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

Core Tip: Liver transplantation is the current standard of care for end-stage liver disease. Biliary complications are the leading cause of morbidity and mortality among recipients and despite the advances in surgical techniques they are seen in up to 25% of cases. Surgery, interventional endoscopy and percutaneous approaches are the available therapeutic options. Endoscopic retrograde cholangiography when possible is the most recommended therapeutic modality, replacing more aggressive surgical interventions. New techniques such as cholangioscopy overcome many of the limitations of conventional endoscopy. This article discusses the most common post-transplant biliary complications and the advances in treatment modalities.