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Biliary Complications After Liver Transplantation: Old Problems and New Challenges

2013; Elsevier BV; Volume: 13; Issue: 2 Linguagem: Inglês

10.1111/ajt.12034

1600-6143

Daniel Seehofer, Dennis Eurich, Wilfried Veltzke–Schlieker, P. Neuhaus,

Congenital Anomalies and Fetal Surgery

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable. Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable. Biliary complications are frequently observed after liver transplantation (LT). Different classification systems for biliary complications are based on the time of occurrence, localization or etiology. Specific complications have a predominant manifestation period (Figure 1), but from the therapeutic aspect the clinical phenotype is the most suitable classification. Thereby anastomotic complications (stenosis or leak) are distinguished from nonanastomotic complications of the donor biliary system (Figure 2).Figure 2:Blood supply of the bile ducts after liver transplantation, classification of biliary complications and etiology of nonanastomotic strictures (NAS).View Large Image Figure ViewerDownload Hi-res image Download (PPT) The vascular supply is the most vulnerable point of the biliary system. Whereas the liver parenchyma is nourished via a dual vascular supply via portal vein and hepatic artery, the bile ducts are supplied only arterially. It is known, that the biliary epithelium is more liable to ischemic injury than hepatocytes (1McKeown CM Edwards V Phillips MJ Harvey PR Petrunka CN Strasberg SM Sinusoidal lining cell damage: The critical injury in cold preservation of liver allografts in the rat.Transplantation. 1988; 46: 178-191Crossref PubMed Google Scholar, 2Imamura H Brault A Huet PM Effects of extended cold preservation and transplantation on the rat liver microcirculation.Hepatology. 1997; 25: 664-671Crossref PubMed Scopus (49) Google Scholar, 3Noack K Bronk SF Kato A Gores GJ The greater vulnerability of bile duct cells to reoxygenation injury than to anoxia.Transplantation. 1993; 56: 495-500Crossref PubMed Google Scholar). Severe hypotension eventually leads to an ‘ischemic cholangiopathy’ (4Deltenre P Valla DC Ischemic cholangiopathy.Semin Liver Dis. 2008; 28: 235-246Crossref PubMed Scopus (74) Google Scholar) with biliary necrosis, cast formation, subsequent scarring and multifocal stenosis. Likewise, severe hypotension in organ donors causes microcirculatory disturbances and an additional ischemic injury. This hinders optimal preservation of the biliary plexus during organ procurement, but optimal preservation is essential for a low biliary morbidity (5Fan ST Fan ST Lo CM Liu CL Tso WK Wong J Biliary reconstruction and complications of right lobe live donor liver transplantation.Ann Surg. 2002; 236: 676-683Crossref PubMed Scopus (162) Google Scholar). The common bile duct is supplied via two main arteries running at the right and left border of the bile duct, the “3 o’clock“and “9 o’clock“arteries, which variably arise form the retroportal, retroduodenal or gastroduodenal arteries and communicate with the right or less often with the left hepatic artery (6Northower JMA Terblanche J A new look at the arterial supply of the bile duct in man and its surgical implications.Br J Surg. 1979; 66: 379-384Crossref PubMed Scopus (397) Google Scholar) (Figure 2). Approximately 60% of the arterial perfusion comes from the gastroduodenal, and only 30–40% downward from the hepatic artery. The nonaxial supply is sparse, contributing to less than 5% of blood supply (6Northower JMA Terblanche J A new look at the arterial supply of the bile duct in man and its surgical implications.Br J Surg. 1979; 66: 379-384Crossref PubMed Scopus (397) Google Scholar). Therefore after LT blood supply of the distal donor bile duct is crucial, since upstream arterial perfusion is lacking. The hilar and intrahepatic ducts are nourished by the peribiliary vascular plexus, a network of capillaries arising form the terminal arterial branches. Thereby the hilar region of the bile ducts is supplied mostly via the communicating arcade (7Gunji H Gunji H Cho A et al.The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries.Am