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Background: Biliary complications can affect 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 placed manually during OLTx can splint a choledochocholedochal 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, acute renal failure, graft and patient survival. Propensity scoring was used to diminish selection bias. Outcomes were analyzed for a minimum of 5 years. Results: 265 OLTx patients were included between 2002-2011. 95 patients (36%) received intraoperative stents whereas 170 did not. 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. non-stented (10%), (P=0.02). Five-year rates of cholangitis, choledocholithiasis, and acute renal failure were similar between both groups. A propensity score model based on multiple covariates including surgeon, year of transplantation and Charlson comorbidity score was used to match 95 patients in each group. The rate of biliary leaks remained significantly lower in the stented group, OR= 0.19 (95%CI= 0.04; 0.86). Conclusion: Intraoperative use of biliary stents at OLTx is feasible and safe, resulting in less biliary leaks without significantly greater adverse events. 5-year biliary stricture rates appear similar. This study suggests a stenting strategy is feasible and that a randomized trial is worthwhile.

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