No need for surgery: endoscopic management of posttransplant biliary strictures in the modern era

Abstract

Background: Biliary strictures are a common source of morbidity following orthotopic liver transplantation (OLT). While traditional management has been biliary reconstruction with Roux-en-Y hepaticojejunostomy (RYHJ), advances in endoscopic and percutaneous therapies have made these non-operative interventions commonplace in the management of both early and late posttransplant strictures. We set out to evaluate our center’s experience with the management of biliary stricture following OLT. Methods: All OLTs from January 2013 to June 2018 at a single institution were reviewed from a prospectively-maintained database. Patients with biliary bypass prior to or at time of transplantation were excluded. All biliary anastomoses were performed as a choledochocholedochostomy without the use of stents or T-tubes. Patients with biliary strictures were identified, and patient demographics, donor and operative details, and postoperative outcomes were collected. Descriptive statistics are reported as medians and interquartile range (IQR). Groups were compared using Wilcoxon rank-sum test, and p-values <0.05 were considered statistically significant. Results: A total of 462 grafts were transplanted into 449 patients during the study period. Among the 462 transplants that occurred, the biliary stricture rate was 15.6% (n = 72), with 95.8% (n = 69) being anastomotic strictures and 22.2% (n = 16) associated with a concurrent biliary leak. All patients underwent initial attempt at endoscopic treatment. 57 patients (79.2%) achieved stricture resolution with endoscopy alone. Among this group, the median time to first endoscopic retrograde cholangiopancreatography (ERCP) was 28 days (13–80 days) and treatment included a median of 3 (2–4) ERCP interventions over a median 186 days (142–273 days). The interventions utilized during ERCP included sphincterotomy, balloon dilation, and stent placement (TABLE). Patients who underwent balloon dilation at the time of first ERCP were further out from transplantation compared to those who had balloon dilation deferred until subsequent ERCP (40 vs 16 days, p < 0.01), reflecting our practice of avoiding dilation on a new ductal anastomosis. However, balloon dilation at initial ERCP was not associated with quicker stricture resolution (186 days vs 174 days, p = 0.58). Overall, only 3 patients (4.2%) required additional “step up” intervention beyond ERCP – two patients were managed with percutaneous transhepatic cholangiography (PTC) catheter placement and only one patient underwent RYHJ over the entire experience for a refractory biliary stricture. Conclusion: In our experience with liver transplantation over 5.5 years, endoscopic management of posttransplant biliary strictures resulted in successful stricture resolution. While repeat endoscopies are required for treatment, a strategy of watchful waiting in collaboration with an experienced endoscopist may avert the need for surgical reconstruction.