J Surg. 2006; 192: 276-280Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar) (Figure 2), although substantial anatomical variability exists (7Gunji H Gunji H Cho A et al.The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries.Am J Surg. 2006; 192: 276-280Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar). It is generally recommended to avoid denudation of the bile duct to preserve the biliary arterial supply. The proper hepatic artery should be dissected only at its origin. Further preparation of the right and left hepatic arteries increases the risk of injury to biliary arteries, which eventually arise very proximally. The communicating arcade arises at a mean of 2.5 ± 0.8 cm (range 1.0 to 4.0 cm) from the origin of the right hepatic artery and 1.8 ± 0.8 cm (range 0.5 to 4.0 cm) from the origin of the left hepatic artery (7Gunji H Gunji H Cho A et al.The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries.Am J Surg. 2006; 192: 276-280Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar), which has to be respected especially in partial LT. Early symptoms of biliary complications are often unspecific or missing. Biliary leaks typically occur early and are diagnosed by routine cholangiography or bilious secretion. Increased inflammatory parameters or fever might occur in the case of undrained bilious collections. Anastomotic or nonanastomotic stenoses are often affiliated with jaundice, increased cholestatic enzymes and fever. Also recurrent cholangitis is a common symptom and should entail additional diagnostic measures. A cholangiography is easily performed if an external biliary drainage is present. Otherwise, the diagnostic workup is mostly started with noninvasive imaging studies, bearing in mind that these sometimes fail to detect relevant stenoses after LT. Especially ultrasound is less sensitive after LT, since severe dilatation of the intrahepatic bile ducts is absent in >60% of patients with anastomotic stenosis (AS) (8Zemel G Zajko A Skolnick ML et al.The role of sonography and transhepatic cholangiography in the diagnosis of biliary complications after liver transplantation.Am J Roentgenol. 1988; 151: 943-946Crossref PubMed Google Scholar). Even 1 week before ERC diagnosis of AS, 96% of patients revealed a normal ultrasound (9Mahajani RV Cotler SJ Uzer MF Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation.Endoscopy. 2000; 32: 943-949Crossref PubMed Scopus (84) Google Scholar). However, in a newer series 92% of patients with biliary complications revealed ultrasound abnormalities (10Holt AP Thorburn D Mirza D Gunson B Wong T Haydon G A prospective study of standardized nonsurgical therapy in the management of biliary anastomotic strictures complicating liver transplantation.Transplantation. 2007; 84: 857-863Crossref PubMed Scopus (92) Google Scholar). Hepatic artery thrombosis (HAT)—or stenosis is excluded by additional Doppler examination. Contrast-enhanced ultrasound has been used recently to investigate the perfusion of the hilar bile ducts, since detection of severely impaired perfusion may facilitate the early diagnosis of biliary complications (11Ren J Lu MD Zheng RQ et al.Evaluation of the microcirculatory disturbance of biliary ischemia after liver transplantation with contrast-enhanced ultrasound: Preliminary experience.Liver Transplant. 2009; 15: 1703-1708Crossref PubMed Scopus (0) Google Scholar). Normal ultrasound findings should not preclude further diagnostic measures An ERC is able to detect the cause of biliary obstruction in 95% and the site of bile leaks in 90% of cases (12Pfau PR Kochman ML Lewis JD et al.Endoscopic management of postoperative biliary complications in orthotopic liver transplantation.Gastrointest Endoscopy. 2000; 52: 55-63Abstract Full Text Full Text PDF PubMed Google Scholar). However, a prospective study of MRCP and ERC revealed comparable sensitivities for detection of biliary obstruction (13Adamek HE Albert J Weitz M et al.A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction.Gut. 1998; 43: 680-683Crossref PubMed Google Scholar). Other studies confirmed a ≥90% sensitivity and specificity and positive and negative predictive values of 90% for MRCP (14Katz LH Benjaminov O Belinki A et al.Magnetic resonance cholangiopancreatography for the accurate diagnosis of biliary complications after liver transplantation: Comparison with endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography—long-term follow-up.Clin Transplant. 