High-level biliary strictures after living-donor liver transplantation

High-level biliary strictures are defined as a narrowing at or around the bifurcation of the left and right hepatic ducts. Benign biliary stricture is a common complication after hepatobiliary surgery, such as liver transplantation (LT) or cholecystectomy. The incidence of biliary stricture is 25-32% after living-donor LT and <15% after deceased-donor LT. The causes of biliary strictures after LT vary depending on whether the stricture is anastomotic or non-anastomotic, and biliary strictures occur early or late after LT. The pathophysiology of biliary stricture involves the inflammatory response. The risk factors for biliary stricture after LT include postoperative bile leakage, female donor/male recipient combination, LT for acute liver failure, and ABO-compatible non-identical LT. Endoscopic management is the first-line treatment for benign biliary stricture balloon dilatation and is followed by insertion of multiple plastic stents or a fully covered self-expanding metal stent, which has a large diameter and requires a small number of procedures. If endoscopic treatment fails, surgery may be considered. Surgical treatment includes repair of the biliary anastomosis, conversion from duct-to-duct anastomosis to hepaticojejunostomy, and retransplantation.