Routine External Biliary Stenting via the Cystic Duct in Living Donor Liver Transplantation: Is it Always Safe?

Objectives: External biliary stenting via the cystic duct is widely used in living donor liver transplantation (LDLT) to reduce biliary complications, particularly bile leakage, and to facilitate postoperative biliary management. While some centers apply this technique selectively, others routinely use external biliary stents in all recipients. However, stent-related complications, including mechanical failure, remain a concern.
Methods: Between January-2009 and May-2025, a total of 365 adult LDLTs were performed at our center. In all cases, duct-to-duct biliary reconstruction was completed with routine placement of an external biliary stent via the cystic duct, planned for removal at 5–6 months postoperatively. This retrospective analysis focused on patients who required surgical re-exploration due to stent fracture. Clinical presentation, imaging findings, intraoperative observations, surgical management, and postoperative outcomes were reviewed.
Results: Among 365 LDLT recipients, seven patients(1.9%) required laparotomy due to stent fracture. Stent fracture occurred between postoperative months 3 and 6, prior to the planned stent removal. All patients presented with acute abdominal pain and signs of peritonitis. Imaging demonstrated retained stent fragments within the biliary tract in all cases, with findings suggestive of biliary irritation or leakage. Urgent laparotomy was performed in all patients. Intraoperatively, fractured stent segments were identified in the biliary system. In two patients, fragments were embedded in the biliary tract, necessitating meticulous dissection. No perioperative mortality occurred however, all patients experienced prolonged hospitalization and postoperative morbidity. No graft loss directly attributable to stent fracture was observed.
Conclusion: Routine external biliary stenting via the cystic duct in adult LDLT may reduce bile leakage but is not without risk. Although stent fracture is rare, it can result in severe complications requiring reoperation and significant morbidity. These findings support reconsideration of a routine stenting policy and suggest that a selective approach based on intraoperative and patient-specific factors may be safer.

Keywords: Living Donor Liver Transplantation, external biliary stent, risk, stent-related complication