To review a single-center experience of percutaneous biliary recanalization for liver transplantation-related benign biliary stricture, particularly focusing on the technical aspect

Twenty-three recipients of liver transplantation (LT) with 27 benign biliary strictures underwent percutaneous recanalization using a step-by-step technique from June 2017 to March 2020. The step-by-step technique includes a hairy wire or an usual 0.035-inch wire passage, a coaxial system, supporting catheters of various shapes and wires, and an extraluminal passage. The success rate of percutaneous biliary recanalization, degree of stricture, interval between LT and biliary recanalization, procedure time, number of sessions, and recanalization techniques were analyzed.

Among the 27 lesions, 26 (96 %) were successfully recanalized using a percutaneous approach without major complications. Of the 27 lesions, 8 were complete obstructions and 19 were partial obstructions. Consequently, the average interval between LT and biliary recanalization was 28.8 ± 42.7 months (range, 2–192 months). The average procedure time was 50 ± 65 min (range, 8–345 min). The average number of sessions was 1.4 ± 1 (range, 1–6). The case distribution for the used recanalization techniques was as follows: twelve cases utilized step 1, 10 utilized step 2, 4 utilized step 3, and only 1 case utilized step 4. The complete obstruction group required a more advanced technique and spent more recanalization time than the partial obstruction group.

The step-by-step percutaneous biliary recanalization technique had a high success rate without major complications. According to the patient’s biliary anatomy appropriate selection of an angled 5-Fr support catheter and wire is essential in increasing the recanalization success rate.

• Bile ducts
• Liver transplantation
• Percutaneous
• Recanalization
• Stricture

A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.

• Anastomotic stricture
• Benign biliary stricture
• Magnetic compression anastomosis

• Aged
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Bile Ducts/diagnostic imaging
• Bile Ducts/pathology
• Bile Ducts/surgery
• Bile Ducts, Intrahepatic/diagnostic imaging
• Bile Ducts, Intrahepatic/surgery
• Biliary Tract Surgical Procedures/adverse effects
• Biliary Tract Surgical Procedures/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholangitis/etiology
• Cholangitis/pathology
• Cholangitis/surgery
• Constriction, Pathologic/etiology
• Constriction, Pathologic/surgery
• Drainage/adverse effects
• Drainage/methods
• End Stage Liver Disease/etiology
• End Stage Liver Disease/surgery
• Female
• Humans
• Liver Cirrhosis, Biliary/complications
• Liver Cirrhosis, Biliary/surgery
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Living Donors
• Magnetics
• Postoperative Complications/etiology
• Postoperative Complications/pathology
• Postoperative Complications/surgery
• Tomography, X-Ray Computed

• Bile leaks
• Biliary strictures
• Endotherapy
• Living donor liver transplantation

• Biliary stricture
• Diagnostic accuracy
• Endoscopic retrograde cholangiopancreatography
• Liver transplant

Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.

• Biliary complication
• Endoscopic retrograde cholangiography
• Endoscopic management
• Living donor
• Liver transplantation

• Anastomosis, Surgical
• Anastomotic Leak/surgery
• Biliary Tract Diseases/surgery
• Biliary Tract Surgical Procedures/methods
• Catheterization
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Constriction, Pathologic
• Dilatation
• Endoscopy, Digestive System/methods
• Humans
• Liver Transplantation
• Living Donors
• Postoperative Complications/surgery
• Sphincter of Oddi Dysfunction/surgery
• Stents

Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.

• Living donor liver transplant
• Biliary complications
• Biliary strictures
• Endoscopic retrograde cholangiopancreatography
• Percutaneous transhepatic biliary drainage

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.

• Biliary strictures
• Living donor liver transplantation
• Endoscopic retrograde cholangiography
• Percutaneous transhepatic cholangiography
• Biliary complication

• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Cholestasis/diagnostic imaging
• Cholestasis/etiology
• Cholestasis/therapy
• Constriction, Pathologic
• Dilatation
• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Living Donors
• Predictive Value of Tests
• Risk Factors
• Stents
• Treatment Outcome

Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Liver transplantation

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Liver transplantation

• Biliary obstruction
• Biliary stricture
• Choledochocholedochostomy
• Choledochoenterostomy
• Magnetic compression anastomosis

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Orthotopic liver transplantation
• Surgical anastomosis