title: Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation.
abstract: Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
authors.affiliation: Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.
authors.forename: Jae Hyuck
authors.initials: JH
authors.lastname: Chang
authors.affiliation: Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.
authors.forename: Inseok
authors.initials: I
authors.lastname: Lee
authors.affiliation: Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.
authors.forename: Myung-Gyu
authors.initials: MG
authors.lastname: Choi
authors.affiliation: Jae Hyuck Chang, Inseok Lee, Myung-Gyu Choi, Sok Won Han, Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 137-701, South Korea.
authors.forename: Sok Won
authors.initials: SW
authors.lastname: Han
mesh_terms: D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000295:instrumentation; D002779:Cholestasis / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy*; D003251:Constriction, Pathologic; D004106:Dilatation; D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods*; D019520:Living Donors; D011237:Predictive Value of Tests; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome
keywords: Biliary complication; Biliary strictures; Endoscopic retrograde cholangiography; Living donor liver transplantation; Percutaneous transhepatic cholangiography
references.citation: Transplantation. 2008 Nov 27;86(10):1468-9
references.pmid: 19034019
references.citation: Liver Transpl. 2009 Feb;15(2):263-5
references.pmid: 19177445
references.citation: Transplantation. 2003 May 27;75(10):1659-63
references.pmid: 12777852
references.citation: J Vasc Interv Radiol. 2005 Feb;16(2 Pt 1):241-5
references.pmid: 15713925
references.citation: Gastrointest Endosc. 2002 Feb;55(2):224-31
references.pmid: 11818927
references.citation: Ann Surg. 2007 Jan;245(1):110-7
references.pmid: 17197973
references.citation: Liver Transpl. 2011 Jan;17(1):47-52
references.pmid: 21254344
references.citation: Liver Transpl. 2006 May;12(5):831-8
references.pmid: 16528711
references.citation: Transplantation. 2009 Jun 15;87(11):1672-80
references.pmid: 19502959
references.citation: Surg Radiol Anat. 1988;10(4):311-6
references.pmid: 3145573
references.citation: N Engl J Med. 2003 Feb 27;348(9):818-25
references.pmid: 12606737
references.citation: Clin Transplant. 1997 Jun;11(3):209-13
references.pmid: 9193844
references.citation: Liver Transpl. 2007 Aug;13(8):1168-73
references.pmid: 17663414
references.citation: Dig Dis. 2008;26(4):324-9
references.pmid: 19188723
references.citation: Gastrointest Endosc. 2000 Jul;52(1):55-63
references.pmid: 10882963
references.citation: Clin Transplant. 2004 Dec;18(6):647-53
references.pmid: 15516238
references.citation: Transplantation. 2004 Mar 15;77(5):726-32
references.pmid: 15021836
references.citation: Endoscopy. 2005 Sep;37(9):857-63
references.pmid: 16116539
references.citation: Gut Liver. 2010 Jun;4(2):226-33
references.pmid: 20559526
references.citation: Gastrointest Endosc. 2010 Mar;71(3):505-12
references.pmid: 20189508
references.citation: Liver Transpl. 2010 Sep;16(9):1069-74
references.pmid: 20818745
references.citation: Gastrointest Endosc. 2003 Nov;58(5):777-84
references.pmid: 14595323
references.citation: Transpl Int. 2011 Apr;24(4):379-92
references.pmid: 21143651
references.citation: Gut Liver. 2010 Mar;4(1):68-75
references.pmid: 20479915
references.citation: Endoscopy. 2012 Dec;44(12):1158-60
references.pmid: 23188664
references.citation: Br J Surg. 1999 Apr;86(4):447-52
references.pmid: 10215812
references.citation: N Engl J Med. 2002 Apr 4;346(14):1074-82
references.pmid: 11932476
references.citation: Liver Transpl. 2006 Jun;12(6):920-7
references.pmid: 16721780
references.citation: Transplantation. 2003 Feb 15;75(3 Suppl):S12-5
references.pmid: 12589131
references.citation: Transpl Int. 2008 Apr;21(4):320-7
references.pmid: 18069923
references.citation: Endoscopy. 2008 Sep;40(9):746-51
references.pmid: 18702031
references.citation: J Gastroenterol. 2013 Sep;48(9):1097-104
