Biliary Reconstruction in Liver Transplantation with Primary Sclerosing Cholangitis: Roux-en-Y Hepaticojejunostomy or Duct-to-Duct Anastomosis?

<b>Background/Objectives</b>: Biliary reconstruction in liver transplantation (LT) for primary sclerosing cholangitis (PSC) is controversial. A Roux-en-Y hepaticojejunostomy (HJ) is associated with fewer anastomotic strictures, while a duct-to-duct reconstruction (DD) shows a decreased rate of cholangitis and preserves anatomy for endoscopy. The aim of our study was to analyze patient survival and postoperative outcomes after LT for PSC based on the type of reconstruction in two high-volume LT centers. <b>Methods</b>: We included 94 PSC patients who underwent a primary LT between 2010 and 2024. The association of biliary reconstruction with patient survival was assessed with the Kaplan-Meier method. Predictors of mortality and postoperative complications were identified via Cox and logistic regression. <b>Results</b>: In total, 42 patients received an HJ and 52 patients received a DD. There was no difference in patient survival or major complications. DD resulted in an increased number of anastomotic strictures, whereas anastomotic insufficiency, ischemia, cholangitis, and the need for revision surgery showed no difference. The choice of biliary reconstruction technique was not a predictor for mortality or major complications. <b>Conclusions</b>: Both types of biliary reconstruction are effective for PSC patients, with comparable patient survival and postoperative outcomes. Although DD is associated with an increased number of strictures, endoscopic treatment options provide a feasible solution.