Biliary Complications In Liver Transplantation Research Articles

Percutaneous Transhepatic Sphincterotome–Guided Management of Post–Living Donor Liver Transplant Biliary Anastomotic Stricture: An Innovative Approach

ABSTRACT Post–liver transplantation biliary complications remain a serious concern and are associated with reduced patient and graft survival. Among various biliary complications, anastomotic stricture (AS) is the most frequent and challenging one. The frequency of AS after living donor liver transplantation (LDLT) is higher as compared to deceased donor liver transplantation. The management involves endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage, but refractory cases necessitate surgical revision. We present a case of complex biliary AS in a 63-year-old man after LDLT. The conventional approaches including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and cholangioscope-guided interventions remained unsuccessful. An innovative approach using a wire-guided sphincterotome through percutaneous transhepatic route successfully managed the complex post-LDLT AS. This is perhaps the first reported case of novel utilization of sphincterotome through transhepatic route for the management of AS in LDLT, averting major surgical interventions with related morbidity and mortality.

The Usefulness of High-Magnification Loupe for Reducing Biliary Complications After Liver Transplantation

Despite advances in surgical techniques, biliary complications are still considered to be a technical "Achilles' heel" of liver transplantation (LT). The purpose of this study was to evaluate the effect of loupe magnification in reducing biliary complications after LT. From April 2017 to February 2022, LT was performed on 307 patients in our center. Among them, except for 3 patients who underwent hepaticojejunostomy, 304 adult patients with LT were enrolled. They were divided into 3 groups according to the loupe magnification: 2.5 times (×2.5 group, n = 105), 3.5 times (×3.5 group, n = 95), and 5.0 times (×5.0 group, n = 105). Biliary complications occurred in 63 (20.7%) patients. Anastomosis site leakage occurred in 37 patients (12.2%), and stricture occurred in 52 patients (17.1%). Anastomosis site leakage occurred in 15 patients (14.3%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 7 patients (6.7%) in the ×5.0 group (P = .097). Biliary stricture occurred in 26 patients (24.8%) in the ×2.5 group, 15 patients (16.0%) in the ×3.5 group, and 11 patients (10.5%) in the ×5.0 group (P = .021). Total biliary complications occurred in 31 patients (29.5%) in the ×2.5 group, 19 patients in the ×3.5 group (20.2%), and 13 patients in the ×5.0 group (12.4%) (P = .009). The use of a high magnification loupe can reduce biliary complications in liver transplantation. Further large-scale analyses of clinical data or randomized controlled trials are required to support this study.

Modern approaches to the diagnosis and treatment of biliary complications after liver transplantation (literature review)

Relevance. The choice of biliary anastomosis is the main factor determining the risk of developing biliary complications after orthotopic liver transplantation. The two most common forms of biliary tract reconstruction are choledocholedochostomy (duct-to-duct anastomosis) and choledochoeunostomy (connection of the bile duct to the jejunum). The choice of biliary tract reconstruction is determined by a variety of factors, including the underlying pathology of the liver, the size of the bile ducts of the donor and recipient, previous transplantation or previous biliary tract surgery, as well as the preferences of the surgeon performing the operation. Despite the correctly chosen method of reconstruction, complications such as strictures, lithiasis, biloma, and bile leakage occur infrequently.Objective: to present a review of the literature on methods of diagnosis and treatment of biliary complications after liver transplantation.Materials and methods. The analysis of literary sources in English and Russian from 2010 to 2023 on this topic in the databases PubMed, MEDLINE, Google Scholar was carried out. The review highlights clinical studies, as well as literature reviews on similar topics with an emphasis on the treatment and diagnosis of biliary complications.Conclusion. The problem of biliary complications of liver transplantation remains relevant and unresolved to the end. Noninvasive imaging techniques for complications arising after biliary tract surgery have prospects for development. The tactics of percutaneous, endoscopic and open interventions on the biliary graft tree require further improvement.

