Aujla UI, Syed IA, Malik AK, Khan MMZ, Rafi K, Dar FS. Endoscopic management of post-living donor liver transplant anastomotic biliary strictures: A quaternary care transplant center experience. World J Gastrointest Endosc 2026; 18(5): 119587 [DOI: 10.4253/wjge.v18.i5.119587]
Corresponding Author of This Article
Imran Ali Syed, Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, One PKLI Avenue, Phase 6, DHA, Lahore 54100, Punjab, Pakistan. imranali.syed@pkli.org.pk
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Endosc. May 16, 2026; 18(5): 119587 Published online May 16, 2026. doi: 10.4253/wjge.v18.i5.119587
Endoscopic management of post-living donor liver transplant anastomotic biliary strictures: A quaternary care transplant center experience
Usman Iqbal Aujla, Imran Ali Syed, Ahmad Karim Malik, Muhammad Mohsin Zaman Khan, Kashif Rafi, Faisal Saud Dar
Usman Iqbal Aujla, Imran Ali Syed, Ahmad Karim Malik, Muhammad Mohsin Zaman Khan, Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54100, Punjab, Pakistan
Kashif Rafi, Department of Gastroenterology, Harrogate and District NHS Foundation Trust, Harrogate HG27SX, North Yorkshire, United Kingdom
Faisal Saud Dar, Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Punjab, Pakistan
Author contributions: Aujla UI contributed to conceptualization, study design, manuscript drafting, supervision of the study, critical revision of the manuscript, provided expert clinical insight and interpretation of findings and final approval; Syed IA contributed to literature review, manuscript drafting, and critical revision of the manuscript; Malik AK, Khan MMZ, and Rafi K contributed to data curation and formal analysis; Dar FS contributed to expert oversight for the manuscript and provided critical review; all authors read and approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of Pakistan Kidney and Liver Institute and Research Center (Approval No. 00672025).
Informed consent statement: Due to the retrospective nature of the research and utilization of anonymized data, the requirement for informed consent was waived.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement: Raw data is available upon reasonable request from the corresponding author at imranali.syed@pkli.org.pk.
Corresponding author: Imran Ali Syed, Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, One PKLI Avenue, Phase 6, DHA, Lahore 54100, Punjab, Pakistan. imranali.syed@pkli.org.pk
Received: February 2, 2026 Revised: April 4, 2026 Accepted: April 21, 2026 Published online: May 16, 2026 Processing time: 101 Days and 4.2 Hours
Abstract
BACKGROUND
Biliary complications are the Achilles heel of the living donor liver transplantation (LDLT) and compromise the graft survival and the overall survival. Anastomotic biliary strictures (ABS) are the most common and challenging complication within this category. While endoscopic retrograde cholangiopancreatography (ERCP) serves as the standard first-line treatment modality to navigate the strictures, intraductal cholangioscopy, percutaneous transhepatic cholangiography (PTC), and surgical approaches are reserved for the technically challenging cases where standard ERCP remains unsuccessful.
AIM
To investigate the prevalence of ABS across various biliary reconstructions in LDLT recipients and analyze the outcomes of endoscopic interventions.
METHODS
This retrospective cohort study was conducted between March 2019 and December 2024 at the Pakistan Kidney and Liver Institute & Research Centre. Among 820 LDLT recipients, 176 (21.5%) developed ABS and were included. Treatment outcomes were assessed in 114 patients following completion of therapeutic interventions and availability of follow-up data. Categorical data was compared using the χ2 test/Fisher’s exact test. Nominal data were analyzed using the t-test and the ANOVA test. Data was analyzed using IBM SPSS version 27.
RESULTS
Frequency of anastomotic biliary stricture was 16.2% (102 of 631), in single duct-duct anastomosis, 34.8% (56 of 161) in two duct-duct anastomosis, and 64.3% (18 of 28) where 2 ducts were reconstructed on a single patch. The dual duct reconstruction exhibited a higher risk for ABS development vs single duct anastomosis (odds ratio = 3.34, 95%CI: 2.33-4.78). A total of 792 ERCPs were performed in 176 patients. Only 114 (65%) cases completed the therapeutic course and were included in the treatment outcome analysis. Stricture resolution with endotherapy alone was achieved in 90.2%. PTC improved the overall stricture resolution rates to 99.1%. Stricture recurred among 15 (13.3%) patients. Procedure-related complications included cholangitis (2.4%), pancreatitis (2.3%), and bleeding in (1.52%); no perforation or death occurred.
CONCLUSION
In the LDLT setting, dual duct biliary reconstruction is strongly associated with ABS. ERCP is a highly effective, safe, and preferred modality for managing post-LDLT ABS.
Core Tip: Anastomotic biliary strictures (ABS) remain the most common and challenging biliary complication after living donor liver transplantation (LDLT). Dual duct biliary reconstruction in the LDLT setting is associated with a significantly high risk of stricture incidence and recurrence. Endoscopic retrograde cholangiopancreatography complemented with intraductal cholangioscopy (IDC) has emerged as a highly effective and safe treatment modality in managing complex biliary strictures. Knowledge and understanding of biliary reconstruction are critical in defining treatment strategies to achieve optimal outcomes. percutaneous transhepatic cholangiography is the preferred modality when endotherapy remains unsuccessful despite using IDC. Surgery serves as a rescue strategy when percutaneous and endoscopic approaches remain unsuccessful to address the ABS.
