Al-Rubaye R, Elshaer M, Moawad KR, Gaurav R. Biliary complications following donation after brainstem death liver transplantation. World J Gastrointest Surg 2026; 18(1): 112906 [DOI: 10.4240/wjgs.v18.i1.112906]
Corresponding Author of This Article
Mohamed Elshaer, MD, FRCS (Gen Surg), Department of Hepato-Pancreato-Biliary and Transplantation Surgery, Cambridge University Hospitals, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, Cambridgeshire, United Kingdom. mohamed.elshaer@nhs.net
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Surgery
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Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jan 27, 2026 (publication date) through Jan 28, 2026
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Publication Name
World Journal of Gastrointestinal Surgery
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1948-9366
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Al-Rubaye R, Elshaer M, Moawad KR, Gaurav R. Biliary complications following donation after brainstem death liver transplantation. World J Gastrointest Surg 2026; 18(1): 112906 [DOI: 10.4240/wjgs.v18.i1.112906]
World J Gastrointest Surg. Jan 27, 2026; 18(1): 112906 Published online Jan 27, 2026. doi: 10.4240/wjgs.v18.i1.112906
Biliary complications following donation after brainstem death liver transplantation
Rawan Al-Rubaye, Mohamed Elshaer, Karim R Moawad, Rohit Gaurav
Rawan Al-Rubaye, Mohamed Elshaer, Karim R Moawad, Rohit Gaurav, Department of Hepato-Pancreato-Biliary and Transplantation Surgery, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge CB2 0QQ, Cambridgeshire, United Kingdom
Co-first authors: Rawan Al-Rubaye and Mohamed Elshaer.
Author contributions: Al-Rubaye R and Elshaer M analyzed the data and wrote the manuscript; Elshaer M performed the research; Moawad KR and Gaurav R revised and critically appraised the manuscript; Al-Rubaye R and Elshaer M contributed equally to this manuscript and are co-first authors. All authors have read and approved the final manuscript.
Institutional review board statement: This retrospective study was conducted in accordance with the Declaration of Helsinki and local institutional guidelines. Given the retrospective nature of the study using anonymized data from routine clinical care, formal ethical approval from the Research Ethics Committee/institutional review board was not required under United Kingdom research governance frameworks.
Informed consent statement: Given the retrospective nature of the study using anonymized data from routine clinical care, informed consent was not required under United Kingdom research governance frameworks.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mohamed Elshaer, MD, FRCS (Gen Surg), Department of Hepato-Pancreato-Biliary and Transplantation Surgery, Cambridge University Hospitals, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, Cambridgeshire, United Kingdom. mohamed.elshaer@nhs.net
Received: August 27, 2025 Revised: October 20, 2025 Accepted: November 11, 2025 Published online: January 27, 2026 Processing time: 166 Days and 2.1 Hours
Abstract
BACKGROUND
Biliary complications are increasingly seen after liver transplantation. Different modalities are used to overcome these complications. In this study, we investigated the occurrence of biliary complications following donation after brainstem death (DBD) liver transplant and their management.
AIM
To investigate the occurrence and management of biliary complication in patients who underwent orthotopic liver transplant (OLT) with grafts from DBD donors between October 2014 and October 2020.
METHODS
A retrospective review of patients who underwent DBD OLT from October 2014 to October 2020. The primary outcome was biliary stricture, and the secondary outcome was return to theatre.
RESULTS
A total of 366 patients underwent DBD whole OLT during the study period. There were 229 (62.6%) males and 137 (37.4%) females. Recipients median age was 55 years (range 16-73 years) and donors median age was 51 years (range 11-89 years). Mean cold ischemic time was 581 ± 218.7 minutes. Duct to duct anastomosis was performed in 240 (65.6%) patients, and 126 (34.4%) patients underwent Roux-en-Y hepaticojejunostomy (RYHJ). Eighteen (4.9%) patients experienced bile leak, 39 (10.7%) patients experienced anastomotic biliary stricture and 18 (4.9%) patients had ischemic cholangiopathy. Main and segmental hepatic artery thrombosis occurred in 27 (7.4%) patients, 29 (7.9%) patients had early allograft dysfunction, and six (1.6%) patients experienced primary non function. Among 39 patients who developed anastomotic biliary stricture, 21 (53.8%) were treated with RYHJ representing 5.7% of the total transplant group. Endoscopic retrograde cholangiopancreatography was performed in nine patients (23.1%), conservative management in six patients (15.4%), percutaneous transhepatic cholangiography in two patients (5.1%) and re-transplantation in one patient who had concomitant ischemic cholangiopathy (2.6%). Overall, 84 (22.9%) patients returned to theatre and 27 (7.4%) patients underwent retransplant over five years follow up period. Multivariate analysis confirmed that RYHJ reconstruction emerged as the only significant independent protective factor against biliary complications (odds ratio = 0.473, 95% confidence interval: 0.23-0.97, P = 0.041).
CONCLUSION
Biliary complications following DBD liver transplant are a frequent occurrence and careful monitoring and planning are required to improve patients’ outcomes.
Core Tip: This retrospective study of 366 liver transplant after brainstem death, demonstrates that anastomotic biliary stricture remains a significant complication, occurring in 10.7% of patients. Roux-en-Y hepaticojejunostomy (RYHJ) was associated with significantly lower rates of bile leaks and anastomotic strictures compared to duct-to-duct anastomosis. However, patients undergoing primary RYHJ had higher reoperation and re-transplantation rates, primarily due to selection bias, as RYHJ was preferentially performed in patients with complex recipient pathology. Early detection and appropriate management with a stepwise approach - from endoscopic intervention to surgical revision - are crucial for optimizing post-transplant outcomes.