Surgical and Interventional Radiology Management of Vascular and Biliary Complications in Liver Transplantation: Narrative Review

AbstractLiver transplant patients require a multidisciplinary and personalized approach to optimize outcomes. Posttransplant complications can be devastating for the patient and can jeopardize graft survival. Therefore, a careful evaluation and stepwise decision-making process is necessary to determine the best strategy, whether it is surgical, interventional, or a combination of both. While access to liver transplant interventions in Latin America can be more limited compared with other parts of the world, many countries in the region have made significant progress in developing their liver transplant programs and improving the management of posttransplant complications. For example, in Brazil, specialized transplant centers and multidisciplinary teams have been established to reduce morbidity and improve graft survival rates. The article also explores the latest advancements in interventional radiology techniques, such as angioplasty, stent placement, and embolization, and how they can be used to successfully treat these complications. Overall, this article highlights the importance of a comprehensive approach to managing complications in liver transplant patients and emphasizes how individualized treatment plans can lead to improved outcomes, even in settings with limited resources.

Co-Relation between MELD Scoring System prior Living Donor Liver Transplantation and Occurrence of Post-Transplant Biliary Complications

Background Liver transplantation is considered the treatment of choice for patients with end stage liver disease who have failed standard medical and surgical therapy. The development of liver transplantation has revolutionized the field of hepatology and greatly improved the outlook of patients suffering from various liver diseases. The Model for EndStage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. It was initially developed to predict mortality within three months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure and was subsequently found to be useful in determining prognosis and prioritizing for receipt of a liver transplant. This score is now used by the United Network for Organ Sharing (UNOS) and Eurotransplant for prioritizing allocation of liver transplants instead of the older Child-Pugh score. Biliary tract complications are abundantly occurring post-operative, and they may include a variety of scenarios, as biliary leakage, ischemic bile duct injuries, and biliary stenosis. Aim of the Work Aim of the work is to study the relation between the Model of End Stage Liver Disease (MELD) scoring system and the occurrence of post liver transplantation biliary complications. Patients and Methods A combined retrospective and prospective cohort study was carried out. We retrospectively analyzed the available database of all patients that underwent LDLT, at Ain Shams Center of Organ Transplantation (ASCOT), during the period from January 2013 till May 2019, and suffered from post-operative biliary complications during the first 3 months Post-operative and correlated it with their MELD score before the operation. To do so, we studied 50 patients that are aged more than or equal 18 years old, any gender, that underwent living donor liver transplantation. We excluded patients with cholestatic liver disease and patients that underwent preoperative biliary intervention. All patients were subjected to complete history taking and thorough clinical examination, full laboratory workup, full radiological workup, post-operative cholangiography and Endoscopic retrograde colangio-pancreatography if needed.

Absorbable Biliary Stent as a Preventive Treatment of Biliary Complications in Liver Transplantation: A Pilot Study

Absorbable Biliary Stent as a Preventive Treatment of Biliary Complications in Liver Transplantation: A Pilot Study

Incidence of Ischemia Reperfusion Injury Related Biliary Complications in Liver Transplantation: Effect of Different Types of Donors

Liver transplantation from donors after circulatory death (DCD) is associated with considerable rates of primary nonfunction and ischemic-type biliary lesions. Compared with donation was after brain death (DBD), the biggest disadvantage of DCD is warm ischemia injury in the procurement stage. Donation after brain death followed by circulatory death (DBCD) is a unique practice in China. Such donors should donate according to the DCD procedure, that is, remove life support and donate after cardiac arrest. We retrospectively analyzed donor and recipient characteristics with preoperative and postoperative parameters according to 3 donation types to comprehensively describe incidence of ischemia reperfusion injury (IRI) related biliary complications among different donor type adult liver transplantation recipients. A total of 50 patients were included in this study (DBD group n=17, DCD group n=26, DBCD group n=7). Only 1 patient, whose donor type was DBCD was diagnosed with ischemic-type biliary lesions demonstrated cast and retrograde ascending cholangitis. Rates of primary graft non-function (DBD n=1, 5.9%; DCD n=2, 7.7%; DBCD, 0%; P=.546) were similar and total biliary complications (DBD n=1, 5.9%; DCD n=1, 3.8%; DBCD N=2, 28.6%; P=.042) were different. No differences were found regarding development of postreperfusion syndrome or coagulopathy in 3 groups. Compared with standard DBD donor, the clinical outcome of DCD donor liver transplantation was satisfactory, with no increase in the incidence of IRI, and, no difference in the incidence of ischemic bile duct complications. This work was carried out in compliance with the Helsinki Congress and the Declaration of Istanbul.

