Shrestha UK. Mitigating challenges in endoscopic management of post-liver transplant biliary strictures. World J Gastrointest Endosc 2026; 18(7): 123520 [DOI: 10.4253/wjge.123520]
Corresponding Author of This Article
Umid K Shrestha, MD, PhD, Professor, Department of Gastroenterology and Hepatology, Nepal Mediciti Hospital, Bhaisepati, Ward No. 18, Lalitpur 44700, Bagmati, Nepal. umidshrestha@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
editorial
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World J Gastrointest Endosc. Jul 16, 2026; 18(7): 123520 Published online Jul 16, 2026. doi: 10.4253/wjge.123520
Mitigating challenges in endoscopic management of post-liver transplant biliary strictures
Umid K Shrestha
Umid K Shrestha, Department of Gastroenterology and Hepatology, Nepal Mediciti Hospital, Lalitpur 44700, Bagmati, Nepal
Author contributions: Shrestha UK contributed to the conceptualization and design, writing the original draft, and reviewing and editing.
AI contribution statement: AI tools were not used.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Corresponding author: Umid K Shrestha, MD, PhD, Professor, Department of Gastroenterology and Hepatology, Nepal Mediciti Hospital, Bhaisepati, Ward No. 18, Lalitpur 44700, Bagmati, Nepal. umidshrestha@gmail.com
Received: May 21, 2026 Revised: June 12, 2026 Accepted: June 17, 2026 Published online: July 16, 2026 Processing time: 57 Days and 2.4 Hours
Abstract
In this editorial, we comment on the paper from Aujla et al on this issue of World Journal of Gastrointestinal Endoscopy. Post-liver transplant biliary strictures (PTBS) can be anastomotic biliary stricture (ABS) and non-ABS, depending on their location in the biliary tree and ABS being the most encountered type. Endoscopic management of PTBS is the first-line therapeutic treatment, with a higher success rate for ABS. However, there are certain challenges encountered during the endoscopic therapy. Inability to pass the guidewire through dense, fibrotic anastomotic strictures is mitigated with the use of peroral cholangioscopy and aggressive dilation using high-pressure balloon dilation followed by placing multiple plastic stents (MPS). Traditional MPS requires three to five repeat endoscopic retrograde cholangiopancreatography over 12-24 months, which can be mitigated by using fully covered self-expandable metal stents (FCSEMS). The increased rate of migration of FCSEMS can be mitigated by the use of dedicated anti-migration stents with specialized flanges. In the case of Roux-en-Y hepaticojejunostomy, deep enteroscopy or rendezvous technique is used to access the ABS. A multidisciplinary approach with the close collaboration between transplant hepatologists, interventional endoscopists, transplant surgeons, and interventional radiologists is the cornerstone of the successful management of PTBS.
Core Tip: Post-liver transplant biliary strictures (PTBS) are divided into anastomotic and non-anastomotic biliary strictures. Endoscopic therapy with balloon dilation of stricture followed by the placement of multiple plastic stents or fully covered self-expandable metal stents is currently the first-line therapy for PTBS. In cases of stricture recurrence, repeat endoscopic therapy remains a highly effective option. However, endoscopic treatment encounters challenges in certain conditions, such as tight or tortuous stenosis and altered anatomy, which are mitigated through advanced techniques, specialized stent designs, peroral cholangioscopy, deep enteroscopy and multidisciplinary approaches, thereby achieving long-term stricture resolution and reducing the need for surgery.
