Objectives: Bile leak remains an important complication after biliary reconstruction, particularly in living donor liver transplant. We evaluated the effect of routine intraoperative placement of a double J stent across the biliary anastomosis on postoperative bile leak in patients undergoing biliary reconstruction.
Materials and Methods: This retrospective cohort study included 63 patients who underwent biliary reconstruction with intraoperative double J stent placement at Başkent University Hospital between November 2021 and January 2025. Fifty-five patients were liver transplant recipients, and 8 patients underwent hepatopancreatobiliary surgery for tumor resection, trauma, or complex benign biliary disease. We analyzed demographic characteristics, biliary anatomy, number of bile ducts, type and number of biliary anastomoses, and postoperative biliary complications.
Results: Of 63 patients, 35 were male and 28 were female. Among the liver transplant recipients, 51 underwent living donor liver transplant and 4 underwent auxiliary liver transplant; 30 were pediatric and 25 were adult recipients. Duct-to-duct anastomosis was the most commonly used reconstruction technique, followed by Roux-en-Y hepaticojejunostomy and hepaticoduodenostomy. Multiple bile ducts were present in 17 patients. Early bile leak developed in 6 of 63 patients (9.52%). Among living donor liver transplant recipients, bile leak occurred in 5 of 51 patients (9.8%). All patients with bile leak had more than 1 bile duct. Four patients were managed endoscopically with stent removal, sphincterotomy, and internal biliary stent placement, and 2 patients underwent percutaneous drainage. No patient required reoperation, and no mortality related to bile leak was observed. No clinically significant stent migration, severe cholangitis, or stent-related obstruction developed during follow-up.
Conclusions: Intraoperative placement of a double J stent during biliary reconstruction appears to be a safe and practical adjunct in both liver transplant and complex hepatopancreatobiliary surgery, particularly in patients with multiple bile ducts. Prospective controlled studies are needed to better define its role. Key words: Anastomotic healing, Biliary complication, Double J stent, Living donor liver transplantation

Introduction
Bile leakage remains a frequent and clinically significant complication following biliary reconstruction, particularly after living donor liver transplant (LDLT) and complex hepatopancreatobiliary (HPB) surgery. Despite advances in surgical techniques and perioperative care, incidence of biliary complications continues to be an important cause of morbidity in both transplant and nontransplant biliary surgery, prolonging hospital stay and increasing health care costs. Reported bile leakage rates in the literature range widely from approximately 5% to 25%, and this variability is influenced by patient characteristics, graft type, surgical technique, and diagnostic criteria.^1-3 In the context of LDLT, biliary reconstruction is particularly challenging because of the small duct caliber, variable anatomy, and the frequent presence of multiple biliary openings. These technical difficulties render the biliary anastomosis especially vulnerable to leakage, stricture, and ischemic injury. Even in high-volume centers, biliary complications remain a persistent problem, underscoring the need for additional strategies to support anastomotic healing.⁴ Various suture techniques, internal drainage, external drainage, and internal-external drainage methods to prevent bile leakage have been described in the literature.^5,6 In this study, we evaluated the preventive effect of double J stents (DJS) placed across the biliary anastomosis on the incidence of bile leakage.

Materials and Methods
This retrospective cohort study included 63 patients who underwent biliary reconstruction with intraoperative placement of a DJS at Baskent University Hospital between November 2021 and January 2025. The cohort comprised 55 liver transplant recipients and 8 nontransplant HPB surgery patients who underwent biliary reconstruction following tumor resection, trauma, or complex benign biliary disease. The study protocol was approved by the Baskent University School of Medicine Ethics Committee (No. KA 25/181) We analyzed the following variables: demographic characteristics of the patients, the etiology of liver failure and biliary disease, the number of bile ducts involved in the anastomosis, the number of biliary anastomoses, the type of anastomosis, and postoperative biliary complications. Because of the radiopaque nature of the DJS device, plain abdominal radiography was used to postoperatively monitor the DJS position (Figure 1). Bile duct anastomoses were performed individually using 6-0 absorbable sutures. The DJS was inserted after completion of the posterior wall of the biliary anastomosis (Figure 2). During placement, the stent was advanced as far as possible into the proximal intrahepatic bile duct using a guidewire. The distal end of the stent was then advanced into the intestinal lumen.

