Endoscopic management of anastomotic stricture after living-donor liver transplantation

Article information

Korean J Intern Med. 2019;34(2):261-268
Publication date (electronic) : 2019 February 25
doi : https://doi.org/10.3904/kjim.2019.044
Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
Correspondence to Jimin Han, M.D. Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Namgu, Daegu 42472, Korea Tel: +82-53-650-3442 Fax: +82-53-624-3281 E-mail: jmhan@cu.ac.kr

This paper was contributed by The Korean Society of Gastrointestinal Endoscopy.

Received 2019 January 30; Accepted 2019 February 8.


The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.


Liver transplantation (LT) is a revolutionary treatment for patients with acute liver failure or end-stage liver disease, and it prolongs survival and allows for full recovery [1,2]. LT can be divided into deceased-donor and living-donor LT (DDLT and LDLT, respectively) according to the organ delivery method [3]. In Western countries, where social systems are well established to enable a smooth process of organ procurement from deceased donors, DDLT is the preferred procedure. In Eastern countries, where organ procurement systems are not well established and still developing, LDLT is more common [4,5].

The management of complications occurring after LT is very important for the patient and graft survival. Patients with complications post-LT may experience frequent hospitalization, increased treatment costs, and, rarely, liver failure. Biliary stricture is the most common (approximately 40%) biliary complication occurring after LT [6,7]. The incidence of biliary stricture is approximately 5% after DDLT and approximately 24% and 60% for left and right lobe grafts, respectively, after LDLT [8-10].

This article provides an overview of the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-LT biliary stricture, with a focus on anastomotic stricture (AS).


Bile duct epithelium is more vulnerable to ischemic damage compared with hepatocytes and the vascular endothelium. Such damage is a major cause of the development of biliary stricture after LT [11]. In addition, differences in the diameter between donor and recipient bile ducts are often large, and AS can occur frequently, depending on the surgeon’s skill and experience with duct-to-duct anastomosis in LDLT [12].


Biliary strictures occurring after LT can be anastomotic or non-anastomotic, with approximately 80% being AS [13]. ASs are usually isolated, localized (within 5 mm) to the anastomosis site, and formed over short ductal lengths [14]. Non-anastomotic strictures (NASs) account for approximately 10% to 25% of post-LT biliary strictures. Unlike ASs, they often develop at multiple sites and over greater lengths [15-17].


Established risk factors for AS include the operator’s low technical proficiency, a large difference between donor and recipient bile duct diameters, excessive anastomotic tension, frequent use of electrocautery for hemostasis, and concomitant infection [18-22]. Risk factors for NAS include hepatic artery injury or thrombosis, reversible bile duct fibrosis caused by prolonged ischemia, blood type incompatibility, and use of vasopressin in donors [18,23]. In rare cases, hepatitis C and cytomegalovirus may also be risk factors for NAS [24,25].


Post-LDLT biliary stricture is often accompanied by symptoms of obstructive jaundice, such as dark urine and pruritus. However, it is often asymptomatic. As most LT recipients take immunosuppressant drugs and/or show hepatic denervation, they rarely complain of abdominal pain, even when biliary stricture occurs [26-28].


Abnormalities on liver function tests, such as altered serum transaminase, bilirubin, alkaline phosphatase, and/or gamma-glutamyl transferase levels, are often found in patients with biliary stricture. However, such abnormalities can also reflect acute or chronic rejection, reactivation of underlying viral hepatitis, or drug-induced hepatitis. To determine the most appropriate treatment, further evaluation must be performed to confirm that abnormalities on liver function tests are caused by biliary stricture [12].



Ultrasonography (USG) i s a non-invasive imaging modality that enables observation of the intrahepatic bile ducts and confirmation of the surrounding vascular patency. However, USG is not suitable for confirmation of the presence of biliary stricture. Sharma et al. [29] reported that only 38% to 66% of biliary strictures occurring after LT are diagnosed successfully by USG. Therefore, diagnosis and screening for biliary stricture cannot be performed using USG alone.

