Biliary strictures following liver transplantation: past, present and preventive strategies

Biliary complications are still the major source of morbidity for liver transplant recipients. The reported incidence of biliary strictures is 5%-15% after deceased donor liver transplantation and 28%-32% after right-lobe live donor surgery. Presentation is usually within the first year, but the incidence is known to increase with longer follow-up. The anastomotic variant is due to technical factors, whereas the nonanastomotic form is due to immunological and ischemic events, which later may lead to graft loss. Endoscopic management of anastomotic strictures achieves a success rate of 70%-100%; it drops to 50%-75% for nonanastomotic strictures with a higher recurrence rate. Results of endoscopic maneuvers are disappointing for biliary strictures after live donor liver transplantation, and the success rate is 60%-75% for anastomotic strictures and 25%-33% for the nonanastomotic variant. Preventive strategies in the cadaveric donor include the standardization of the type of anastomosis and maintenance of a vascularized ductal stump. In right-lobe live donor livers, donor liver duct harvesting also involves a major risk. The concept of high hilar intrahepatic Glissonian dissection, dissecting the artery and the duct as one unit, use of microsurgical techniques for smaller ducts, use of ductoplasty, and flexibility in the performance of double ductal anastomosis are the critical components of the preventive strategies in the recipient. In the case of live donors, judicious use of intraoperative cholangiograms, minimal dissection of the hilar plate, and perpendicular transection of the duct constitute the underlying principals for obtaining a vascularized duct.