Transplantation ■ September 2019 ■ Volume 103 ■ Number 9 www.transplantjournal.com 1893 ISSN: 0041-1337/19/10309-1893 DOI: 10.1097/TP.0000000000002601 Received 29 August 2018. Revision received 30 October 2018. Accepted 4 December 2018. 1 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. The authors declare no funding or conflicts of interest. J.R. participated in the research design, research conduction, manuscript writing, and data analysis. J.M.K. participated in the research design, research conduction, and manuscript writing. G.S.C. participated in the research design, research conduction, and manuscript writing. C.H.D.K. participated in the research design, research conduction, and manuscript writing. J.-W.J. participated in the research design, research conduction, and manuscript writing. Correspondence: Jong Man Kim, MD, PhD, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. (yjongman21@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Impact of Extra-anatomical Hepatic Artery Reconstruction During Living Donor Liver Transplantation on Biliary Complications and Graft and Patient Survival Jinsoo Rhu, MD, 1 Jong Man Kim, MD, PhD, 1 Gyu-Seong Choi, MD, PhD, 1 Choon Hyuck David Kwon, MD, PhD, 1 and Jae-Won Joh, MD, PhD 1 INTRODUCTION Liver transplantation (LT) can be a life-saving inter- vention in patients with cirrhosis or hepatocellular car- cinoma (HCC). Owing to a shortage of donors, living donor LT is often performed in lieu of deceased donor LT. However, living donor LT is one of the most tech- nically demanding procedures. Despite technical refne- ments in the procedure, it is often associated with high morbidity. 1–3 Living donor LT is challenging for both the donor and the recipient. During the donor surgery, it is critical to minimize morbidity to maintain the integrity of the graft liver. During the recipient surgery, surgeons face the challenge of anastomosing the vasculatures and ducts. Among these challenging procedures, the most diffcult is hepatic artery (HA) reconstruction under the microscope. Despite its diffculty, however, HA reconstruction is cru- cial for maintenance of graft function, especially during the immediate post-LT period. HA can be reconstructed using the recipient’s HA as long as artery size, wall integ- rity, and blood fow are appropriate. Unfortunately, LT recipients with a history of locoregional therapies or radi- ation therapies for HCC may have an incompetent HA that is unsuitable for use in reconstruction. 4 If the HA is unsuitable, other arteries with proper length, integrity, and blood fow must be used. Although there are some published reports of these so-called extra-anatomical Original Clinical Science—Liver Background. This study was designed to analyze the feasibility of extra-anatomical hepatic artery (HA) reconstruction in living donor liver transplantation (LT). Methods. Patients who underwent their first living donor LT at our center between January 2008 and December 2017 were reviewed. HA reconstruction was classified as anatomical or extra-anatomical reconstruction (EAR). We compared the background characteristics and posttransplantation outcomes, including compli- cations, biliary complications, graft survival, and overall survival. The potential risk factors for bile leakage were analyzed using multivariable logistic regression, while risk factors for biliary stricture-free survival, graft survival, and overall survival were analyzed using multivariable Cox regression. Results. Among 800 patients, 35 (4.4%) underwent EAR, of whom 7 (7/35, 20.0%) experienced HA complications after the initial anatomical reconstruction and required EAR during reop- eration. Patients who underwent EAR (n = 2/35, 5.7%) had a similar rate of HA complications compared with those who underwent anatomical reconstruction (n = 46/772, 5.9%, P = 0.699). EAR was a significant risk factor for bile leakage (odds ratio [OR], 4.167; 95% confidence interval [CI], 1.928-9.006; P < 0.001) along with multiple bile ducts (OR, 1.606; 95% CI, 1.022-2.526; P = 0.040) and hepaticojejunostomy (OR, 4.108; 95% CI, 2.190-7.707; P < 0.001). However, EAR had no statistical relationship to biliary stricture-free survival (hazard ratio [HR], 1.602; 95% CI, 0.982-2.613; P = 0.059), graft survival (HR, 1.745; 95% CI, 0.741-4.109; P = 0.203), or overall survival (HR, 1.405; 95% CI, 0.786-2.513; P = 0.251). HA complications were associated with poor biliary stricture-free survival (HR, 2.060; 95% CI, 1.329-3.193; P = 0.001), graft survival (HR, 5.549; 95% CI, 2.883-10.681; P < 0.001), and overall survival (HR, 1.958; 95% CI, 1.195-3.206; P = 0.008). Conclusion. Extra-anatomical HA reconstruction during living donor LT was not a risk factor for biliary stricture, graft failure, or overall survival. (Transplantation 2019;103:1893–1902) Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. <zdoi;10.1097/TP.0000000000002601>