Computed tomography

In recent years, multidetector computed tomography (CT) has been developed, and its resolution has improved. As a result, CT is used widely as a follow-up examination for patients after LT. It is also useful for the identification of non-biliary complications, such as fluid collection around the operation site. However, the utility of contrast-enhanced CT may be limited by the occurrence of adverse events related to the intravenously administered contrast agent [12]. Thus, development of a more stable and safer contrast agent is needed.

Magnetic resonance cholangiography

Magnetic resonance cholangiography (MRC) can be used to obtain detailed images of the whole biliary tract, and its sensitivity and specificity for the diagnosis of AS are both ≥ 90% [30,31]. In addition, the performance of unnecessary interventions can be reduced due to the high negative predictive value of MRC findings [32]. Thus, detailed observation of the biliary tract by MRC not only increases the success rate of interventions to treat biliary stricture but also reduces intervention-related complications. However, MRC has no therapeutic capability and is expensive.

Hepatobiliary scintigraphy

Hepatobiliary scintigraphy using 99m-technetium-labeled iminodiacetic acid has shown excellent accuracy for the diagnosis of bile leaks. However, studies have yielded inconsistent findings regarding its performance in the diagnosis of biliary stricture. Some authors have reported that the sensitivity and specificity of scintigraphy for the diagnosis of post-LT biliary stricture were 75% and 100%, respectively, whereas others have reported a sensitivity of only 60% [33,34]. These results suggest that the use of this imaging modality for the diagnosis of post-LT biliary stricture cannot be strongly recommended [35,36].



Biliary reconstruction in LDLT has been achieved using Roux-en-Y hepaticojejunostomy. In recent years, however, duct-to-duct anastomosis has been used in most cases. As a result, endoscopic management is feasible and can be attempted as first-line therapy for biliary stenosis occurring after LDLT [37,38]. New endoscopic accessories have been developed and endoscopic techniques improved during the past two decades, increasing the success rate of endoscopic management [39]. When NAS occurs post-LDLT, endoscopic management at all affected duct sites is practically impossible. Therefore, endoscopic management should be performed preferentially in patients with AS.

Conventional endoscopic management protocol

In general, selective cannulation of the bile duct is performed as in endoscopic retrograde cholangiography (ERC), and a guidewire is passed to the proximal side of the AS. Next, endoscopic sphincterotomy is performed. Subsequently, balloon dilation is used at the stricture site, and the AS is expanded using a Sohendra biliary dilation catheter or Sohendra stent retriever, as needed. Finally, a plastic stent is inserted into the stricture site. After 2 to 3 months, the stent is replaced by a stent of larger diameter [40-42].

Need for balloon dilatation

Balloon dilation is commonly used before insertion of a plastic stent into a stricture site. However, some endoscopists prefer to insert the stent directly, without dilation, in the first ERC procedure, and to use balloon dilation during the second ERC procedure, prior to stent exchange [12]. No study has shown that this method results in a better outcome compared with the conventional protocol, and further research is needed.

Need for endoscopic sphincterotomy

Endoscopic sphincterotomy may prevent post-ERC pancreatitis due to the blockage of pancreatic juice after the insertion of a plastic stent of large diameter [40]. However, the function of the sphincter of Oddi is lost irreversibly after this procedure, potentially resulting in duodenobiliary reflux, stent occlusion, and bacterial colonization in the biliary system [43-47]. For this reason, sphincterotomy may reduce the advantage of biliary reconstruction with duct-to-duct anastomosis in patients undergoing LDLT.

Recently, Isayama et al. [46] described the “inside stent method” for AS management. In this method, a plastic stent is placed across the AS without performing sphincterotomy, and the distal tip of the stent is positioned inside the bile duct. Using this method, Isayama et al. [46] inserted stents into the desired locations in 80% of 118 patients with post-LDLT AS and confirmed stricture resolution in 69% of the patients.

The performance of sphincterotomy may reduce the overall procedure time, as it facilitates the use of accessories and cannulation in subsequent ERC procedures. A prospective randomized controlled trial comparing the “inside stent method” with the conventional protocol is needed to establish the efficacy of this approach.

