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. 2025 Aug 9;25(1):353.
doi: 10.1186/s12893-025-03106-1.

Post-endoscopic retrograde cholangiopancreatography cholangitis after endoscopic treatment of post-transplant biliary strictures: a retrospective study

Chengcheng Christine Zhang  1   2 , Ronald Koschny  3   4 , Christian Rupp  3   5 , Patrick Michl  3 , Arianeb Mehrabi  6 , Cyrill Wehling  3   4 , Marcus Kantowski  6   4 , Peter Sauer  3   4
Affiliations

Post-endoscopic retrograde cholangiopancreatography cholangitis after endoscopic treatment of post-transplant biliary strictures: a retrospective study

Chengcheng Christine Zhang et al. BMC Surg. .

Abstract

Background and aim: Biliary strictures after liver transplantation are associated with significant morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred approach. Post-ERCP cholangitis is a complication of this procedure. We aimed to evaluate the incidence of post-ERCP cholangitis in patients with post-transplant biliary strictures, their impact on survival, and identify potential risk factors.

Methods: This retrospective study evaluated liver transplant recipients with biliary strictures treated with balloon dilatation at defined intervals. Primary clinical endpoints were the incidence of post-ERCP cholangitis, overall survival, and identification of potential risk factors.

Results: Two hundred patients with a median follow-up period of 6 years (IQR 2-10 years) were included. Anastomotic and non-anastomotic strictures were diagnosed in 132 and 68 patients, respectively. Overall, 930 ERCP procedures were performed, and post-ERCP cholangitis was detected in 148 procedures (15.9%). Patients with post-ERCP cholangitis showed significantly worse overall survival rates (median, 9 vs. 15 years; log-rank test, p < 0.001), were significantly more frequently diagnosed with non-anastomotic strictures (44.6% vs. 25%; p = 0.004), and had significantly higher treatment failure rates (n = 24/92; 26.1% vs. n = 13/108; 12%; p = 0.02) compared to those without cholangitis. Independent risk factors for cholangitis included the presence of non-anastomotic strictures (OR 3.1), and first-time ERCP intervention with sphincterotomy (OR 6.31).

Conclusions: Post-ERCP cholangitis is a relevant complication of endoscopic treatment and is associated with the presence of non-anastomotic strictures and higher treatment failure rates. Since the success rate of endoscopic intervention in these complex strictures is limited, an optimized peri-interventional management and tailored antibiotic therapy may become particularly important for the further treatment and prognosis of these patients.

Keywords: Cholangitis; Cholestasis; Endoscopic retrograde cholangiopancreatography; Liver transplantation; Postoperative complications.

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Conflict of interest statement

Declarations. Consent for publication: Not Applicable. Competing interests: The authors declare no competing interests. Ethics approval statement: The study protocol and data acquisition and evaluation were approved by the local ethics committee of Heidelberg University (Heidelberg, Germany) (approval number S-043/2011). This study was conducted in accordance with the 1975 Declaration of Helsinki (6th revision, 2008) and Declaration of Istanbul. Consent for publication: Not Applicable. Clinical trial number: Not Applicable.

Figures

Fig. 1
Fig. 1
Overall survival rates of patients with post-ERCP cholangitis compared to patients without post-ERCP cholangitis. Kaplan−Meier analysis revealed a reduced median overall survival rate in patients with post-ERCP cholangitis compared to that in patients without post-ERCP cholangitis (9 vs. 15 years; log-rank test: p < 0.001). ERCP, endoscopic retrograde cholangiopancreatography
Fig. 2
Fig. 2
Overall survival rates of patients with anastomotic and non-anastomotic strictures depending on the occurrence of post-ERCP cholangitis. Kaplan−Meier analysis showed a significantly higher median overall survival rate in patients with anastomotic strictures than that in patients with non-anastomotic strictures (15 vs. 8 years; log-rank test: p = 0.03) (A). Although not statistically significant, further subgroup analysis in patients with non-anastomotic strictures revealed a reduced median overall survival rate in patients with post-ERCP cholangitis (7 years) compared to patients without post-ERCP cholangitis (14 years) (log-rank test: p = 0.55) (B), whereas the development of post-ERCP cholangitis in patients with anastomotic strictures resulted in significantly shorter overall survival rates (12 years vs. 16 years; log-rank test: p = 0.02) (C). ERCP, endoscopic retrograde cholangiopancreatography
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