Current Safety and Feasibility of ERCP in Management of Early nd Late Post Liver Transplant Biliary Complications

Background: Biliary complications after living donor liver transplantation (LDLT) represent the most challengeable burden. Aim: We aimed to study safety and efficacy of the ERCP procedures in liver transplant patients. We additionally aimed to study the clinical and biochemical changes before and after ERCP. Patients & Methods: This was retrospective study: between April 2014 and December 2015, we reviewed medical records of 108 patients with LDLL. ERCP was indicated in 30 patients (28 males) at the National Liver Institute-Menoufia University hospital. Results: Stricture was the highest reported complication occurred in (56.6) %followed by leakage in (53.3), % stone formation in (6.6) %, dilatation of CBD (SOD) and cholangitis in (3.3) % for each. The frequencies of complication in every patient were: 1, 2 & > 2 complications in 21, 7 & 2 respectively. Timing of complications: in . 3 months 16 patients, 17 patients in 4-12 month, 3 patients>12 months. Post ERCP complications: mild pancreatitis and GIT bleeding in one patient for each, there were significant changes regarding all liver profile after LDLT before any complication and on the day of presentation (during complication) and one month after ERCP (p<0.05). Conclusion: ERCP was safe and effective in treatment of post liver transplant biliary complications.

Analysis of Adult to Adult Living Donor Liver Transplant Biliary Complications Using Non-Stented Biliary Anastomosis

Abstract Background biliary tract reconstruction during liver transplantation (LT) is the final technical step and the cornerstone of the procedure and is often performed by a duct-to-duct anastomosis. Rarely, recipient and donor biliary stump discrepancies or liver disease-related reasons could lead to a hepaticojejunostomy. Purpose To clarify the role of non-stented biliary anastmosis in reducing biliary complications in adult to adult living donor liver transplant and ending the era of using intraductal removable stent. Patients and Methods this is a retrospective Single arm Cohort study. Our study was performed in Egypt by following the results of 80 cases of adult to adult living donor liver transplant using non-stented biliary anastomosis in Airforce specialized hospitals and Nasser institute in Cairo. Study period was from July 2015 to June 2018. Results The rate of biliary complications in non-stented patients was 23/80 (27%), and (27%) is subdivided as follow; (18%-strictures, 9%-leaks, and 1%-mixed), ) . All biliary complications had been treated with successful outcome representing 20/23(87%), while persistent biliary complication was in 3 (13%). Treatments used in biliary complications were (ERCP n = 22, PTC n = 5, Rendezvous n = 2, Surgical biliary-reconstruction n = 2). Conclusion Stentless biliary anastomosis is a well established and trusted method in biliary reconstruction in adult living donor liver transplant and has a less complications than stented duct to duct biliary anastomosis and biliary-enteric anastomosis and allow better management of biliary complication if occurred.

Percutaneous Management of Posttransplant Biliary Complications

AbstractInterventional radiology plays a major role in the management of posttransplant biliary complications. This review aims to discuss biliary complications of liver transplantation and will outline the role of interventional radiology, diagnosis, and management of these problems.

