Management of Post Liver Transplant Biliary Strictures

• Biliary anastomosis has long been considered the Achilles heel of orthotopic liver transplantation (OLT).
• Biliary strictures are the most frequently described complication, affecting 4% to 15% of patients after liver transplant.
• It can be anastomotic (85%) or nonanastomotic.
• Anastomotic strictures appear more often in living donor liver transplantation (LDLT) than in deceased donor liver transplant (DDLT), in the percentage of 13% to 36% and 5% to 15%, respectively.
• Prompt and systematic evaluation of abnormal liver enzymes after liver transplant surgery is crucial to identify biliary strictures at an early stage.
• Clinicians are advised to retain a high index of suspicion, especially in the first year after the transplant, and investigate all liver function abnormalities with a magnetic resonance cholangiopancreatography (MRCP) to allow early recognition.
• Endoscopic retrograde cholangiopancreatography should be used as the initial therapy for biliary strictures.
• Endoscopist must ascertain the full operative details of the biliary and liver anatomy.
• The rendezvous method, magnetic compression anastomosis and peroral cholangioscopy, endoscopic ultrasound guided-biliary drainage (EUS-BD) are options in difficult scenarios.