Background. Using left living donor grafts, the local ischemia of the left bile duct stump has been suspected to play a crucial role in post-transplant anastomotic biliary strictures. Objective. We hypothesized that the use of atraumatic retrograde hepatic artery perfusion (RHAP) in pediatric living donor liver transplantation (LDLT) reduces the incidence of anastomotic biliary strictures. Patients and methods. Between July 1^st, 1993 and November 1^st, 2010, 203 pediatric LDLT were performed at Cliniques Universitaires Saint-Luc, Brussels, Belgium. Among them, RHAP was carried out in 63 (31%) versus 140 (69%) cases without the use of RHAP. RHAP was introduced since 2006 according to the following protocol: during ex-situ portal perfusion of the graft with University of Wisconsin solution, at the half of portal perfusion (total volume: 3 ml/g of graft), RHAP was carried out by clamping the hepatic vein in order to obtain an inversion of the flow of the preservation fluid backwards through the hepatic artery. Biliary and arterial complications were registered during follow-up.

Results. The incidence of biliary complications was 29% (n=41) in cases without, versus 24% (n=15) in the 63 cases with RHAP (p=0.264). The incidence of anastomotic biliary strictures was significantly lower when RHAP was used (27% versus 61%; p=0.021). In contrast, the incidence of anastomotic fistulae was significantly higher in the RHAP group (8% versus 0%; p= 0.003). Hepatic artery thrombosis was only observed in the group without RHAP (3% versus 0%; p=0.475). The 5-year patient and graft survival rates were 95% and 95% with RHAP, versus 91% and 89% without RHAP, respectively (p=0.196 versus p=0.077).

Conclusion. RHAP is a safe and feasible procedure. This technique significantly reduces the incidence of anastomotic biliary strictures, probably by reducing the arterial ischemia of the left bile duct stump. We suggest to extend RHAP to all types of liver graft, including cadaveric transplants.

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