Ideal treatment interval

When stent exchange is performed every 2 to 3 months, according to the conventional protocol, approximately 1 year is needed to resolve an AS [22,47-51]. Therefore, several attempts have been made to shorten the duration of treatment.

Morelli et al. [52] performed stent exchange every 2 weeks, with a mean treatment duration of 3.6 months and a high (87%) success rate. In another study, stents with maximal diameters were inserted during the initial ERC procedure, and stent exchange was used only when stent occlusion occurred [53]. Neither of these studies involved follow-up of a large number of patients, and these methods cannot yet be recommended as standards of care.

Use of self-expanding metal stents

Because self-expanding metal stents (SEMSs) have larger diameters (up to 30 Fr) than those of plastic stents, their use is expected to achieve excellent resolution of various benign biliary strictures, including post-LDLT AS [54]. When uncovered SEMSs are used, occlusion due to the ingrowth of granulation tissue and other complications, such as pseudoaneurysm in surrounding vascular strictures, may occur [54-57]. The use of fully covered SEMSs (cSEMSs) can overcome these drawbacks but may result in occlusion of secondary branches of the bile duct and subsequent bile stasis [58]. In addition, cSEMSs have a migration rate of 16% to 33%, resulting in failure to expand the AS for a sufficient period of time and an increased number of ERC procedures [59,60]. In a recent study involving the use of a new cSEMS (Kaffes stent, Taewoong Medical, Seoul, Korea) with a central waist, a high treatment success rate (83%) and low migration rate (6%) were achieved [61]. Furthermore, the Kaffes stent can be moved into the endoscopy channel by grasping and pulling of the lasso (Fig. 1).

Figure 1.

Endoscopic management of a biliary anastomotic stricture (AS) using a fully covered self-expanding metal stent. (A) Cholangiography revealed the presence of a biliary AS (white arrow) after living-donor liver transplantation. (B) A fully covered self-expanding metal stent was placed across the AS. (C) Three months later, the metal stent was removed successfully through the duodenoscopy channel by pulling of the lasso. (D) Resolution of the AS (yellow arrow) was observed.

Long-term outcomes

The incidence of stricture recurrence during long-term follow-up after AS treatment using the conventional protocol is 12% to 30% (Table 1) [15,62-65]. However, the use of ERC to treat AS was introduced relatively recently, and longer-term follow-up studies are needed. In addition, existing studies have been criticized due to the heterogeneity of parameters such as donor age and endoscopic management protocols. Thus, no generalization can be made about the long-term outcomes of AS treatment post-LDLT.

Long-term outcomes of endoscopic management of biliary anastomotic strictures after living-donor liver transplantation

Overall survival after LDLT with or without AS

Several studies have shown that the occurrence of AS after LDLT does not affect overall survival [62,66]. Recently, Chok et al. [67] reported that the 1-, 3-, and 5-year survival rates did not differ between patients with AS (n = 55) and those without AS (n = 210; 97.3% vs. 91.4%, 90% vs. 85.3%, and 84.5% vs. 82.5%, respectively; p = 0.574).


LDLT is a fundamental treatment for patients with end-stage liver disease that can cure the disease without the need to wait for a deceased donor. The success rate of LDLT has been improved greatly by development of the surgical technique, use of immunosuppressant drugs, and accumulated experience in postoperative care. However, the occurrence of AS after LDLT remains a problem. In recent years, biliary reconstruction with duct-to-duct anastomosis has been performed, and ASs have been treated with ERC. Several new treatment protocols designed to ensure higher treatment success rates with shorter treatment durations have been developed. In the future, studies examining the use of diverse, novel endoscopic accessories and stents are expected.


No potential conflict of interest relevant to this article was reported.


