Algorithm for Non-Operative Management of Biliary Stricture after Living Donor Liver Transplantation

Background/Aim: Biliary stricture is one of the most important issues to be addressed after living donor liver transplantation (LDLT), but a standard approach remains to be established. The aim of this study was to evaluate the usefulness of the non-operative management in repairing post-LDLT biliary stricture. Methods: A total of 49 patients were referred for management of post-LDLT biliary stricture between July 2004 and September 2006. They underwent endoscopic retrograde cholangiopancreatography (ERCP) if hepatic arterial flow was patent on doppler sonography. If endoscopic therapy failed, percutaneous transhepatic drainage (PTBD) was performed to dilate the stricture. If percutaneous approach also failed, 3-dimentional abdominal computed tomography followed by repetitive PTBD was performed. Results: All 49 patients revealed patent hepatic arterial flow on dopper sonography. ERCP was performed for all patients, and 32 (65%) of them were successfully treated by endoscopy. The success rate of endoscopic treatment was not associated statistically with duration from LDLT to the time of stricture (p = 0.060). During follow-up with median periods of 14.5 months (range 2-28 months), five of the 32 patients developed restenosis, and these were relieved by repetitive endoscopic management. 11 of 17 patients with failed endoscopic therapy were converted to percutaneous intervention. 5 of the 11 patients were successfully managed by PTBD, and 4 of the remained failed 6 patients performed 3-dimentional abdominal computed tomography. They were successfully treated with repetitive PTBD of alternative branch approach. Conclusions: Endoscopic therapy is a feasible first-modality in the treatment of post-LDLT biliary stricture, and in failed cases, percutaneous approach can be deliberated. When percutaneous approach is failed, biliary tract examination such as 3-dimentional abdominal computed tomography can be helpful.