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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2016; 22(4): 1593-1606
Published online Jan 28, 2016. doi: 10.3748/wjg.v22.i4.1593
Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation
Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han
Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea
Author contributions: Chang JH completed the literature search and wrote the first draft of the manuscript; Lee I devised the concept and revised the manuscript; Choi MG and Han SW reviewed and edited the manuscript.
Conflict-of-interest statement: The authors have no conflict of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Inseok Lee, MD, PhD, Associate Professor, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, South Korea.
Telephone: +82-2-22586022 Fax: +82-2-22582089
Received: April 28, 2015
Peer-review started: May 6, 2015
First decision: August 26, 2015
Revised: September 2, 2015
Accepted: October 12, 2015
Article in press: October 13, 2015
Published online: January 28, 2016

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.

Keywords: Biliary strictures, Living donor liver transplantation, Endoscopic retrograde cholangiography, Percutaneous transhepatic cholangiography, Biliary complication

Core tip: The small diameter and complex nature of the duct-to-duct reconstruction of the bile duct in living donor liver transplantation lead to more biliary strictures and difficulties in treatment. A high index of suspicion for the development of biliary stricture should be maintained in order to allow early recognition and early intervention. Nonsurgical methods have become standard therapy. Endoscopic management is generally very effective and has a low incidence of procedure-related complications. Technological advances with newer endoscopic techniques or instruments have continued and may offer the opportunity to widen the indication of endoscopic treatment and to manage more efficiently.