Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions

Abstract

Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.

Keywords: Biliary strictures; Endoscopic management; Stenting; Self-expanding metal stents; Living donor liver transplantation

Core tip: Multiple lacunae exist in our current understanding of biliary strictures complicating living donor liver transplantation (LDLT). Although endoscopic management is regarded the mainstay of treatment, results are variable with multiple determinants of success. The definition of these strictures itself may need to be re-examined, from a mere narrowing on imaging studies to a more comprehensive approach which can signify functional impedance to bile flow. This review outlines the current practices of management and endeavours to incorporate novel concepts, such as functionally significant obstructions, endoscopic protocols and outcome definitions, into the wider understanding of endoscopic management for biliary strictures complicating LDLT.