Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation

Background and Study Aims: Anastomotic biliary strictures are the most comm on cause of biliary obstruction following liver transplantation. We studied the efficacy and safety of endoscopic management of anastomotic strictures retrospectively. Patients and Methods: A stricture at choledocho-choledochal anastomosis was identified in 30 of 354 sequential adult liver-transplant recipients at ou r institution. Balloon dilation was performed in 29 patients and a stent wa s inserted across the anastomotic stricture in one patient at initial endos copy, A total of nine patients did not require further treatment; ten had r epeated dilation (median 2), A stent was placed for persistent anastomotic stricture in six patients and for other indications in four patients. Outco mes studied were improvement in cholestasis, stricture diameter, and need f or surgical treatment. Safety of therapy was assessed with nature and numbe r of procedural complications. Results: The median serum bilirubin level decreased from 3.25 mg/dl to 1.1 mg/dl (P < 0.001) and median alkaline phosphatase decreased from 451.5 IU/I to 125 IU/I (P = 0.001) following endoscopic therapy. Cholestasis improved in 26 of 30 patients with therapy, Of the remainder, three of three patien ts with concurrent nonanastomotic strictures and one patient with anastomot ic stricture and histologic evidence of rejection showed worsening cholesta sis at follow-up. Stricture diameter improved from a median of 2.5 mm to 7 mm (P < 0.001), Median follow-up was 17.9 months from the last therapeutic endoscopy. Five treatable, nonlethal complications occurred after 77 proced ures. None of the patients required surgery for anastomotic stricture durin g a follow-up period up to 58 months. Conclusions: Endoscopic management offers effective and safe treatment for posthransplantation anastomotic biliary strictures and avoids the need for surgical intervention.