Anatomical Classification of the Peripheral Right Hepatic Duct: Early Identification of a Preventable Source of Morbidity and Mortality in Adult Live Donor Liver Transplantation A. Radtke, G. Sgourakis, G.C. Sotiropoulos, E.P. Molmenti, I. Fouzas, T. Schroeder, F.H. Saner, A. Schenk, S. Beckebaum, M. Malagó, and H. Lang ABSTRACT Introduction. The purpose of this study was to determine the impact of our classification on right graft adult live donor liver transplantation (ALDLT) outcomes. Methods. Three-dimensional computed tomography (CT) reconstructions were used to classify the hilar and sectorial biliary anatomy of 71 consecutive live liver donors. Four possible clinical types were defined, based on the normal (N) or abnormal (A) features of the corresponding hilar/sectorial ducts: type I, N/N; type II, N/A; type III, A/N; and type IV, A/A. We subsequently performed an analysis of the operative outcomes based on the donor anatomy. Results. Type I was encountered in 47.9% of cases, type II in 29.6%, type III in 19.7%, and type IV in 2.8%. The highest incidence of biliodigestive anastomoses was observed with type III (50%) and type IV (100%) variants. Type I was associated with the highest incidence of single anastomoses (single vs multiple, P = .001) and of single bile duct anastomoses (single vs multiple, P = .004). Type III was associated with more multi-duct reconstructions compared with types I and II (P = .002 and P = .05, respectively). There were no significant differences in early (P = .08) or late (P = .33) biliary complications, or deaths due to a biliary etiology (P = .55) among the 4 types. Conclusions. Complex biliary anatomy in the right liver graft usually requires biliodi- gestive anastomoses, which are often associated with complicated procedures. The precise delineation of the intrahepatic biliary anatomy provided by our clinical classification may contribute to better morbidity and mortality rates, especially for grafts at greatest anatomical risk. A PRECISE knowledge of the intrahepatic biliary sys- tem is crucial for the proper strategy of hilar dissec- tion, determination of the level of transection at the hilar plate, and subsequent biliary reconstruction. A practical classification system is necessary to properly identify donor candidates who hide a “difficult” bile duct anatomy, which may put both donor and recipient at considerable risk. In this study we analyzed the potential impact of the preoper- ative use of a systematic clinical two-level classification of intrahepatic biliary anatomy with regard to morbidity and mortality among right living donor liver grafts with normal versus abnormal hilar and/or sectorial anatomy. From the Department of General and Abdominal Surgery (A.R., G.S., G.C.S., H.L.), Johannes Gutenberg University Hospital, Mainz; Department of General, Visceral, and Transplantation Surgery (A.R., G.S., G.C.S., E.P.M., I.F., F.H.S., S.B., M.M., H.L.); Department of Diagnostic and Interventional Radiology (T.S.), University Hospital Essen, Essen; and MeVis Research (A.S.), Bremen, Germany. This study was supported by Grant No. 117/1-1:A2.2 from the German Society for Research. Address reprint requests to Prof. Hauke Lang, MA, MD, FACS, Department of General and Abdominal Surgery, Johannes Guten- berg University Hospital, Mainz, Langenbeckstraße 1,55131 Mainz, Germany. E-mail: lang@ach.klinik.uni-mainz.de © 2008 Published by Elsevier Inc. 0041-1345/08/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2008.08.044 Transplantation Proceedings, 40, 3155–3157 (2008) 3155