Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Pathophysiol. May 15, 2017; 8(2): 77-86
Published online May 15, 2017. doi: 10.4291/wjgp.v8.i2.77
Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome
Harshavardhan B Rao, Hasim Ahamed, Suprabha Panicker, Surendran Sudhindran, Rama P Venu
Harshavardhan B Rao, Hasim Ahamed, Suprabha Panicker, Rama P Venu, Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, Kerala 682041, India
Surendran Sudhindran, Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala 682041, India
Author contributions: Ahamed H and Panicker S helped in subject recruitment and data entry of the study; Rao HB and Venu RP were involved with data analysis, interpretation and drafted the manuscript; Sudhindran S revised the article critically for important intellectual content.
Institutional review board statement: The study was reviewed and approved by the Amrita Institute of Medical sciences Research Review Board (Kochi, Kerala, India).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrolment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Rama P Venu, Professor and Head, Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara AIMS PO, Kochi, Kerala 682041, India. ramapvenu@yahoo.com
Telephone: +91-75-61090937
Received: January 28, 2017
Peer-review started: February 14, 2017
First decision: March 7, 2017
Revised: March 23, 2017
Accepted: April 18, 2017
Article in press: April 19, 2017
Published online: May 15, 2017
Processing time: 107 Days and 11.4 Hours

To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT).


Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.


Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome (P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis (P < 0.05).


Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.

Keywords: Biliary strictures, Living donor liver transplantation, Endotherapy, Bile leaks

Core tip: Living donor liver transplantation (LDLT) is the definitive treatment for end stage liver disease. Biliary complications complicating LDLT is a major source of morbidity and mortality. Anastomotic strictures seen with LDLT are notorious for gross phenotypical variations which have led to variable results with endotherapy as a treatment option in these patients. In this study, we have looked into the factors that can predict the response with endotherapy (endoscopic retrograde cholangiography, sphincterotomy and stent placement) thereby allowing for better prognostication and selection of patients in order to optimize patient care.