Results
A total of 63 patients underwent biliary reconstruction with intraoperative DJS placement for the period of November 2021 to January 2025. There were 35 male patients (55.6%) and 28 female patients (44.4%). Fifty-five patients were liver transplant recipients, all of whom received grafts from living donors. Among these recipients, 30 were pediatric patients (54.5%) and 25 were adult patients (45.5%). The remaining 8 patients underwent biliary reconstruction following tumor resection, trauma, or complex benign hepatobiliary disease. Among the 55 liver transplant recipients, 51 underwent living donor liver transplant and 4 underwent auxiliary living donor liver transplant (Table 1). In the pediatric group, metabolic liver diseases and biliary atresia constituted a substantial proportion of the indications for transplant. With regard to the type of biliary reconstruction, duct-to-duct anastomosis was performed in most patients. Roux-en-Y hepaticojejunostomy was used in selected cases with unfavorable duct conditions, whereas hepaticoduodenostomy was performed in a limited number of auxiliary transplant recipients (Table 2). Multiple bile ducts were present in a subset of patients. In cases with 2 bile ducts, either separate or combined anastomoses were performed according to intraoperative findings. When 2 ducts were present, 2 DJS devices were placed to ensure adequate drainage and support of both anastomoses. In 1 patient, 3 bile ducts were identified intraoperatively; therefore, 3 DJS devices were placed. Early bile leakage occurred in 6 of 63 patients (9.52%) (Table 1). Among LDLT recipients, 5 of 51 patients (9.8%) developed bile leakage; of these 5 patients who developed bile leakage, 3 were pediatric patients, and 2 were adult patients (Table 3). Management of bile leakage was primarily minimally invasive. In 2 patients, a percutaneous drainage catheter was placed. Serial imaging demonstrated that the leak was contained and did not freely spread into the peritoneal cavity, and the biliary tree could be visualized from the leakage site. Endoscopically, the existing DJS was removed and replaced with a new stent; subsequently, bile drainage progressively decreased and the leak resolved. In 4 additional patients with bile leakage, the intraoperatively placed DJS was removed endoscopically, sphincterotomy was performed, and an internal biliary stent was inserted (Figure 3). These patients were followed without the need for further invasive intervention. In patients without complications, the intraoperatively placed DJS devices were routinely removed endoscopically at approximately 3 months postoperatively. Plain abdominal radiographs were sufficient for postoperative monitoring of stent position due to the radiopaque nature of the DJS. No clinically significant stent migration, severe cholangitis, or stent-induced obstruction was observed during follow-up.

Discussion
This study demonstrates that routine intraoperative placement of a DJS during biliary reconstruction is associated with a relatively low incidence of bile leakage (9.52% of patients overall; 9.8% in LDLT recipients). These rates appear favorable compared with contemporary LDLT series in which bile leakage rates exceeding 10% to 15% have been reported in the absence of routine stenting.^1,3 Several mechanisms may explain the potential protective effect of DJS placement on the biliary anastomosis. First, continuous bile drainage through the stent may reduce intraductal pressure and thereby decrease the risk of bile extravasation at the anastomotic site. Second, the stent may provide mechanical stability to the suture line during the early postoperative period, when tissue edema and inflammation could compromise anastomotic integrity. Third, by maintaining ductal patency in the presence of postoperative edema or spasm, the stent may prevent early biliary obstruction. In addition, because of its flexibility, the DJS does not traumatize the anastomosis during placement and can be easily manipulated intraoperatively, which may further contribute to its safety. Santosh Kumar and colleagues conducted a prospective study in which internal biliary stents were placed in 64 patients. They reported that the use of stents and the creation of an increased number of biliary anastomoses were associated with a higher incidence of bile leakage. Similarly, in a series of 101 patients from Salvalaggio and colleagues, grafts with multiple bile ducts were found to have significantly higher rates of bile leakage.^7,8 In our study, all 6 patients who developed bile leakage had more than 1 bile duct, which is consistent with these previously reported findings and supports the notion that incidence of multiple ducts represents an important risk factor for biliary complications. Regarding suture technique, Ando and colleagues demonstrated that use of interrupted sutures combined with external drainage via a Roux-en-Y limb was associated with reduced bile leakage and anastomotic narrowing. Likewise, Castaldo and colleagues suggested that interrupted biliary anastomosis may be safer, although the difference was not statistically significant.^9,10 In our series, all biliary anastomoses were performed using interrupted sutures; however, external biliary drainage was not routinely applied. Despite this, our bile leak rates remained within an acceptable range, suggesting that interrupted suturing combined with internal stenting may provide adequate anastomotic support without the need for routine external drainage. Presently, evidence indicates that the first-line approach for management of postoperative bile leakage is endoscopic evaluation of the biliary tree, followed by sphincterotomy and internal biliary stenting. When endoscopic management is not feasible, percutaneous biliary drainage and stent placement can be used as alternative strategies.^11-13 In our study, for 4 of the 6 patients with bile leakage, the complication was successfully managed endoscopically. That is, the previously placed DJS was removed, sphincterotomy was performed, and an internal biliary stent was placed; these stents were subsequently removed endoscopically in the third postoperative month. In 2 patients, endoscopic access was not successful, and percutaneous biliary drainage was therefore performed. Importantly, bile leakage did not result in mortality or significant morbidity in any patient in this cohort. Overall, our findings suggest that intraoperative DJS placement is a safe and practical adjunct in biliary reconstruction, particularly in patients with multiple bile ducts, while allowing effective minimally invasive management of any leaks that may occur.

Conclusions
Biliary leaks are a significant complication in biliary anastomosis. In this retrospective cohort, routine intraoperative placement of a DJS during biliary reconstruction was associated with a relatively low rate of bile leakage with no serious stent-related complications in both liver transplant and complex HPB surgery. Given its technical simplicity, flexibility, and ease of endoscopic removal, DJS placement appears to be a safe and practical adjunct to support biliary anastomosis in pediatric and adult patients. However, prospective controlled studies are needed to better define the definitive role of DJS placement in biliary anastomosis.