Biliary anastomosis using T-tube versus no T-tube for liver transplantation in adults.

Abstract

Rationale: In liver transplantation, biliary reconstruction by performing bile duct anastomosis is a critical step of the operation. Biliary complications, especially fistula (leaks) and stenosis, remain the leading causes of morbidity and mortality. During the operation, surgeons can insert a T-tube into the bile duct following the bile duct reconstruction. This drain decompresses the biliary tract, and it is thought to reduce biliary tract-related complications. There is, however, no consensus on the use of a T-tube as a drainage technique during biliary reconstruction.

Objectives: To assess the benefits and harms of biliary anastomosis with the use of a T-tube compared with biliary anastomosis without the use of a T-tube in adults undergoing liver transplantation.

Search methods: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, Latin American and Caribbean Health Science Information Database (LILACS; VHL Regional Portal), Science Citation Index Expanded (Web of Science), and Conference Proceedings Citation Index - Science (Web of Science). We also searched online trial registries, reviewed reference lists of identified studies, and contacted, when necessary, the main authors of the included trials. All electronic searches were performed on 28 April 2026.

Eligibility criteria: We considered for inclusion parallel-group randomised controlled trials (RCTs) comparing biliary reconstruction techniques, with or without a T-tube, in adults undergoing liver transplantation, irrespective of publication type, year, format, status, language, or reported outcomes.

Outcomes: Our critical outcomes were all-cause mortality, serious adverse events (including biliary leakage/fistula, stenosis, complications attributable to T-tube, retransplantation, and others), and health-related quality of life (HRQoL). Important outcomes were non-serious adverse events and pain.

Risk of bias: We used the Cochrane's risk of bias 1 (RoB 1) tool to assess the risk of bias.

Synthesis methods: We used standard methodological procedures expected by Cochrane to develop the review. We analysed dichotomous outcomes using random-effects meta-analysis (inverse-variance method with restricted maximum likelihood estimation of the between-study variance) and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We assessed the certainty of the evidence in the outcome results using the GRADE approach. We used the GRADE summary of findings table to display the outcome results for all-cause mortality and, among serious adverse events, anastomotic bile leak, anastomotic biliary stenosis, complications attributable to the T-tube, retransplantation, and serious biliary adverse events. We also presented HRQoL.

Included studies: We included six RCTs in 844 adults (range 60 to 194 participants). Three studies were conducted in Spain, and one each in France, Germany, and the UK. The studies were published between 1996 and 2013. The mean age ranged from 42 years to 55.3 years (average 53.9 years), and most participants were men (60.8%). All six studies compared choledochocholedochostomy biliary anastomosis with a T-tube versus choledochocholedochostomy biliary anastomosis without a T-tube during adult liver transplantation. Follow-up ranged from 9 to 35 months (mean 23 months).

Synthesis of results: The evidence is very uncertain about the effects of biliary anastomosis with a T-tube versus without a T-tube on all-cause mortality (RR 0.98, 95% CI 0.58 to 1.63; I² = 7%; 6 studies, 826 participants; very low-certainty evidence) and on anastomotic bile leak (RR 0.79, 95% CI 0.37 to 1.69; I² = 31%; 4 studies, 586 participants; very low-certainty evidence). The use of a T-tube in biliary anastomosis in liver transplantation may reduce the incidence of anastomotic biliary stenosis (RR 0.33, 95% CI 0.15 to 0.71; I² = 27%; 6 studies, 826 participants; very low-certainty evidence), but the evidence is very uncertain. Biliary anastomosis with T-tube may increase complications attributable to the T-tube (RR 17.81, 95% CI 5.51 to 57.58; I² = 0%; 6 studies, 826 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain about the effects of biliary anastomosis with a T-tube versus without a T-tube on retransplantation (RR 1.22, 95% CI 0.38 to 3.89; I² = 0%; 3 studies, 427 participants; very low-certainty evidence) and serious biliary adverse events (RR 1.16, 95% CI 0.51 to 2.64; I² = 90%; 6 studies, 826 participants; very low-certainty evidence). No studies reported HRQoL. The very low-certainty evidence was due to risk of bias, imprecision, and heterogeneity.

Authors' conclusions: The very low-certainty evidence precluded us from drawing robust conclusions regarding the clinical benefits or harms of using a T-tube versus no T-tube use in biliary anastomosis during adult liver transplantation. We are very uncertain about the benefits and harms of T-tube use regarding all-cause mortality, anastomotic bile leak, retransplantation, and serious biliary adverse events. We are also very uncertain whether the T-tube may reduce the incidence of anastomotic biliary stenosis and increase complications attributable to the T-tube. We lack data on HRQoL. We lack high-quality studies.

Funding: This study did not have any external sources of funding.

Registration: Protocol: doi.org/10.1002/14651858.CD013289.