Evolving treatment of biliary strictures following liver transplantation.

BACKGROUND: The optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy. OBJECTIVE: To determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement. SETTING: Tertiary-care academic medical center. PATIENTS: Of 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures. INTERVENTIONS: Patients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement. MAIN OUTCOME MEASUREMENTS: Treatment outcomes, including bileduct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively. RESULTS: Endoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 or 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 or 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Medical duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P < .01). Multiple stent placement was not technically difficult, and no major complications were encountered. CONCLUSIONS: Aggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.