Original article Clinical endoscopy| Volume 77, ISSUE 1, P47-54, January 2013

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Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy

Published:October 12, 2012DOI:


      Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era of organ shortage. However, biliary strictures are a common complication of LDLT, and these strictures frequently require surgical revision after unsuccessful endoscopic therapy. The optimal endoscopic treatment for anastomotic biliary strictures (ABSs) after LDLT is undefined.


      To determine the outcome of an aggressive endoscopic approach to ABSs after LDLT that uses endoscopic dilation followed by maximal stent placement.


      A retrospective study.


      A tertiary-care academic medical center.


      Forty-one patients with a diagnosis of ABS.


      Endoscopic retrograde cholangiography with balloon dilation and maximal stenting.

      Main Outcome Measurements

      Stricture resolution, stricture recurrence, and complication rates.


      Of 110 LDLTs completed, a biliary stricture developed after transplantation in 41 (37.3%), which included 38 patients with duct-to-duct anastomosis. The median (interquartile range [IQR]) follow-up time is 74.2 (2.5-120.8) months. Among them, 23 (60.5%) were male, and 20 (52.6%) had bile leakage associated with ABSs. The median time (IQR) to the development of an ABS after LDLT was 2.1 (1.2-4.1) months. Endoscopic retrograde cholangiography was attempted as initial therapy in all patients: 32 were managed entirely by endoscopic therapy, and 6 required initial percutaneous transhepatic cholangiography (PTC) to cross the biliary stricture, with endoscopic therapy performed thereafter. A median (IQR) of 4.0 (3.0-5.3) endoscopic interventions and 7.0 (4.0-10.3) stents were required to resolve the stricture. The time from the first intervention to stricture resolution was 5.3 (range 3.8-8.9) months. Biochemical markers including aspartate transaminase (76 vs 39 U/L, P = .001), alanine transaminase (127.5 vs 45.5 U/L, P < .001), alkaline phosphatase (590 vs 260 IU/L, P < .001), and total bilirubin (2.57 vs 1.73 mg/dL, P = .017) significantly improved after intervention. Recurrent stricture was observed after initial treatment in 8 (21%) patients. All recurrences were successfully re-treated endoscopically. All patients have been managed without surgical revision or retransplantation, resulting in 100% success by an intention-to-treat analysis.


      Retrospective study, small sample size.


      In this series, aggressive endoscopy-based treatment with maximal stent placement strategy allows 100% resolution of all duct-to-duct ABSs after LDLT without the need for surgical intervention or retransplantation.