1. Murray KF, Carithers RL Jr, ; AASLD. AASLD practice guidelines: evaluation of the patient for liver transplantation. Hepatology 2005;41:1407–1432.
2. Ahmed A, Keeffe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis 2007;11:227–247.
3. Lee SG. Asian contribution to living donor liver transplantation. J Gastroenterol Hepatol 2006;21:572–574.
4. Lo CM. Deceased donation in Asia: challenges and opportunities. Liver Transpl 2012;18:S5–7.
5. Rela M, Reddy MS. Living donor liver transplant (LDLT) is the way forward in Asia. Hepatol Int 2017;11:148–151.
6. Oh HC. Percutaneous transhepatic cholangioscopy in bilioenteric anastomosis stricture. Clin Endosc 2016;49:530–532.
7. Morioka D, Egawa H, Kasahara M, et al. Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases. Ann Surg 2007;245:315–325.
8. Lee HW, Shah NH, Lee SK. An update on endoscopic management of post-liver transplant biliary complications. Clin Endosc 2017;50:451–463.
9. Kawachi S, Shimazu M, Wakabayashi G, et al. Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Rouxen-Y hepaticojejunostomy biliary reconstruction. Surgery 2002;132:48–56.
10. Azoulay D, Marin-Hargreaves G, Castaing D, Bismuth H. Duct-to-duct biliary anastomosis in living related liver transplantation: the Paul Brousse technique. Arch Surg 2001;136:1197–1200.
11. Noack K, Bronk SF, Kato A, Gores GJ. The greater vulnerability of bile duct cells to reoxygenation injury than to anoxia. Implications for the pathogenesis of biliary strictures after liver transplantation. Transplantation 1993;56:495–500.
12. Rao HB, Prakash A, Sudhindran S, Venu RP. Biliary strictures complicating living donor liver transplantation: problems, novel insights and solutions. World J Gastroenterol 2018;24:2061–2072.
13. Thethy S, Thomson BN, Pleass H, et al. Management of biliary tract complications after orthotopic liver transplantation. Clin Transplant 2004;18:647–653.
14. Balderramo D, Navasa M, Cardenas A. Current management of biliary complications after liver transplantation: emphasis on endoscopic therapy. Gastroenterol Hepatol 2011;34:107–115.
15. Hsieh TH, Mekeel KL, Crowell MD, et al. Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc 2013;77:47–54.
16. Lee DW, Jo HH, Abdullah J, Kahaleh M. Endoscopic management of anastomotic strictures after liver transplantation. Clin Endosc 2016;49:457–461.
17. Chang JH, Lee IS, Choi JY, et al. Biliary stricture after adult right-lobe living-donor liver transplantation with duct-to-duct anastomosis: long-term outcome and its related factors after endoscopic treatment. Gut Liver 2010;4:226–233.
18. Koneru B, Sterling MJ, Bahramipour PF. Bile duct strictures after liver transplantation: a changing landscape of the Achilles' heel. Liver Transpl 2006;12:702–704.
19. Tung BY, Kimmey MB. Biliary complications of orthotopic liver transplantation. Dig Dis 1999;17:133–144.
20. Porayko MK, Kondo M, Steers JL. Liver transplantation: late complications of the biliary tract and their management. Semin Liver Dis 1995;15:139–155.
21. Testa G, Malago M, Broelseh CE. Complications of biliary tract in liver transplantation. World J Surg 2001;25:1296–1299.
22. Bourgeois N, Deviere J, Yeaton P, et al. Diagnostic and therapeutic endoscopic retrograde cholangiography after liver transplantation. Gastrointest Endosc 1995;42:527–534.
23. Colonna JO 2nd, Shaked A, Gomes AS, et al. Biliary strictures complicating liver transplantation. Incidence, pathogenesis, management, and outcome. Ann Surg 1992;216:344–350.
24. Guichelaar MM, Benson JT, Malinchoc M, Krom RA, Wiesner RH, Charlton MR. Risk factors for and clinical course of non-anastomotic biliary strictures after liver transplantation. Am J Transplant 2003;3:885–890.
25. Sankary HN, Rypins EB, Waxman K, et al. Effects of portacaval shunt and hepatic artery ligation on liver surface oxygen tension and effective hepatic blood flow. J Surg Res 1987;42:7–9.
26. Pascher A, Gerlach U, Neuhaus P. Bile duct strictures after liver transplantation. Curr Opin Gastroenterol 2014;30:320–325.
27. Thuluvath PJ, Pfau PR, Kimmey MB, Ginsberg GG. Biliary complications after liver transplantation: the role of endoscopy. Endoscopy 2005;37:857–863.
28. Verdonk RC, Buis CI, Porte RJ, Haagsma EB. Biliary complications after liver transplantation: a review. Scand J Gastroenterol Suppl 2006;243:89–101.
29. Sharma S, Gurakar A, Camci C, Jabbour N. Avoiding pitfalls: what an endoscopist should know in liver transplantation: part II. Dig Dis Sci 2009;54:1386–1402.
30. Katz LH, Benjaminov O, Belinki A, et al. Magnetic resonance cholangiopancreatography for the accurate diagnosis of biliary complications after liver transplantation: comparison with endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography: longterm follow-up. Clin Transplant 2010;24:E163–E169.
31. Cereser L, Girometti R, Como G, et al. Impact of magnetic resonance cholangiography in managing liver-transplanted patients: preliminary results of a clinical decision-making study. Radiol Med 2011;116:1250–1266.
32. Xu YB, Min ZG, Jiang HX, Qin SY, Hu BL. Diagnostic value of magnetic resonance cholangiopancreatography for biliary complications in orthotopic liver transplantation: a meta-analysis. Transplant Proc 2013;45:2341–2346.
