*Purpose: Surgery learning is based on a master-apprentice model, a learning curve is essential to measure the acquisition and improvement of surgical skills without compromising outcomes. Within Transplantation there is no formal structure for feedback that allows fellows and trainees to monitor their progression over time. In transplant biliary complications have a high incidence (11-25%) with a significant impact on morbidity and mortality (0-19%); risk factors include technical aspects which may be exacerbated during first years of training. In order to better characterize the learning curve during biliary anastomosis we aimed our study to review the incidence of biliary complications (Biliary stricture (BS) Biliary Leak (BL) ) during the first 6 months of each academic year in order to examine a possible causal relationship with trainee learning curves and incidence of complications

*Methods: We performed a retrospective review of all liver transplants (LT) performed from July 2016 to June 2021. Biliary complications were examined with emphasis on the first half of each academic year. The variables included: Number of BL, BS, Other biliary complications, anastomosis type: duct-duct (DD) , Roux en Y hepaticojejunostomy (RYHJ); biliary stent use and insertion site: Donor Cystic duct or Recipient Cystic Duct; Deceased donor liver transplant (DDLT) and Living donor Liver Transplant (LDLT) At our institution most of the deceased donor biliary anastomosis are performed by junior fellows with direct supervision of an attending surgeon, however anastomosis in complex and living donor patients are performed by senior team members.

*Results: 438 LT performed with a total of 107 (24.4%) biliary complications; there were 24 BL and 88 BS (Graph 1). Of the 232 LT that happened on the first half of the academic year there was 50 biliary complications with 10(20%) BL and 43(86%) BS. Table 1. Of these, 43 (86%) had a DD anastomosis and 7 (14%) a RYHJ, the biliary stent was inserted 18 (36%) times through the recipient cystic duct and 21 (42%) through the donor cystic duct. A total of 19 complications presented early within 30 days of transplant. There was 2 cut edge leaks that occurred on LDLT recipients.

*Conclusions: Our study did not show an increased number of biliary complications at the beginning of the academic year compared to the second half. The impact of trainees on the incidence of complications was noncontributory however there still further need to establish a learning curve that allows to monitor trainee proficiency and outcome improvement in liver transplant biliary anastomosis.

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