Biliary tract complications (especially biliary stricture) remain a significant cause of morbidity and mortality following liver transplantation. Various prophylactic intraoperative strategies have been proposed, but a gold-standard surgical technique remains unestablished. The primary objective of this study is the description of biliary anastomosis outcomes in small-caliber bile ducts categorized by the surgical technique utilized in liver transplant recipients.

An observational, retrospective, single-center study. A consecutive series of liver transplant recipients between January 2021 and December 2024 presenting with a small-caliber biliary tract (defined as at least one of the two bile ducts measuring ≤7 mm) was reviewed. The primary variable evaluated was anastomotic biliary stricture, defined by radiological criteria combined with laboratory evidence of cholestasis. The intraoperative management of the small bile duct was performed using three surgical techniques: T-tube placement, bioabsorbable self-expanding biliary stent placement or no additional measures.

Two hundred and three patients receiving a deceased-donor liver transplant were evaluated. Small-caliber biliary tract management was performed via T-tube placement in 27 cases (13.3 %), self-expanding biliary stent placement in 20 (9.8 %) or without additional measures in 156 (76.8 %). Stricture rates of 3.7 %, 25 % and 14.7 % were observed in each respective group, with median times to stricture development of 2, 8 and 4 months, respectively. The use of a T-tube (as a protective factor), the presence of initial graft dysfunction and a biliary fistula (as risk factors) were found to be statistically significantly associated with the occurrence of biliary anastomotic stricture ( p   <  0.05).

Despite advancements in liver transplantation anastomotic biliary stricture remains a significant complication and currently no effective strategy is available for the prevention of its onset in high-risk biliary tracts.