Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Dec 24, 2017; 7(6): 349-358
Published online Dec 24, 2017. doi: 10.5500/wjt.v7.i6.349
Risk factors and clinical indicators for the development of biliary strictures post liver transplant: Significance of bilirubin
Elizabeth Ann Forrest, Janske Reiling, Geraldine Lipka, Jonathan Fawcett
Elizabeth Ann Forrest, Janske Reiling, Geraldine Lipka, Jonathan Fawcett, Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
Elizabeth Ann Forrest, Department of Surgery, Gold Coast Hospital and Health Service, Gold Coast, Queensland 4215, Australia
Janske Reiling, Jonathan Fawcett, Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
Janske Reiling, Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Queensland 4120, Australia
Janske Reiling, Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, AZ Maastricht 6202, The Netherlands
Janske Reiling, PA Research Foundation, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
Author contributions: Forrest EA, Reiling J and Fawcett J designed the research; Forrest EA, Reiling J and Lipka G performed the research; Forrest EA and Reiling J analyzed the data; Forrest EA wrote the paper; Reiling J, Lipka G and Fawcett J revised the manuscript prior to submission.
Institutional review board statement: The study was reviewed and approved by the Princess Alexandra Hospital (HREC/13/QPAH/382) and University of Queensland (UQ: 2015001248) Human Research Ethics Committee.
Informed consent statement: Approval was obtained from the Queensland Government to access confidential patient information, held by Queensland Health, for the Purpose of Research under the provision of section 280 of the Public Health Act 2005.
Conflict-of-interest statement: The authors of this study have no conflict of interests to disclose.
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: Elizabeth Ann Forrest, MD, BSc BA, Resident Medical Officer, Department of Surgery, Gold Coast Hospital and Health Service, 1 Hospital Boulevard, Southport, Gold Coast, Queensland 4215, Australia.
Telephone: +61-7-56870000 Fax: +61-7-56870098
Received: August 13, 2017
Peer-review started: August 14, 2017
First decision: September 4, 2017
Revised: September 18, 2017
Accepted: November 1, 2017
Article in press: November 2, 2017
Published online: December 24, 2017

To identify risk factors associated with the formation of biliary strictures post liver transplantation over a period of 10-year in Queensland.


Data on liver donors and recipients in Queensland between 2005 and 2014 was obtained from an electronic patient data system. In addition, intra-operative and post-operative characteristics were collected and a logistical regression analysis was performed to evaluate their association with the development of biliary strictures.


Of 296 liver transplants performed, 285 (96.3%) were from brain dead donors. Biliary strictures developed in 45 (15.2%) recipients. Anastomotic stricture formation (n = 25, 48.1%) was the commonest complication, with 14 (58.3%) of these occurred within 6-mo of transplant. A percutaneous approach or endoscopic retrograde cholangiography was used to treat 17 (37.8%) patients with biliary strictures. Biliary reconstruction was initially or ultimately required in 22 (48.9%) patients. In recipients developing biliary strictures, bilirubin was significantly increased within the first post-operative week (Day 7 total bilirubin 74 μmol/L vs 49 μmol/L, P = 0.012). In both univariate and multivariate regression analysis, Day 7 total bilirubin > 55 μmol/L was associated with the development of biliary stricture formation. In addition, hepatic artery thrombosis and primary sclerosing cholangitis were identified as independent risk factors.


In addition to known risk factors, bilirubin levels in the early post-operative period could be used as a clinical indicator for biliary stricture formation.

Keywords: Biliary stricture, Liver transplantation, Bilirubin, Anastomotic stricture, Ischemic type biliary lesion, Magnetic resonance cholangiopancreatography

Core tip: Biliary stricture formation post liver transplantation is a frequent cause for patient morbidity and mortality and is referred to as the Achilles’ Heel of transplant. Strictures can be anastomotic or non-anastomotic depending on their number and anatomical location. Early stricture identification is key to providing successful treatment options. Known risk factors for biliary stricture formation include surgical technique, bile leak, hepatic artery thrombosis, primary sclerosing cholangitis, donation after circulatory death donors and increased cold ischemic time. This study identifies risk factors and clinical indicators for the development of biliary strictures post liver transplantation. It also discusses the importance of bilirubin and its potential role when implementing surveillance tools for biliary stricture formation post-transplant.