2010; 24: E163-E169Crossref PubMed Scopus (0) Google Scholar,15Boraschi P Braccini G Gigoni R et al.Detection of biliary complications after orthotopic liver transplantation with MR cholangiography.Magn Reson Imaging. 2001; 19: 1097-1105Crossref PubMed Scopus (78) Google Scholar). A normal MRCP therefore might avoid further invasive measures. In the case of ongoing clinical suspicion, cholangiography remains the gold standard. The route of access to the biliary system is among others based on local experience. In our own practice ERC is the method of choice in patients with duct-to-duct anastomosis and PTC is used as a first-line method only in patients with bilioenteric anastomosis. To exclude other causes of graft dysfunction (e.g. rejection, CMV-hepatitis) a liver biopsy might be useful. Additional investigations like hepatobiliary scintigraphy (HIDA-scan) have been described with controversial results (16Hopkins LO Feyssa E Parsikia A et al.Tc-99m-BrIDA hepatobiliary (HIDA) scan has a low sensitivity for detecting biliary complications after orthotopic liver transplantation in patients with hyperbilirubinemia.Ann Nucl Med. 2011; 25: 762-767Crossref PubMed Scopus (7) Google Scholar) and are rarely used in the routine workup nowadays (17Thuluvath PJ Pfau PR Kimmey MB Ginsberg GG Biliary complications after liver transplantation: The role of endoscopy.Endoscopy. 2005; 37: 857-863Crossref PubMed Scopus (164) Google Scholar). Anastomotic complications include anastomotic leakage and segmental narrowing around the anastomosis (anastomotic stricture). For practical reasons this category also encompasses the site of T-tube insertion, since time of manifestation and therapy is similar. Risk factors for anastomotic-leaks and -strictures are closely associated. Major risk factors are inadequate surgical technique, arterial complications or local ischemia of the donor bile duct, the type of biliary reconstruction and the type of liver graft (partial vs. whole LT). Moreover, a preceding bile leak is associated with later AS (18Verdonk RC Buis CI Porte RJ et al.Anastomotic biliary strictures after liver transplantation: Causes and consequences.Liver Transplant. 2006; 12: 726-735Crossref PubMed Scopus (241) Google Scholar, 19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar, 20Akamatsu N Sugawara Y Hashimoto D Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: A systematic review of the incidence, risk factors and outcome.Transpl Int. 2011; 24: 379-392Crossref PubMed Scopus (215) Google Scholar). Other risk factors under discussion include the usage of an external or internal drainage, donor factors and different surgical techniques. Verdonk et al. have shown that the incidence of AS significantly increased from 5.3% before 1995 to 16.7% after 1995 (18Verdonk RC Buis CI Porte RJ et al.Anastomotic biliary strictures after liver transplantation: Causes and consequences.Liver Transplant. 2006; 12: 726-735Crossref PubMed Scopus (241) Google Scholar), possibly related to an increased use of organs with extended donor criteria. Similarly, Sundaram found more biliary strictures in the post-MELD than in the pre-MELD era (6.4% vs. 15.4%) (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar). This is supposed to be multifactorial, since donor age was older and the incidence of hepatic artery thrombosis (HAT) higher in the post-MELD era. Nevertheless, transplantation in the post-MELD era was an independent predictor of stricture development (OR = 2.30). Other risk factors were donor age (OR = 1.01), a prior bile leak (OR = 2.24) and a choledocho-choledochostomy (OR = 2.22) (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar). However, Serran found no differences in the rate of AS in donors > = 60 but a markedly higher rate of nonanastomotic strictures (NAS) in older donors (21Serrano MT Garcia-Gil A Arenas J et al.Outcome of liver trans-plantation using donors older than 60 years of age.Clin Transplant. 