Endoscopic Management of Biliary Strictures After Liver Transplantation: Current Evidence and Emerging Approaches

Liver transplantation is a definitive treatment for end-stage liver disease and can improve quality of life and long-term prognosis. However, postoperative biliary complications remain an important limitation to transplant outcomes, and biliary stricture is among the most prevalent. Patients may present with jaundice, abdominal pain, recurrent cholangitis, and abnormal liver function, while delayed treatment may progress to biliary cirrhosis or graft failure. Endoscopic retrograde cholangiopancreatography (ERCP) has become the first-line therapeutic approach because it is minimally invasive, repeatable, and limits adverse effects on the graft. This review summarizes the pathogenic mechanisms, clinical manifestations, diagnostic modalities, and endoscopic treatment strategies for biliary strictures after liver transplantation. It distinguishes anastomotic from non-anastomotic strictures and examines the roles of magnetic resonance cholangiopancreatography and ERCP in diagnosis and treatment. The review also discusses balloon dilation, multiple plastic stents, fully covered self-expandable metal stents, and emerging endoscopic techniques, with attention to treatment efficacy, recurrence, complications, and procedural burden. Current evidence supports the effectiveness of endoscopic management but remains limited by heterogeneous protocols and a lack of long-term randomized controlled trials. This review aims to support standardized management, improve clinical decision-making, and identify priorities for future research in this complex and clinically important post-transplant patient population.