Endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction

Biliary complications after living donor liver transplantation (LDLT) with duct-to-duct reconstruction are one of the most common postoperative complications, and they are associated with postoperative morbidity and mortality. Biliary strictures are a major issue among all biliary complications, and which still require resolution. Endoscopic procedures such as balloon dilation and stent deployment are available as primary therapies for patients with biliary strictures after LDLT. However, endoscopic procedures after LDLT are more technically demanding than those after deceased donor liver transplantation (DDLT) or other biliary operations because of anatomy-associated reasons. Endoscopic procedures include the endoscopic retrograde cholangiography, the passage of the guidewire through the strictures, the balloon dilation and the stent deployment. Each procedure has its own difficulties which we should overcome. Moreover, in LDLT, it is sometimes difficult to understand the run of the bile ducts due to rotation and hypertrophy of the transplant liver. Therefore, we should have the information from the surgeon about the type of sutures and the image inspection such as MRCP before endoscopic procedures. Since each case is different regarding the degree of the strictures and the run of the bile ducts, specific treatments are necessary on a case-by-case basis. To obtain more favorable outcomes, more effective procedures with refined devices need to be established.