Post Liver Transplant Biliary Complications and Management in Local University Hospital

Introduction Biliary complications have still remained as major problem after liver transplant (LT) and accepted as Achilles’ heel. Herein, we introduce our experience of biliary complications after LT in small volume center. Methods From November 2002 to July 2017, 100 patients underwent LT at Dongsan Medical center, Daegu, Korea. Among these patients, 60 patients underwent deceased donor liver transplant (DDLT) and 40 patients underwent living donor liver transplant (LDLT). Medical records of these patients were reviewed retrospectively Results Among these patients, biliary complications (bile leakage in 10 patients and bile duct stricture in 26 patients) were developed in 28 patients (28%). For the management of biliary complications, reoperation was performed in 2 patients for bile leakage, percutaneous transhepatic biliary drainage (PTBD) in 11 patients and endoscopic retrograde biliary drainage (ERBD) in 22 patients for bile leakage and biliary stricture. All patients were improved after treatment and followed up without biliary problem until now. Conclusion The rate of biliary complications in our center was comparable with that of other centers reported previously and the outcome of treatment was acceptable. Co-operation with interventionist and gastroenterologist is important to overcome biliary complications after liver transplant.

Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

Donation after circulatory death (DCD) liver transplantation (LT) reportedly yields inferior survival and increased complication rates compared with donation after brain death (DBD). We compare 100 consecutive DCD LT using a protocol that includes thrombolytic therapy (late DCD group) to an historical DCD group (early DCD group n = 38) and a cohort of DBD LT recipients (DBD group n = 435). Late DCD LT recipients had better 1- and 3-year graft survival rates than early DCD LT recipients (92% vs. 76.3%, p = 0.03 and 91.4% vs. 73.7%, p = 0.01). Late DCD graft survival rates were comparable to those of the DBD group (92% vs. 93.3%, p = 0.24 and 91.4% vs. 88.2%, p = 0.62). Re-transplantation occurred in 18.4% versus 1% for the early and late DCD groups, respectively (p = 0.001). Patient survival was similar in all three groups. Ischemic-type biliary lesions (ITBL) occurred in 5%, 3%, and 0.2% for early DCD, late DCD, and DBD groups, respectively, but unlike in the early DCD group, in the late DCD group ITBL was endoscopically managed and resolved in each case. Using a protocol that includes a thrombolytic therapy, DCD LT yielded patient and graft survival rates comparable to DBD LT.

Current Safety and Feasibility of ERCP in Management of Early and Late Post Liver Transplant Biliary Complications

Background: Biliary complications after living donor liver transplantation (LDLT) represent the most challengeable burden. Aim: Safety, feasibility, clinical and biochemical changes before and after treatment of biliary complications after LDLT. Patients & Methods: This was retrospective study: between April 2014 and December 2015, we reviewed medical records of 108 patients with LDLL. ERCP was indicated in 30 patients (28 males) at the National Liver Institute. Results: Stricture was the highest reported (56.7%) >leakage (53.3%) >dilatation of CBD (SOD), and cholangitis (3.3%). Post ERCP complication: pancreatitis and bleeding in one case for each. The frequencies of complication in every patient were: 1, 2 & 3 complications in 21, 7 & 2 respectively. Timing of complications: in ≤ 3 months 16 patients, 22 patients in 4-12 month, 3 patients>1 year. Post ERCP complications: mild pancreatitis and GIT bleeding in one patient for each, there were significant changes regarding all liver profile after LDLT before any complication and on the day of presentation (during complication) and between the last one and Follow up (one month) after ERCP (p<0.05). Conclusion: ERCP was safe and effective in treatment of post liver transplant biliary complications.

Thrombolytic protocol minimizes ischemic-type biliary complications in liver transplantation from donation after circulatory death donors.

Liver transplantation (LT) with donation after circulatory death (DCD) donors has been associated with a high rate of ischemic-type biliary strictures (ITBSs) and inferior graft survival. To investigate the impact of an intraoperative tissue plasminogen activator (tPA) on outcomes following DCD LT, we conducted a retrospective analysis of DCD LT at the Toronto General Hospital (TGH) and the Ochsner Medical Center (OMC). Between 2009 and 2013, 85 DCD LTs were performed with an intraoperative tPA injection (n = 30 at TGH, n = 55 at OMC), and they were compared with 33 DCD LTs without a tPA. Donor and recipient characteristics were similar in the 2 groups. There was no significant difference in the intraoperative packed red blood cell transfusion requirement (3.2 ± 3.4 versus 3.1 ± 2.3 U, P = 0.74). Overall, biliary strictures occurred less commonly in the tPA-treated group (16.5% versus 33.3%, P = 0.07) with a much lower rate of diffuse intrahepatic strictures (3.5% versus 21.2%, P = 0.005). After 1 and 3 years, the tPA group versus the non-tPA group had superior patient survival (97.6% versus 87.0% and 92.7% versus 79.7%, P = 0.016) and graft survival (96.4% versus 69.7% and 90.2% versus 63.6%, P < 0.001). In conclusion, a tPA injection into the hepatic artery during DCD LT reduces ITBSs and improves graft and patient survival without increasing the risk for bleeding.

