Stratifying Risk of Biliary Complications in Adult Living Donor Liver Transplantation by Magnetic Resonance Cholangiography Randeep Kashyap, 1,5 Adel Bozorgzadeh, 1 Peter Abt, 1,4 Georgios Tsoulfas, 1 Manoj Maloo, 1 Rajeev Sharma, 1 Siddharth Patel, 1 David Dombroski, 2 Parvez Mantry, 3 Saman Safadjou, 1 Ashok Jain, 1 and Mark Orloff 1 Background. Accurate preoperative assessment of biliary anatomy in live donor hepatectomy may be helpful to assess the suitability of a graft and to stratify risk of biliary complications. Methods. A retrospective review of existing data among donor and recipients of 36 living donor transplants was performed to assess role of preoperative magnetic resonance cholangiography (MRC) for defining biliary anatomy and to stratify risk of biliary complications. Results. Thirty-six living liver donors underwent MRC, and subsequently right lobectomy. Intraoperative cholangiog- raphy and biliary exploration revealed that 24 donors (66.6%) had conventional and 12 (33.3%) had aberrant biliary anatomy. Intraoperative cholangiography demonstrated a strong correlation with MRC (P=0.001) and intraoperative findings (P=0.001). MRC had specificity and positive predictive value of 100%. The risk of developing biliary compli- cation was 5.9 times higher if the biliary anatomy was of any type other than A (P=0.03, CI 1.06 –32.9) after controlling for donor age, recipient age, and type of anastomosis. Conclusion. MRC reliably identified variant biliary anatomy. The preoperative MRC demonstrated congruence with the intraoperative cholangiogram and with the intraoperative findings. MRC is helpful in predicting risk of biliary complications in recipients, and identifies donors who would otherwise be excluded intraoperatively by cholangiog- raphy, thus limiting the risk of an unnecessary operation. Keywords: Living donor, Biliary complications, Magnetic resonance cholangiography. (Transplantation 2008;85: 1569–1572) A dult to adult living donor liver transplantation (LDLT) with a right hepatic lobe was introduced in 1994 (1). Subsequent experience has demonstrated that there is a learn- ing curve to the procedure, however once overcome, LDLT produces outcomes that are similar or superior to whole cadav- eric organs (2). Despite durable survival, bile duct complica- tions in the allograft recipient remain a significant problem, and are the most important technical cause of morbidity after LDLT (2, 3). These complications result in multiple percuta- neous and endoscopic procedures, and reoperation in 26% of recipients (4). The type of biliary drainage, whether duct to duct or through a Roux limb seems to have little impact on the rate of complications (5–7). The biliary system is well known for anatomic variabil- ity. Aberrant or unexpected anatomical variations may have important implications for complications among the donor and the recipient. To make effective use of liver segments from living donors for transplantation, preoperative imaging is of importance and may be helpful in selecting an appropri- ate donor and planning for biliary drainage in the recipient. Several approaches and techniques for biliary imaging have been used with intraoperative cholangiography (IOC) the traditional method for mapping the anatomy of the biliary tract. Alternatively, magnetic resonance cholangiography (MRC), helical CT cholangiography, endoscopic retrograde cholangiography, and percutaneous cholangiography have been used to evaluate the biliary tract (8 –10). However, MRC compared with IOC has the advantage of preoperative delin- eation of biliary anatomy (11). Accurate preoperative assessment of biliary anatomy in live donor hepatectomy may be helpful to assess the risk of biliary complications imposed on the donor, to deter- mine the suitability of a graft, and to stratify the risk of biliary complications in the recipient. We hypothesized that aberrations in donor biliary anatomy detected during the pre- operative evaluation would result in an increased risk of re- cipient biliary complications and morbidity. A retrospective review of MRC, IOC, and operative findings from living liver donors was conducted to assess the role of preoperative MRC, to define biliary anatomy, and to stratify the risk of biliary complications. PATIENTS AND METHODS From April 2004 to June 2006, a cohort of 36 sequential living liver donors underwent right hepatectomy for adult LDLT at the University of Rochester Medical Center. All hep- atectomies were performed by a single surgeon. A retrospec- tive review of MRC and IOC’s, intraoperative findings, and postoperative biliary complications in recipients of living liver donors was performed. MRC and IOC findings were 1 Division of Transplantation, Department of Surgery, University of Roch- ester Medical Center, Rochester, NY. 2 Department of Radiology, University of Rochester Medical Center, Roch- ester, NY. 3 Department of Gastroenterology, University of Rochester Medical Center, Rochester, NY. 4 Transplant Surgery, University of Pennsylvania Health System, Philadel- phia, PA. 5 Address correspondence to: Randeep Kashyap, M.D., Division of Trans- plantation, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642-8410. E-mail: randeep_kashyap@urmc.rochester.edu Received 9 January 2008. Revision requested 30 January 2008. Accepted 18 February 2008. Copyright © 2008 by Lippincott Williams & Wilkins ISSN 0041-1337/08/8511-1569 DOI: 10.1097/TP.0b013e31816ff21f Transplantation • Volume 85, Number 11, June 15, 2008 1569