*Purpose: Biliary complications can affect up to 40% of patients after orthotopic liver transplantation (OLTx). Endoscopic management has a high success rate but involves multiple sessions and up to 21% complications. Biliary plastic stents (BPS) placed manually during OLTx can splint a choledocho-choledochal anastomosis, possibly reducing biliary strictures and leaks. This study evaluates the feasibility and clinical outcomes of “prophylactic” intraoperative stenting at a single center, using a propensity-matched analysis.

*Methods: All consecutive OLTx patients over a 10-year period are included except for patients with hepaticojejunostomy, fulminant hepatic failure redo grafts and combined organ transplants. The primary outcome is the incidence of biliary complications (leaks and strictures). Secondary outcomes include: stent morbidity, number of biliary interventions, cholangitis, graft and patient survival. Propensity scoring was used to diminish selection bias. Long term outcomes were analyzed for a minimum of 5 years.

*Results: 265 OLTx patients were included. BPS was attempted and successful in 95 patients whereas 170 did not receive stents. Age, Gender, and medical comorbidities were similar between groups. Total biliary complications (44.2% Vs 44.7%, P=0.94) and biliary stricture rates (45.3%Vs 43.5%, P= 0.79) were similar between groups. However biliary leaks were significantly less frequent in the stented group, 2% Vs 10% (P=0.02). Five-year rates of cholangitis, choledocholithiasis, and acute renal failure were similar between both groups. Multivariate analysis of predictors of biliary leak found cold ischemia time (CIT) to be the only significant variable, OR=1.36 (1.06; 1.75). A propensity score model based on CIT was used to match 95 patients in each group. Total biliary complication rate remained similar between both groups however the rate of biliary leaks was even significantly lower in the stented group (P<0.01). The number of biliary interventions per complication was also significantly lower in the stented group, P<0.01.

*Conclusions: BPS at OLTx is feasible and safe, resulting in less biliary leaks without significantly greater adverse events. Moreover, the number of biliary interventions was significantly lower in the stented group possibly indicating that stents facilitated subsequent endoscopic management. This study suggests a stenting strategy is feasible and that a randomized trial is worthwhile.

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