Biliary complications in liver transplantation: Impact of anastomotic technique and ischemic time on short- and long-term outcome.

To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation. We retrospectively reviewed 200 patients of our newly established liver transplantation (LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side (SS), end-to-end (EE) anastomosis or hepeaticojejunostomy (HJ). Biliary complications (BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion (ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography (ERCP)]. Laboratory results included alanine aminotransferase (ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional (e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC. A total of 200 patients [age: 56 (19-72), alcoholic cirrhosis: n = 64 (32%), hepatocellular carcinoma: n = 40 (20%), acute liver failure: n = 23 (11.5%), cryptogenic cirrhosis: n = 22 (11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13 (6.5%), primary sclerosing cholangitis: n = 13 (6.5%), others: n = 25 (12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5% (n = 75) with anastomotic strictures (AS): n = 38 (19%), bile leak (BL): n = 12 (6%), biliary drain complication: n = 12 (6%); papillary stenosis (PS): n = 7 (3.5%), ITBL: n = 6 (3%). Clinically relevant were only 19% (n = 38). We established a comprehensive classification for AS with four grades according to clinical relevance. The reconstruction techniques [SS: n = 164, EE: n = 18, HJ: n = 18] showed no significant impact on the development of BCs in general (all n < 0.05), whereas in the HJ group significantly less AS were found (P = 0.031). The length of donor intensive care unit stay over 6 d had a significant influence on BC development (P = 0.007, HR = 2.85; 95%CI: 1.33-6.08) in the binary logistic regression model, whereas other reviewed variables had not [warm ischemic time > 45 min (P = 0.543), cold ischemic time > 10 h (P = 0.114), ALT init > 1500 U/L (P = 0.631), bilirubin init > 5 mg/dL (P = 0.595), donor age > 65 (P = 0.244), donor sex (P = 0.068), rescue organ (P = 0.971)]. 13% (n = 10) of BCs had no therapeutic consequences, 36% (n = 27) resulted in repeated lab control, 40% (n = 30) received ERCP and 11% (n = 8) surgical therapy. Fifteen (7.5%) patients developed cholangitis [AS (n = 6), ITBL (n = 5), PS (n = 3), biliary lesion BL (n = 1)]. One patient developed ITBL twelve months after LT and subsequently needed retransplantation. Rehospitalisation rate was 10.5 % (n= 21) [AS (n = 11), ITBL (n = 5), PS (n = 3), BL (n = 1)] with intervention or reinterventional therapy as main reasons. Retransplantation was performed in 5 (2.5%) patients [ITBL (n = 1), acute liver injury (ALI) by organ rejection (n = 3), ALI by occlusion of hepatic artery (n = 1)]. In total 21 (10.5%) patients died within the follow-up period. Out of these, one patient with AS developed severe fatal chologenic sepsis after ERCP. In our data biliary reconstruction technique and ischemic times seem to have little impact on the development of BCs.

Incidence of and risk factors for bile duct stones after living donor liver transplantation: An analysis of 100 patients.

