*Purpose: Biliary leaks and anastomotic strictures comprise the majority of biliary complications (BCs) following liver transplantation. Most case series of BCs in adult deceased donor liver transplant are older studies from an era when biliary T-tube usage was common, limiting their application to contemporary transplant practices. Indeed, few large contemporary case series of BCs in adult deceased donor liver transplant (DDLT) recipients exist in the literature. We examined the pre-transplant and intra-operative risk factors associated with BCs at a high-volume tertiary care center and determined the impact of these BCs on their long-term post-transplant outcomes.

*Methods: We retrospectively reviewed all adult patients undergoing a DDLT from a donor after brain death at Emory University between January 1, 2015 and December 31, 2019.

*Results: 647 patients underwent DDLT during the study period with a median follow-up of 2.5 years. A total of 27 bile leaks (4.2%) and 69 biliary strictures (10.7%) were detected. Whereas bile leaks were detected a median of 4 days after transplant (range: 0-65 days), biliary strictures were detected a median of 139 days after transplant (range: 5-1060 days). Biliary complications are often defined as presenting early (occurring <30 days post-transplant) or late (occurring >30 days post-transplant). Of patients who developed a bile leak, only 11.1% presented late, whereas 87% of biliary strictures presented late. Risk factors associated with biliary strictures included alcoholic cirrhosis as the etiology of liver failure. Risk factors for bile leaks included viral hepatitis as etiology of liver failure and MELD exception points. Utilization of biliary stents was strongly associated with development of both bile leaks and biliary strictures (RR= 2.25, 95% CI 1.39-3.57). In our series, 77% of biliary leaks were managed surgically through either a revision of the biliary anastomosis (42.3%) or conversion to a Roux-en-Y hepaticojejunostomy (19.2%). “Early” bile leaks diagnosed prior to POD 14 (n = 19) were exclusively managed surgically (100%), while “late” biliary leaks (n = 7) were managed primarily endoscopically (71%). In contrast, the vast majority of anastomotic strictures were definitively managed endoscopically (95.7%), with a mean of 3.2 procedures per patient. Post-transplant, biliary leaks significantly increased the risk of subsequent episodes of acute rejection (RR= 2.47, 95% CI 1.04-5.93) but did not impact patient survival. In contrast, biliary strictures did not impact acute rejection rates but was associated with a significantly reduced patient survival at one- and four-years post-transplant (RR= 5.70, 95% CI 2.4-13.5).

*Conclusions: BCs are a major source of morbidity and mortality following DDLT. Comprehensive analyses from high-volume centers are needed to identify risk factors for BCs to facilitate improved outcomes.

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