CI, 0.71-1.97) and leaks (OR, 1.23; 95% CI, 0.68-2.20) did not differ significantly. DD reconstruction was associated with a lower risk of cholangitis (OR, 0.37; 95% CI, 0.15-0.91). Importantly, patient (HR, 0.69; 95% CI, 0.55-0.86) and graft (HR, 1.38; 95% CI, 1.12-1.69) survival were superior in the RY group. No significant differences were found in other secondary outcomes. DD reconstruction decreases the risk of cholangitis but is associated with worse patient and graft survival compared with RY in PSC patients undergoing OLT. RY anastomosis may represent the safer reconstructive strategy in this population.