The Impact of Normothermic Machine Perfusion on Biliary Complications in Donation After Circulatory Death Donor Liver Transplantation

Background. The incidence of ischemic cholangiopathy (IC) in liver transplant (LT) patients from donation after circulatory death (DCD) has been observed to be higher compared with those from donation after brain death (DBD). It has been reported that the normothermic machine perfusion (NMP) technique was associated with lower rates of IC. However, the effect of NMP on anastomotic biliary complications remains unclear. Methods. A total of 450 LTs performed between January 2019 and December 2023 were analyzed in a retrospective study. The primary outcome included biliary complications within 180 d after LT and those classified by type (bile leak, stricture, or IC). Risk factors for biliary complications were compared between the NMP group and the non-NMP group within both the DBD and DCD groups. Results. The incidence of IC was higher in the DCD without NMP group at 17.5% (10/57), compared with the DCD with NMP group (0%). DCD was independently associated with the development of biliary complications by all causes after LT (odds ratio, 2.29 [95% confidence interval, 1.29-4.07], P < 0.01), whereas NMP did not reduce the risk of biliary complications by all causes (odds ratio, 0.54 [confidence interval, 0.29-1.02], P = 0.06). NMP also did not reduce the risk of biliary anastomotic complications, excluding IC in either DBD or DCD groups. Conclusions. Although NMP might prevent IC, it did not reduce the risk of biliary complications regardless of donor type. Blood circulation to the biliary system may not be adequate, leading to anastomotic biliary complications.