BACKGROUND Biliary complications (BC) remain a significant cause of morbidity and mortality after orthotopic liver transplantation (OLT). METHODS In an effort to determine the incidence of BC after OLT and the success of management options, 157 hepatic transplants performed from January 1987 to July 1991 were reviewed. RESULTS The incidence of BC was 25 percent, with a one year mortality rate of 43.5 percent compared with 23.4 percent for patients in a control group (p < 0.05). Most BC occurring before postoperative day 30 presented as leaks, with a one year mortality rate of 50 percent (p < 0.03 versus control group). Biliary complications presenting after postoperative day 30 presented as strictures, with a one year mortality rate of 36.8 percent (p = NS versus control group). Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), and operative treatment were analyzed to determine relative patency rates after intervention for BC. The analysis showed that ERCP and PTHC were equivalent, with a one year patency rate of 45 percent. Operative treatment had a patency rate of 89 percent (p < 0.05 compared to ERCP and PTHC). CONCLUSIONS The results from ERCP and PTHC may be useful for delineation of rejection versus BC after OLT. However, operative treatment is significantly more effective for definitive treatment of BC after OLT.