title: Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India.
abstract: BACKGROUND
  Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures.
  
  
  METHODS
  We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated.
  
  
  RESULTS
  Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3%) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4-60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40%), asymptomatic elevation of liver enzymes in four (40%) and jaundice in two patients (20%). The median time from transplantation to the detection of the stricture was 12 months (2-42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2-5) endoscopic sessions and 3.4 (1-6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2-12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7-11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis.
  
  
  CONCLUSIONS
  Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.
authors.affiliation: Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India. piyushranjan70@gmail.com.
authors.forename: Piyush
authors.initials: P
authors.lastname: Ranjan
authors.affiliation: Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: Rinkesh Kumar
authors.initials: RK
authors.lastname: Bansal
authors.affiliation: Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: N
authors.initials: N
authors.lastname: Mehta
authors.affiliation: Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: S
authors.initials: S
authors.lastname: Lalwani
authors.affiliation: Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: V
authors.initials: V
authors.lastname: Kumaran
authors.affiliation: Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: M K
authors.initials: MK
authors.lastname: Sachdeva
authors.affiliation: Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: M
authors.initials: M
authors.lastname: Kumar
authors.affiliation: Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
authors.forename: S
authors.initials: S
authors.lastname: Nundy
mesh_terms: D000293:Adolescent; D000328:Adult; D001652:Bile Ducts / Q000473:pathology* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002779:Cholestasis / Q000601:surgery*; D003251:Constriction, Pathologic; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007194:India; D016031:Liver Transplantation / Q000009:adverse effects*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery*; D011446:Prospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D055815:Young Adult
keywords: Endotherapy for post-LDLT biliary stricture; Post-LDLT biliary stricture; Post-liver transplant biliary