Fundamental Strategies and Technical Perspectives in Bile Duct Anastomosis for Living Donor Liver Transplantation: Growth From Novice to Maturity

BACKGROUND Biliary reconstruction is the most technically demanding step in living donor liver transplantation (LDLT), yet how a single surgeon's technique matures in the early career, and how this relates to clinical outcomes, remains incompletely characterized. This study evaluated whether the stepwise evolution of surgical technique was associated with a lower anastomotic biliary stricture (BS) rate. MATERIAL AND METHODS We retrospectively analyzed 382 consecutive right-lobe LDLTs with single-surgeon duct-to-duct biliary anastomosis performed between April 2020 and April 2024. Cases were grouped into 3 equal, consecutive time intervals (approximately 16 months each), and cumulative sum (CUSUM) analysis was applied to the learning trajectory. Independent risk factors for BS were identified by multivariable logistic regression, with separate models for surgical period and post-transition-point status. RESULTS BS rates decreased across periods from 14.4% to 10.1% to 5.1% (P trend=0.016). CUSUM identified a primary transition at case 33, ending the initial trial-and-error phase and coinciding with adoption of well-vascularized distal recipient duct selection, and a secondary inflection at case 210 coinciding with eversion-overlap anastomosis with hilar plate anchoring. Portal vein stenting (OR 6.515, P=0.004) and ABO-incompatible transplantation (OR 2.462, P=0.016) were independent risk factors. After adjustment, surgical period (OR 0.596, P=0.027) and post-case-33 status (OR 0.291, P=0.010) remained associated with lower BS odds. CONCLUSIONS In this single-surgeon cohort, the stepwise evolution of surgical technique was associated with a progressive reduction in BS rates, alongside the cumulative standardization of fundamental principles, but a concurrently evolving case mix precludes attribution to technique alone.