Mitigating challenges in endoscopic management of post-liver transplant biliary strictures

Table 1 Risk factors for biliary complications after liver transplantation

Donor type: Transplanted liver from a living donor or a donation after cardiac (circulatory) death donor; older age of donor; high donor body mass index; macrovascular graft steatosis > 25%

Duct anatomy: Utilizing multiple donor bile ducts increases the complexity and risk of leaks or strictures compared to a single duct

Type of anastomosis: Duct-to-duct biliary anastomosis or Roux-en-Y hepaticojejunostomy carry specific, differing risks for biliary complications

Surgical or technical factors: Excessive dissection of the periductal tissue during the procurement or mobilization of the native liver; excessive use of electrocautery to control bleeding from the peribiliary tissues; presence of tension between the two ends of the biliary anastomosis that can lead to an incomplete seal and subsequently to leaks and formation of peri-hepatic abscesses; mismatched size between donor and recipient bile ducts; ischemia or reperfusion injury; prolonged cold and or warm ischemia times

Placement of T-tubes

Pre-LT cytomegalovirus infection

Diagnosis of primary sclerosing cholangitis as the primary indication for LT

LT performed between donors and recipients with ABO blood group incompatibility

Intra-abdominal infections in the perioperative period

Post-operative bile leak

LT: Liver transplantation.

Table 2 Primary causes and risk factors of non-anastomotic biliary stricture

Ischemic:

Macroangiopathic:

Hepatic artery thrombosis

Microangiopathic:

Prolonged cold and warm ischemia times

Donation after cardiac death

Prolonged use of vasopressors in the donor

Immunogenic:

Chronic rejection

ABO incompatibility

Primary sclerosing cholangitis

Autoimmune hepatitis