Post-liver transplant biliary complications: Current knowledge and therapeutic advances

Abstract

Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.

Keywords: Cholangioscopy; Endoscopic retrograde cholangiopancreatography; Liver transplantation; Living-donor liver transplantation; Percutaneous biliary interventions; Post-transplant biliary complications.

Figure 1

Endoscopic treatment of anastomotic stricture after living donor liver transplantation. A: Two plastic stents; and B: Occlusive cholangiogram after treatment.

Figure 2

Anastomotic stricture. A: Cholangiogram; B: Balloon dilation; and C: Multiple stent treatment.

Figure 3

Anastomotic stricture after living donor liver transplantation (right lobe). A: Guidewire insertion; B: Balloon dilation; C: Second guidewire insertion; and D: Stent placement (7Fr + 5Fr).

Figure 4

Complex anastomotic stricture. A: Impossible insertion of guidewire through a stricture; B: Guidewire insertion under direct visual control; and C: Guidewire inserted above anastomosis.

Figure 5

Digital cholangioscopy image of an anastomotic stricture.

Figure 6

Anastomotic leak. A: Guidewire insertion; and B: Stent placement (10Fr).

Figure 7

Multiple intrahepatic stones above anastomotic stricture. A: Fluoroscopic image; B: Digital cholangioscopic image; C: Electrohydraulic lithotripsy performance; and D: Fluoroscopic image after treatment.

Figure 8

Biliary cast syndrome. A: Fluoroscopic image; B: Magnetic resonance cholangiopancreatography; and C: Digital cholangioscopic image.