Management of Biliary Strictures After Liver Transplantation

Abstract

Strictures of the bile duct are a well-recognized complication of liver transplant and account for more than 50% of all biliary complications after deceased donor liver transplant and living donor liver transplant. Biliary strictures that develop after transplant are classified as anastomotic strictures or nonanastomotic strictures, depending on their location in the bile duct. The incidence, etiology, natural history, and response to therapy of the 2 types vary greatly, so their distinction is clinically important. The imaging modality of choice for the diagnosis of biliary strictures is magnetic resonance cholangiopancreatography because of its high rate of diagnostic accuracy and limited risk of complications. Biliary strictures that develop after liver transplant may be managed with endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), or surgical revision, including retransplant. The initial treatment of choice for these strictures is ERC with progressive balloon dilation and the placement of increasing numbers of plastic stents. PTC and surgery are generally reserved for failures of endoscopic therapy or for anatomic variants that are not suitable for ERC. In this article, we discuss the classification of biliary strictures, their diagnosis, and the therapeutic strategies that can be used to manage these common complications of liver transplant.

Keywords: Anastomotic strictures; biliary dilation; biliary stenting; deceased donor liver transplant; endoscopic retrograde cholangiography; living donor liver transplant; nonanastomotic strictures.

Figure 1

Cholangiograms of anastomotic strictures in a deceased donor liver transplant (arrow, A) and a living donor liver transplant (arrows, B).

Figure 2

A cholangiogram showing access to a hepaticojejunos-tomy through single-balloon enteroscopy.

Figure 3

Cholangiograms showing an anastomotic stricture before endoscopic therapy (A) and with progressive stent placement to a maximum of 5 stents (B). Resolution of the stricture after progressive stent placement over a 9-month period (C).

Figure 4

Cholangiograms showing a nonanastomotic stricture before endoscopic therapy (arrow, A), with dilation (B), and with progressive stent placement (C). Resolution of the stricture after progressive stent placement (D).