Although bile duct stone (BDS) is one of the biliary complications of liver transplantation, analytical studies, particularly on living donor liver transplantation (LDLT) cases, are rare. This study aimed to clarify the incidence of and risk factors for BDS following LDLT. We retrospectively reviewed the medical records of 100 patients who underwent LDLT at our institute from August 2000 to May 2012, and analyzed their clinical characteristics and risk factors for BDS. Of these, 10 patients (10.0%) developed BDS during the observation period. The median follow-up period to BDS diagnosis was 45.5 months (range, 5-84) after LDLT. Univariate analysis revealed male sex, right lobe graft and bile duct strictures as factors that significantly correlated with BDS formation. Multivariate analysis revealed bile duct strictures (odds ratio, 7.17; P = 0.011) and right lobe graft (odds ratio, 10.20; P = 0.040) to be independent risk factors for BDS formation. One patient with BDS and biliary strictures succumbed to sepsis from cholangitis. In the present study, right lobe graft and bile duct strictures are independent risk factors for BDS formation after LDLT. More careful observation and monitoring are required in the patients with high-risk factors.

Risk factors of biliary complications after liver transplantation from donation after cardiac death

To analyze the risk factors for biliary complications of liver transplantation from donation after cardiac death (DCD). Clinical data of 109 patients undergoing liver transplantation from DCD in First Affiliated Hospital of Zhejiang University School of Medicine from October 2010 to October 2013 were studied retrospectively. The risk factors of biliary complications following DCD liver transplantation were analyzed. Twenty-four (22%) patients developed biliary complications after DCD liver transplantation. Univariate analysis showed that biliary complications were associated with warm ischemia time (P<0.001) and length of ICU stay (P=0.013), but not associated with ABO blood types match (P>0.05). Administration of inotropic agents and fatty liver increased the trend of biliary complications. Multivariate analysis demonstrated that warm ischemia time and length of ICU stay were independent risk factors for predicting biliary complications. Warm ischemia time and days of ICU stay are independent risk factors for predicting biliary complications after DCD liver transplantation.

Variation in the Incidence Biliary Complications in Liver Transplantation: Outcome and Economic Implications.

Background: Despite improvement in patient and graft outcomes following liver transplantation (LT), biliary complications (BC) remain a significant source of morbidity and expense. Using a novel data base linking OPTN registry data and Medicare claims, we report a national assessment of variation in the incidence of BC in transplant centers (TC) using brain dead (DBD) and cardiac death (DCD) donors. Methods: 16,286 LTs performed from 2002-8 were analyzed to identify BC, defined as having both a diagnosis (leak, stricture, cholangitis) and a procedure (IR, ERCP, surgery) for BC. Multivariate logistic models calculated the TC’s expected incidence of BC given donor and recipient factors. TCs observed to expected (O:E) ratios were calculated separately for DCD and DBD transplantation, assigned to quartiles, and correlated with clinical and financial outcomes Results: The incidence of BC varied widely between TC for both DBD (N=104 TCs) and DCD (N=42 TCs). BC following DBD LT ranged from 70% less than expected (O:E 0.3) to 1100% higher than expected (O:E: 11) which was greater than the range for DCDs (O:E 0.42-9.0). TCs with greater O:E ratios for BC in both DBD and DCD LT actually used lower risk organs and had similar MELD scores (table).Table: No Caption available.LT in TCs with the highest adjusted rates of BC was associated with increased post-transplant mortality after DCDs (Q4 vs Q1: OR 2.75 P<.001) and graft loss in DBDs (Q4 vs Q1 OR 1.2 p<.05). Incremental Medicare spending was $22,367 (p<.05) higher in TCs in the highest quartile of BC complications (DBD/DCD combined). Conclusion: The incidence of post-operative BC varies substantially across TCs nationally. High O:E ratios of BC are associated with higher graft loss, patient death, and Medicare spending.

Post Liver Transplant Biliary Complications in Deceased Donor Liver Grafts: Analysis of Preservation Solution.

Post Liver Transplant Biliary Complications in Deceased Donor Liver Grafts: Analysis of Preservation Solution.

Endoscopic Management of Post Liver Transplant Biliary Complications: A Prospective Study from Tertiary Centre in India

Background: Liver transplantation has become more common in India in last decades. Biliary complications after transplantation are common and have been termed as “Achilles heel” for liver transplantation. Role of endoscopic treatment in post transplant biliary stricture are unclear.