The technical aspects of the biliary anastomosis should be discussed separately for cadaveric and living donor liver transplantation.

In cadaveric transplantation, the most preferred technique is a duct-to-duct anastomosis. The use of a T-tube declined markedly in the last decade although practices still vary widely. A tension-free anastomosis between well-vascularized ends should be constructed with fine, monofilament absorbable sutures. Bile duct redundancy and inadvertent suture closure of the cystic duct should be avoided to prevent kinking and mucocele formation respectively. The major complications are leakage and stricture, which can usually be managed by endoscopic methods. Recurrent anastomotic stricture after multiple ERCP procedures may be an indication for a Roux-Y reconstruction. A biliodigestive anastomosis is performed in patients with primary sclerosing cholangitis (PSC), damaged bile ducts (inadvertent embolization during radiologic treatment of hepatocellular carcinoma, retransplantation) or biliary atresia. The use of a transanastomotic catheter depends on physician preference. The major complications are leakage and stricture, which can usually be managed by percutaneous methods. Graft loss due to a biliary anastomotic complication is rare in the absence of concomitant vascular problems.

In living donor liver transplantation, a Roux-Y reconstruction is preferred for left-sided grafts (mandatory in children with biliary atresia) because a tension-free duct-to-duct anastomosis is not usually possible and traction of an originally acceptable anastomosis may occur during graft regeneration. The use of a transanastomotic catheter depends on physician preference. The major complications are leakage and stricture. For right-sided grafts, a duct –to-duct anastomosis is preferred for technical ease, avoidance of intestinal contamination and the possibility of endoscopic treatment of complications. Keeping the dissection plane very close to the vascular structures in the hepatoduodenal ligament and cutting the biliary tree transparenchymally at the end of the recipient hepatectomy preserves a well-vascularized, multiple-ended ‘pedicle’ that may make it possible to reconstruct multiple bile ducts of the right lobe. The cystic duct may also serve as a conduit. The use of a transanastomotic catheter depends on physician preference. The major complications are leakage and stricture, which can usually be managed by endoscopic and radiologic methods, depending on center experience. A Roux-Y reconstruction is used if the biliary tree of the recipient is unsuitable for anastomosis or special situations such as PSC are present. In living donor liver transplantation, biliary anastomotic leakage is a risk factor for early hepatic artery thrombosis with catastrophic consequences and for late stricture formation. Graft loss due to a biliary anastomotic complication is an infrequent but well-recognized problem that is further complicated by the fact that the recipient may have to turn to one more family member for donation.

The reported complication (10-35% for cadaveric and 15-50% for living donor liver transplantation) and treatment success rates vary widely depending on definitions, center experience and length of follow up. Biliary anastomotic complications remain significant causes of morbidity, potential graft loss and even mortality.