2010; 24: 543-549Crossref PubMed Scopus (0) Google Scholar). Foley detected a donor BMI of more than 25 kg/m2 or a donor weight > 82 kg as risk factors for AS (22Foley DP Fernandez LA Leverson G et al.Biliary complications after liver transplantation from donation after cardiac death donors: An analysis of risk factors and long-term outcomes from a single center.Ann Surg. 2011; 253: 817-825Crossref PubMed Scopus (297) Google Scholar). Likewise, a multivariate analysis revealed a >25% macrovacuolar steatosis of the graft as only risk factor for biliary complications (23Baccarani U Isola M Adani GL et al.Steatosis of the hepatic graft as a risk factor for post-transplant biliary complications.Clin Transplant. 2010; 24: 631-635Crossref PubMed Scopus (52) Google Scholar). In HCV patients, early HCV recurrence was shown to additionally increase the risk of AS to 16% compared to 6% in patients with late HCV-recurrence (24Fujita S Fujikawa T Mizuno S et al.Is early recurrence of hepatitis C associated with biliary anastomotic stricture after liver transplantation?.Transplantation. 2007; 84: 1631-1635Crossref PubMed Scopus (0) Google Scholar), possibly based on inflammatory reactions of the hilar region. Interestingly, donation after cardiac death (DCD, see below) seems not to be a risk faktor for anastomotic complications. In most studies the incidence is not increased (22Foley DP Fernandez LA Leverson G et al.Biliary complications after liver transplantation from donation after cardiac death donors: An analysis of risk factors and long-term outcomes from a single center.Ann Surg. 2011; 253: 817-825Crossref PubMed Scopus (297) Google Scholar,25Suarez F Suárez F Otero A et al.Biliary complications after liver transplantation from maastricht category-2 non-heart-beating donors.Transplantation. 2008; 85: 9-14Crossref PubMed Scopus (0) Google Scholar). However, anastomotic complications might be obscured by a high number of diffuse NAS (26Abt P Crawford M Desai N Markmann J Olthoff K Shaked A Liver transplantation from controlled nonheart-beating donors: An increased incidence of biliary complications.Transplantation. 2003; 75: 1659-1663Crossref PubMed Scopus (0) Google Scholar). Bile leaks may occur at the anastomosis, the T-tube insertion, the cystic duct or the cut surface of partial liver grafts. In a recent literature review enclosing more than 11 000 LT, an incidence of 8.2% was calculated. Thereby, the incidence after Living Donor Liver Transplantation (LDLT) was higher than after full-size LT (9.5% vs. 7.8%). The majority of bile leaks are either seen in the first month after LT or after T-tube removal (17Thuluvath PJ Pfau PR Kimmey MB Ginsberg GG Biliary complications after liver transplantation: The role of endoscopy.Endoscopy. 2005; 37: 857-863Crossref PubMed Scopus (164) Google Scholar). Late forms until 6 months are occasionally reported (20Akamatsu N Sugawara Y Hashimoto D Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: A systematic review of the incidence, risk factors and outcome.Transpl Int. 2011; 24: 379-392Crossref PubMed Scopus (215) Google Scholar). A recent analysis (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar) suggested, that the incidence of bile leaks has decreased from 7.5% in the pre-MELD to 4.9% in the MELD era (p = 0.02). However, the use of a T-tube was the strongest risk factor (OR 3.38) for bile leaks and T-tubes were used less often in the MELD era. However, less than 10% of bile leaks occurred within 2 weeks after surgery (mean 102 days), therefore most of the leaks presumably occurred after T-tube removal (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar). There is still an ongoing debate about the use of a T-tube. The incidence of T-tube-related complications often exceeds the incidence of anastomotic leaks. Pfau et al. found 74% of leaks to be related to the T-tube (12Pfau PR Kochman ML Lewis JD et al.Endoscopic management of postoperative biliary complications in orthotopic liver transplantation.Gastrointest Endoscopy. 