references.pmid: 23325164
references.citation: Liver Transpl. 2006 May;12(5):718-25
references.pmid: 16482553
references.citation: J Am Coll Surg. 1994 Aug;179(2):177-81
references.pmid: 8044387
references.citation: Clin Transplant. 2015 May;29(5):465-74
references.pmid: 25740227
references.citation: Gastrointest Endosc. 2008 Mar;67(3):446-54
references.pmid: 18294506
references.citation: South Med J. 1977 Apr;70(4):389-90
references.pmid: 322306
references.citation: HPB (Oxford). 2010 Mar;12(2):109-14
references.pmid: 20495654
references.citation: J Surg Res. 2009 Jan;151(1):85-8
references.pmid: 18674784
references.citation: Liver Transpl. 2006 Jun;12(6):979-86
references.pmid: 16721777
references.citation: J Hepatobiliary Pancreat Surg. 2006;13(6):517-24
references.pmid: 17139425
references.citation: Transplant Proc. 2013 Jul-Aug;45(6):2341-6
references.pmid: 23953547
references.citation: AJR Am J Roentgenol. 1988 Nov;151(5):943-6
references.pmid: 3051961
references.citation: Radiology. 2008 Jun;247(3):880-6
references.pmid: 18487540
references.citation: Endoscopy. 2012 May;44(5):536-8
references.pmid: 22370701
references.citation: Liver Transpl. 2011 Oct;17(10):1127-36
references.pmid: 21761548
references.citation: Liver Transpl. 2009 Dec;15(12):1766-75
references.pmid: 19938121
references.citation: Am J Surg Pathol. 2005 Mar;29(3):318-23
references.pmid: 15725799
references.citation: J Clin Gastroenterol. 2007 May-Jun;41(5):501-6
references.pmid: 17450034
references.citation: J Hepatobiliary Pancreat Surg. 2006;13(6):487-96
references.pmid: 17139421
references.citation: Ann Surg. 1992 Sep;216(3):344-50; discussion 350-2
references.pmid: 1417184
references.citation: Transplant Proc. 2005 Mar;37(2):1129-30
references.pmid: 15848645
references.citation: Gastroenterology. 2008 Aug;135(2):468-76
references.pmid: 18505689
references.citation: Clin Transplant. 2010 Sep-Oct;24(5):E137-44
references.pmid: 20047615
references.citation: J Vasc Interv Radiol. 2005 Sep;16(9):1263-7
references.pmid: 16151070
references.citation: Transpl Int. 1996;9(4):392-5
references.pmid: 8819276
references.citation: Scand J Gastroenterol Suppl. 2006;(243):89-101
references.pmid: 16782628
references.citation: Dig Dis Sci. 1992 May;37(5):689-96
references.pmid: 1563308
references.citation: Transplant Proc. 2012 Oct;44(8):2503-4
references.pmid: 23026631
references.citation: Clin Liver Dis. 2010 May;14(2):359-71
references.pmid: 20682241
references.citation: Gastrointest Endosc. 2008 May;67(6):879-85
references.pmid: 18178206
references.citation: Endoscopy. 2008 Sep;40 Suppl 2:E19-20
references.pmid: 18278720
references.citation: Dig Dis Sci. 2009 Jul;54(7):1386-402
references.pmid: 19085103
references.citation: Transplantation. 1998 Jan 27;65(2):193-9
references.pmid: 9458013
references.citation: World J Gastroenterol. 2012 Nov 7;18(41):5957-64
references.pmid: 23139613
references.citation: Expert Rev Gastroenterol Hepatol. 2015 Apr;9(4):529-38
references.pmid: 25583036
references.citation: Am J Transplant. 2003 Jul;3(7):885-90
references.pmid: 12814481
references.citation: Transplantation. 2012 Jul 15;94(1):e4-5
references.pmid: 22766729
references.citation: Gastrointest Endosc. 2013 May;77(5):679-91
references.pmid: 23473000
references.citation: Liver Transpl. 2006 May;12(5):702-4
references.pmid: 16628684
references.citation: Gastrointest Endosc. 2003 Jan;57(1):78-85
references.pmid: 12518136
references.citation: Endoscopy. 2012 Mar;44(3):246-50
references.pmid: 22354824
references.citation: Ann Surg. 1994 Jan;219(1):40-5
references.pmid: 8297175
references.citation: Liver Transpl. 2007 May;13(5):725-32
references.pmid: 17457935
references.citation: J Pediatr Surg. 2012 Jul;47(7):1399-403
references.pmid: 22813803
references.citation: Am J Gastroenterol. 2006 Oct;101(10):2230-6
references.pmid: 16952286
references.citation: Liver Transpl. 2006 Jan;12(1):88-94
references.pmid: 16382450
references.citation: Gastrointest Endosc. 2007 Jul;66(1):44-51
