Management of the bile duct anastomosis and its complications after liver transplantation

The functional recreation of the biliary system has long been a source of morbidity in patients undergoing hepatic transplantation. The methods used to recreate a biliary system have undergone a metamorphosis over time. Gall bladder conduits and loop choledochojejunostomies have given way to duct-to-duct choledochocholedochostomies and the Roux-en-Y choledojejunostomy with resulting improvements in biliary outcomes. Stenting, stapling, and suture techniques have also evolved in an effort to improve transplant biliary outcomes. As the methods for the re-creation of the biliary system have evolved, so too have the methods used to deal with the subsequent complications. Primary surgical exploration has given way to less invasive percutaneous and endoscopic techniques. This article focuses on aspects of the surgical management of the bile duct anastomosis during liver transplantation and the subsequent management of biliary complications.