      ABS (anastomotic biliary stricture), DDLT (deceased donor liver transplantation), ERC (endoscopic retrograde cholangiography), HIDA (hepatobiliary iminodiacetic acid), IQR (interquartile range), LDLT (living donor liver transplantation), PTC (percutaneous transhepatic cholangiography)
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        • Berg C.L.
        • Merion R.M.
        • Shearon T.H.
        • et al.
        Liver transplant recipient survival benefit with living donation in the MELD allocation era.
        Hepatology. 2011; 54: 1313-1321
        • Chok K.S.
        • Chan S.C.
        • Cheung T.T.
        • et al.
        Bile duct anastomotic stricture after adult-to-adult right lobe living donor liver transplantation.
        Liver Transpl. 2011; 17: 47-52
        • Krok K.L.
        • Cardenas A.
        • Thuluvath P.J.
        Endoscopic management of biliary complications after liver transplantation.
        Clin Liver Dis. 2010; 14: 359-371
        • Kato H.
        • Kawamoto H.
        • Tsutsumi K.
        • et al.
        Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction.
        Transpl Int. 2009; 22: 914-921
        • Qian Y.B.
        • Liu C.L.
        • Lo C.M.
        • et al.
        Risk factors for biliary complications after liver transplantation.
        Arch Surg. 2004; 139: 1101-1105
        • Spada M.
        • Cescon M.
        • Aluffi A.
        • et al.
        Use of extended right grafts from in situ split livers in adult liver transplantation: a comparison with whole-liver transplants.
        Transplant Proc. 2005; 37: 1164-1166
        • Gomez C.M.
        • Dumonceau J.M.
        • Marcolongo M.
        • et al.
        Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation.
        Transplantation. 2009; 88: 1280-1285
        • Duailibi D.F.
        • Ribeiro Jr, M.A.
        Biliary complications following deceased and living donor liver transplantation: a review.
        Transplant Proc. 2010; 42: 517-520
        • Lee Y.Y.
        • Gwak G.Y.
        • Lee K.H.
        • et al.
        Predictors for the feasibility of primary endoscopic management of biliary strictures after adult living donor liver transplantation.
        Liver Transpl. 2011; 17: 1467-1473
        • Rossi A.F.
        • Grosso C.
        • Zanasi G.
        • et al.
        Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation.
        Endoscopy. 1998; 30: 360-366
        • Kim T.H.
        • Lee S.K.
        • Han J.H.
        • et al.
        The role of endoscopic retrograde cholangiography for biliary stricture after adult living donor liver transplantation: technical aspect and outcome.
        Scand J Gastroenterol. 2011; 46: 188-196
        • Seo J.K.
        • Ryu J.K.
        • Lee S.H.
        • et al.
        Endoscopic treatment for biliary stricture after adult living donor liver transplantation.
        Liver Transpl. 2009; 15: 369-380
        • Yazumi S.
        • Yoshimoto T.
        • Hisatsune H.
        • et al.
        Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis.
        J Hepatobiliary Pancreat Surg. 2006; 13: 502-510
        • Costamagna G.
        • Pandolfi M.
        • Mutignani M.
        • et al.
        Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents.
        Gastrointest Endosc. 2001; 54: 162-168
        • Wang S.F.
        • Huang Z.Y.
        • Chen X.P.
        Biliary complications after living donor liver transplantation.
        Liver Transpl. 2011; 17: 1127-1136
        • Pasha S.F.
        • Harrison M.E.
        • Das A.
        • et al.
        Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy.
        Gastrointest Endosc. 2007; 66: 44-51
        • Tabibian J.H.
        • Asham E.H.
        • Goldstein L.
        • et al.
        Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures.
        Gastrointest Endosc. 2009; 69: 1236-1243
        • Morelli J.
        • Mulcahy H.E.
        • Willner I.R.
        • et al.
        Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement.
        Gastrointest Endosc. 2003; 58: 374-379
        • Morelli G.
        • Fazel A.
        • Judah J.
        • et al.
        Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures.
        Gastrointest Endosc. 2008; 67: 879-885
        • Sanna C.
        • Giordanino C.
        • Giono I.
        • et al.
        Safety and efficacy of endoscopic retrograde cholangiopancreatography in patients with post-liver transplant biliary complications: results of a cohort study with long-term follow-up.
        Gut Liver. 2011; 5: 328-334
        • Tzakis A.G.
        • Gordon R.D.
        • Shaw Jr, B.W.
        • et al.
        Clinical presentation of hepatic artery thrombosis after liver transplantation in the cyclosporine era.
        Transplantation. 1985; 40: 667-671
        • Sanchez-Urdazpal L.
        • Gores G.J.
        • Ward E.M.
        • et al.
        Diagnostic features and clinical outcome of ischemic-type biliary complications after liver transplantation.
        Hepatology. 1993; 17: 605-609
        • Greif F.
        • Bronsther O.L.
        • Van Thiel D.H.
        • et al.
        The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation.
        Ann Surg. 1994; 219: 40-45
        • Schwartz D.A.
        • Petersen B.T.
        • Poterucha J.J.
        • et al.
        Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation.
        Gastrointest Endosc. 2000; 51: 169-174
        • Rizk R.S.
        • McVicar J.P.
        • Emond M.J.
        • et al.
        Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival.
        Gastrointest Endosc. 1998; 47: 128-135
        • Van Thiel D.H.
        • Fagiuoli S.
        • Wright H.I.
        • et al.
        Biliary complications of liver transplantation.
        Gastrointest Endosc. 1993; 39: 455-460
        • Graziadei I.W.
        • Schwaighofer H.
        • Koch R.
        • et al.
        Long-term outcome of endoscopic treatment of biliary strictures after liver transplantation.
        Liver Transpl. 2006; 12: 718-725
        • Mahajani R.V.
        • Cotler S.J.
        • Uzer M.F.
        Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation.
        Endoscopy. 2000; 32: 943-949
        • Thuluvath P.J.
        • Atassi T.
        • Lee J.
        An endoscopic approach to biliary complications following orthotopic liver transplantation.
        Liver Int. 2003; 23: 156-162
        • Chang J.H.
        • Lee I.S.
        • Choi J.Y.
        • et al.
        Biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis: long-term outcome and its related factors after endoscopic treatment.
        Gut Liver. 2010; 4: 226-233