references.pmid: 17591473
references.citation: Endoscopy. 2009 Sep;41(9):781-6
references.pmid: 19693751
references.citation: Am J Transplant. 2007 Jan;7(1):161-7
references.pmid: 17227565
references.citation: Gastrointest Endosc. 2003 Sep;58(3):374-9
references.pmid: 14528211
references.citation: Clin Gastroenterol Hepatol. 2006 Oct;4(10):1296; author reply 1296
references.pmid: 17045213
references.citation: Gut Liver. 2010 Sep;4 Suppl 1:S96-8
references.pmid: 21103303
references.citation: Transplantation. 2002 Jun 27;73(12):1972-3
references.pmid: 12131702
references.citation: Gastrointest Endosc. 1998 Feb;47(2):128-35
references.pmid: 9512276
references.citation: World J Gastroenterol. 2009 Aug 14;15(30):3725-33
references.pmid: 19673012
references.citation: Br J Surg. 1998 Feb;85(2):202-7
references.pmid: 9501816
references.citation: Liver Transpl. 2009 Apr;15(4):369-80
references.pmid: 19326412
references.citation: Gastrointest Endosc. 2011 May;73(5):955-62
references.pmid: 21316670
references.citation: Transplantation. 2010 May 27;89(10):1276-82
references.pmid: 20216482
references.citation: Rev Gastroenterol Disord. 2005 Fall;5(4):206-14
references.pmid: 16369216
references.citation: Transplantation. 2009 Nov 15;88(9):1123-30
references.pmid: 19898209
references.citation: Surg Endosc. 1996 Oct;10(10):970-3
references.pmid: 8864087
references.citation: Liver Transpl. 2013 Feb;19(2):207-14
references.pmid: 23197399
references.citation: Transplantation. 2004 Jun 27;77(12):1842-8
references.pmid: 15223901
references.citation: Liver Transpl. 2011 Feb;17(2):159-66
references.pmid: 21280189
references.citation: Liver Transpl. 2008 Jan;14(1):73-80
references.pmid: 18161843
references.citation: J Gastroenterol Hepatol. 2014 Oct;29(10):1756-63
references.pmid: 24909190
references.citation: Hepatol Int. 2008 Dec;2(4):399-404
references.pmid: 19669315
references.citation: AJR Am J Roentgenol. 1987 Sep;149(3):485-9
references.pmid: 3303874
references.citation: Gut Liver. 2011 Jun;5(2):133-42
references.pmid: 21814591
references.citation: J Am Coll Surg. 2010 Jul;211(1):24-32
references.pmid: 20610245
references.citation: Ann Surg. 2001 Mar;233(3):432-7
references.pmid: 11224633
references.citation: Gastrointest Endosc. 2008 Nov;68(5):1013-5
references.pmid: 18534587
references.citation: Gastrointest Endosc. 2013 Jan;77(1):47-54
references.pmid: 23062758
references.citation: Br J Surg. 1997 May;84(5):620-3
references.pmid: 9171746
references.citation: World J Radiol. 2014 Jul 28;6(7):424-36
references.pmid: 25071883
references.citation: Transplantation. 2004 Jan 15;77(1):110-5
references.pmid: 14724444
references.citation: Liver Transpl. 2007 May;13(5):708-18
references.pmid: 17457932
references.citation: Gastrointest Endosc. 2012 Apr;75(4):783-9
references.pmid: 22325806
references.citation: Liver Transpl. 2013 May;19(5):482-98
references.pmid: 23417867
references.citation: Transpl Int. 2009 Sep;22(9):914-21
references.pmid: 19497069
references.citation: Ann Surg. 2005 Jun;241(6):905-16; discussion 916-8
references.pmid: 15912040
references.citation: Liver Transpl. 2000 Nov;6(6):710-4
references.pmid: 11084056
references.citation: Ann Surg. 2006 Apr;243(4):559-66
references.pmid: 16552210
references.citation: Liver Transpl. 2008 Jun;14(6):759-69
references.pmid: 18508368
references.citation: Transplantation. 2009 Feb 15;87(3):445-50
references.pmid: 19202452
references.citation: Gastrointest Endosc. 2008 Jun;67(7):1201-3
references.pmid: 18308314
references.citation: Gastrointest Endosc. 2000 Feb;51(2):169-74
references.pmid: 10650259
references.citation: J Hepatobiliary Pancreat Surg. 2006;13(6):502-10
references.pmid: 17139423
references.citation: Transplantation. 2008 Jun 15;85(11):1569-72
references.pmid: 18551061
references.citation: Liver Transpl. 2006 May;12(5):726-35
references.pmid: 16628689
references.citation: Liver Transpl. 2008 Mar;14(3):385-7
references.pmid: 18306384
references.citation: J Mater Sci Mater Med. 2006 Jul;17(7):611-7
references.pmid: 16770545