Published online Jun 10, 2015. doi: 10.4253/wjge.v7.i6.606
Peer-review started: September 24, 2014
First decision: December 17, 2014
Revised: February 22, 2015
Accepted: March 16, 2015
Article in press: March 18, 2015
Published online: June 10, 2015
Processing time: 268 Days and 14.1 Hours
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
Core tip: One third of liver transplant recipients are affected by biliary tract complications which are the major source of morbidity in these patients. Biliary-biliary (as opposed to bilio-enteric) anastomoses are first treated by endoscopy, with resolution of > 85% and > 75% of cases in deceased and living-donor transplant recipients, respectively. New stenting protocols and new designs of fully covered self-expandable metal stents are at the frontline of efforts aiming to reduce patient burden during treatment. Here, we discuss the latest developments in the endoscopic approaches to these complications.