33. Macfarlane B, Davidson B, Dooley JS, et al. Endoscopic retrograde cholangiography in the diagnosis and endoscopic management of biliary complications after liver transplantation. Eur J Gastroenterol Hepatol 1996;8:1003–1006.
34. Schwarzenberg SJ, Sharp HL, Payne WD, et al. Biliary stricture in living-related donor liver transplantation: management with balloon dilation. Pediatr Transplant 2002;6:132–135.
35. Kurzawinski TR, Selves L, Farouk M, et al. Prospective study of hepatobiliary scintigraphy and endoscopic cholangiography for the detection of early biliary complications after orthotopic liver transplantation. Br J Surg 1997;84:620–623.
36. Kim YJ, Lee KT, Jo YC, et al. Hepatobiliary scintigraphy for detecting biliary strictures after living donor liver transplantation. World J Gastroenterol 2011;17:2626–2631.
37. Mahajani RV, Cotler SJ, Uzer MF. Efficacy of endoscopic management of anastomotic biliary strictures after hepatic transplantation. Endoscopy 2000;32:943–949.
38. Rossi AF, Grosso C, Zanasi G, et al. Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation. Endoscopy 1998;30:360–366.
39. Schwartz DA, Petersen BT, Poterucha JJ, Gostout CJ. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 2000;51:169–174.
40. Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017;10:297–311.
41. Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016;8:461–470.
42. Ryu CH, Lee SK. Biliary strictures after liver transplantation. Gut Liver 2011;5:133–142.
43. van Berkel AM, van Marle J, Groen AK, Bruno MJ. Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy 2005;37:729–734.
44. Weickert U, Venzke T, Konig J, Janssen J, Remberger K, Greiner L. Why do bilioduodenal plastic stents become occluded? A clinical and pathological investigation on 100 consecutive patients. Endoscopy 2001;33:786–790.
45. Yasuda I, Tomita E, Enya M, Kato T, Moriwaki H. Can endoscopic papillary balloon dilation really preserve sphincter of Oddi function? Gut 2001;49:686–691.
46. Isayama H, Komatsu Y, Inoue Y, et al. Preserved function of the Oddi sphincter after endoscopic papillary balloon dilation. Hepatogastroenterology 2003;50:1787–1791.
47. Bergman JJ, van Berkel AM, Groen AK, et al. Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy. Gastrointest Endosc 1997;45:400–405.
48. Rerknimitr R, Sherman S, Fogel EL, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 2002;55:224–231.
49. Morelli J, Mulcahy HE, Willner IR, Cunningham JT, Draganov P. Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement. Gastrointest Endosc 2003;58:374–379.
50. Rizk RS, McVicar JP, Emond MJ, et al. Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival. Gastrointest Endosc 1998;47:128–135.
51. Thuluvath PJ, Atassi T, Lee J. An endoscopic approach to biliary complications following orthotopic liver transplantation. Liver Int 2003;23:156–162.
52. Morelli G, Fazel A, Judah J, Pan JJ, Forsmark C, Draganov P. Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures. Gastrointest Endosc 2008;67:879–885.
53. Tabibian JH, Asham EH, Han S, et al. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc 2010;71:505–512.
54. Nam HS, Kang DH. Current status of biliary metal stents. Clin Endosc 2016;49:124–130.
55. Kwon CI, Ko KH, Hahm KB, Kang DH. Functional self-expandable metal stents in biliary obstruction. Clin Endosc 2013;46:515–521.
56. Harada N, Shirabe K, Soejima Y, et al. Intrahepatic artery pseudoaneurysm associated with a metallic biliary stent after living donor liver transplantation: report of a case. Surg Today 2013;43:678–681.
57. Siriwardana HP, Siriwardena AK. Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture. Ann Surg 2005;242:10–19.
58. Tsujino T, Sugawara Y, Omata M. Management of biliary strictures after living donor liver transplantation. Gastrointest Endosc 2009;70:599–600.
59. Tal AO, Finkelmeier F, Filmann N, et al. Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial. Gastrointest Endosc 2017;86:1038–1045.
60. Kao D, Zepeda-Gomez S, Tandon P, Bain VG. Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review. Gastrointest Endosc 2013;77:679–691.
61. Jang SI, Sung SY, Park H, Lee KH, Joo SM, Lee DK. Salvage therapy using self-expandable metal stents for recalcitrant anastomotic strictures after living-donor liver transplantation. Therap Adv Gastroenterol 2017;10:297–309.
62. Seo JK, Ryu JK, Lee SH, et al. Endoscopic treatment for biliary stricture after adult living donor liver transplantation. Liver Transpl 2009;15:369–380.
63. Kato H, Kawamoto H, Tsutsumi K, et al. Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction. Transpl Int 2009;22:914–921.
64. Ranjan P, Bansal RK, Mehta N, et al. Endoscopic management of post-liver transplant billiary complications: a prospective study from tertiary centre in India. Indian J Gastroenterol 2016;35:48–54.
65. Kim TH, Lee SK, Han JH, et al. The role of endoscopic retrograde cholangiography for biliary stricture after adult living donor liver transplantation: technical aspect and outcome. Scand J Gastroenterol 2011;46:188–196.
66. Kyoden Y, Tamura S, Sugawara Y, et al. Incidence and management of biliary complications after adult-toadult living donor liver transplantation. Clin Transplant 2010;24:535–542.
67. Chok KS, Chan SC, Cheung TT, et al. Bile duct anastomotic stricture after adult-to-adult right lobe living donor liver transplantation. Liver Transpl 2011;17:47–52.