2000; 52: 55-63Abstract Full Text Full Text PDF PubMed Google Scholar). In our own experience T-tube-related complications are rarely observed. In a prospective randomized trial no complications were observed after T-tube removal (27Weiss S Schmidt SC Ulrich F et al.Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: A prospective randomized trial.Ann Surg. 2009; 250: 766-771Crossref PubMed Scopus (71) Google Scholar). This was true even with routine removal after 6 weeks—compared to other reports with removal after 3 months or even later (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar). Possible explanations for these divergent results might be differences in the surgical technique as well as in T-tube material. In our own practice the intraluminal part of a 2.5 mm T-tube is bisected to relief folding during removal. For insertion, a special bile duct probe is connected to the T-tube and pushed through a small hole in the recipient bile duct. After final placement, the opening is further narrowed by PDS 5/0 stitches. Two metaanalyzes found an increased risk for bile leaks if a T-tube is used (28Paes-Barbosa JHPB Sci Paes-Barbosa FC et al.Systematic review and meta-analysis of biliary reconstruction techniques in orthotopic deceased donor liver transplantation.J Hepatobiliary Pancreat Sci. 2011; 18: 525-536Crossref PubMed Scopus (21) Google Scholar,29Sotiropoulos GC Sgourakis G Radtke A et al.Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results.Transplantation. 2009; 87: 1672-1678Crossref PubMed Scopus (68) Google Scholar). A newer metaanalysis found no overall differences in biliary morbidity but a lower rate of biliary strictures in patients with T-tubes (30Huang WD Jiang JK Lu YQ Value of T-tube in biliary tract reconstruction during orthotopic liver transplantation: A meta-analysis.J Zhejiang Univ Sci B. 2011; 12: 357-364Crossref PubMed Scopus (0) Google Scholar). We have shown in a randomized trial using a side-to-side anastomosis (27Weiss S Schmidt SC Ulrich F et al.Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: A prospective randomized trial.Ann Surg. 2009; 250: 766-771Crossref PubMed Scopus (71) Google Scholar), that complications with a T-tube were significantly less and especially less severe. In this trial, only one anastomotic leak occurred in 99 patients with T-tube. However, four additional early and clinically irrelevant leaks at the T-tube insertion site were detected only by routine cholangiography. All these leaks disappeared after prolonged unclamping of the T-tube. These clinically irrelevant leaks are diagnosed more often if a T-tube is present. Thus, comparison of the pure rate of bile leaks is misleading, but one has to consider their clinical severity. However this is not the case in most (meta-)analyses (29Sotiropoulos GC Sgourakis G Radtke A et al.Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results.Transplantation. 2009; 87: 1672-1678Crossref PubMed Scopus (68) Google Scholar,30Huang WD Jiang JK Lu YQ Value of T-tube in biliary tract reconstruction during orthotopic liver transplantation: A meta-analysis.J Zhejiang Univ Sci B. 2011; 12: 357-364Crossref PubMed Scopus (0) Google Scholar). Moreover, leaks after T-tube removal lack severity and are easy to treat, since they do not appear in the critical phase early after LT. Moreover, in retrospective studies a selection bias toward more complicated cases in the T-tube group has to be assumed. The subjective nature of the discussion on T-tubes is underlined by the fact, that even centers which identified a T-tube as significant risk factor for bile leaks in an earlier analysis (31Tepetes K Karavias D Felekouras E Jabour N Tzakis A Starzl E Bile leakage following T-tube removal in orthotopic liver transplantation.Hepatogastroenterology. 1999; 46: 425-427PubMed Google Scholar), still used it in 58% of recent transplantations (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar). Also the ASTS guidelines (32Reich DJ Mulligan DC Abt PL et al.ASTS Standards on Organ Transplantation Committee. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation.Am J Transplant. 