Establishing a systematic endoscopic approach to the management of anastomotic biliary strictures is needed

Barkground 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-choledoch al anastomosis was identified in 30 of 354 sequential adult liver-transplan t recipients at our institution. Balloon dilation was performed in 29 patie nts and a stent was inserted across the anastomotic stricture in one patien t at initial endoscopy. A total of nine patients did not require further tr eatment; ten had repeated dilation (median 2). A stent was placed for persi stent anastomotic stricture in six patients and for other indications in fo ur patients. Outcomes studied mere improvement in cholestasis, stricture di ameter, and need for surgical treatment. Safety of therapy was assessed wit h nature and number 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/l to 125 IU/l (P=0.001) follo wing endoscopic therapy. Cholestasis improved in 26 of 30 patients with the rapy. Of the remainder, three of three patients with concurrent nonanastomo tic strictures and one patient with anastomotic stricture and histologic ev idence of rejection showed worsening cholestasis at follow-up. Stricture di ameter 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, nonle thal complications occurred after 77 procedures. None of the patients requi red surgery for anastomotic stricture during a follow-up period up to 58 mo nths. Conclusions: Endoscopic management offers effective and safe treatmen t for posttransplantation anastomotic biliary strictures and avoids the nee d for surgical intervention.