Article information Continued

Figure 1.

Endoscopic management of a biliary anastomotic stricture (AS) using a fully covered self-expanding metal stent. (A) Cholangiography revealed the presence of a biliary AS (white arrow) after living-donor liver transplantation. (B) A fully covered self-expanding metal stent was placed across the AS. (C) Three months later, the metal stent was removed successfully through the duodenoscopy channel by pulling of the lasso. (D) Resolution of the AS (yellow arrow) was observed.

Table 1.

Long-term outcomes of endoscopic management of biliary anastomotic strictures after living-donor liver transplantation

Study No. of patients No. of ERC Success rate of stricture resolution, % Duration of stent insertion, mon Follow-up duration, mon Recurrence rate, %
Hsieh et al. (2013) [15] 38 4.0 (3.0–5.3)a 100 5.3 (3.8–8.9)a 74.2 21.1
Seo et al. (2009) [62] 68 2.3 (1.6–3.0)b 64.5 6.8 (3.9–9.7)b 12 30
Kato et al. (2009) [63] 41 4 (1–11)a 51 16.6 (0.7–39.6)a - 13
Ranjan et al. (2016) [64] 10 4 (2–5)a 70 4 (2–12)a 9.5 20
Kim et al. (2011) [65] 147 6.3 (2.9–9.7)b 36.9 12.7 (3.2–22.2)b 21.1 11.5

ERC, endoscopic retrograde cholangiography.


Values are presented as median (range).


Values are presented as mean (range).