2009; 9: 2004-2011Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar) suggest the use of a T-tube after DCD donation due to a high risk of biliary complications. The reported incidence of AS is 13% after full size and 19% after LDLT (20Akamatsu N Sugawara Y Hashimoto D Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: A systematic review of the incidence, risk factors and outcome.Transpl Int. 2011; 24: 379-392Crossref PubMed Scopus (215) Google Scholar). AS in the early course are often a result of surgical failure, whereas late AS may develop gradually as consequence of local inflammation due to ischemia, bile leaks and other factors. Clinical manifestation takes place within 6 months (9Mahajani RV Cotler SJ Uzer MF Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation.Endoscopy. 2000; 32: 943-949Crossref PubMed Scopus (84) Google Scholar,17Thuluvath PJ Pfau PR Kimmey MB Ginsberg GG Biliary complications after liver transplantation: The role of endoscopy.Endoscopy. 2005; 37: 857-863Crossref PubMed Scopus (164) Google Scholar), but occasionally also after many years (17Thuluvath PJ Pfau PR Kimmey MB Ginsberg GG Biliary complications after liver transplantation: The role of endoscopy.Endoscopy. 2005; 37: 857-863Crossref PubMed Scopus (164) Google Scholar,20Akamatsu N Sugawara Y Hashimoto D Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: A systematic review of the incidence, risk factors and outcome.Transpl Int. 2011; 24: 379-392Crossref PubMed Scopus (215) Google Scholar). Verdonk reported a cumulative incidence of 6.6%, 10.6%, and 12.3% after 1, 5 and 10 years, respectively (18Verdonk RC Buis CI Porte RJ et al.Anastomotic biliary strictures after liver transplantation: Causes and consequences.Liver Transplant. 2006; 12: 726-735Crossref PubMed Scopus (241) Google Scholar). Other rare causes of biliary obstruction like obstructing mucoceles of the cystic duct or bile duct concrements are not discussed in detail. Many risk factors like donor age or steatosis cannot be influenced. The optimal surgical reconstruction technique including biliary drainage is still under debate. Choledocho-choledochostmy is the standard procedure in full size and LDLT. Some analyses report a similar (33Stratta RJ Wood RP Langnas AN et al.Diagnosis and treatment of biliary tract complications after orthotopic liver transplantation.Surgery. 1989; 106: 675-683PubMed Google Scholar) or even lower (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar) rate of biliary complications after bilioenteric anastomosis, others a higher rate (34Greif F Bronsther OL Van Thiel DH et al.The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation.Ann Surg. 1994; 219: 40-45Crossref PubMed Google Scholar). Technical modifications of choledocho-choledochostomy include an end-to-end versus end-to-side or side-to-side reconstruction as well as running versus interrupted suture. Theoretical disadvantages of an end-to-end anastomosis include the fragility and an impaired perfusion at the distal end of the bile duct. Moreover, incongruence in diameter might be difficult to adjust. For small bile ducts the risk of stenosis is considerable, particularly if a running suture is used. This might be avoided by a side-to-side anastomosis, which allows a long anastomosis irrespective of the bile duct diameter. In addition, a good perfusion of the bile duct is warranted, since the 3 and 9 o’clock vessels are completely preserved by incision of the bile duct at 12 and 6 o’clock (Figure 2). However, a randomized trial comparing these technical modifications showed no significant differences (35Davidson B Rai R Kurzawinski T et al.Prospective randomized trial of end-to-end versus sideto-side biliary reconstruction after orthotopic liver transplantation.Br J Surg. 1999; 86: 447-452Crossref PubMed Scopus (0) Google Scholar). Overall, no differences between running and interrupted sutures have been detected (19Sundaram V Jones DT Shah NH et al.Posttransplant biliary complications in the pre- and post-model for end-stage liver disease era.Liver Transplant. 2011; 17: 428-435Crossref PubMed Scopus (0) Google Scholar,36Castaldo ET Pinson CW Feurer ID et al.Continuous versus interrupted suture for end-to-end biliary anastomosis during liver transplantation gives equal results.Liver Transplant. 2007; 13: 234-238Crossref PubMed Scopus (0) Google Scholar), but there is some indication