1. Presented by
Dr Zubin Sharma
Moderated by
Dr Rajesh Puri

2. Introduction
From 1960s, Liver Transplantation has
evolved into a standard of care for end
stage liver disease
The Biliary complications still remain
the Achillis heel.
Affect graft survival, has serious effects
on lifestyle of patients, an important
cause of morbidity and mortality.

3. Introduction
Endoscopic therapy now the treatment
of choice
Surgery remains a second choice for
most of these patients

4. Incidence
Biliary tract complications after OLT stand around
11-25%
Includes leaks, strictures, casts, sludge, stones and
sphincter of Oddi dysfunction
Biliary epithelium liable to ischemic damage
The reported incidence of biliary strictures is 5%-
15% after deceased donor liver transplantation
(DDLT)
28%-32% after right-lobe live donor liver
transplantation (LDLT).

5. Incidence- Literature
Review

6. Incidence- Literature
Review

7. Anatomy of Bile Ducts
Huang Classification is widely used for
variations in bile duct.
Right Hepatic duct is present in 65% of all
cases

9. Vascular Supply of Biliary tract
Most vulnerable point of biliary system
Liver parenchyma- Dual Blood Supply (Portal Vein and
Hepatic Artery)
Biliary Tract- only Arterial supply
The common bile duct is supplied via two main
arteries running at the right and left border of the
bile duct , the "3 o' clock“ and "9 o' clock“ arteries,
which
variably arise from the retroportal, retroduodenal or
gastroduodenal arteries and communicate with the right
or less often with the left hepatic artery
Severe hypotension can lead to Ischaemic cholangiopathy

10. Vascular Supply

11. Vascular Supply of Biliary tract
Approximately 60% of the arterial
perfusion comes from the
gastroduodenal, and only 30–40%
downward from the hepatic artery
The hilar and intrahepatic ducts are
nourished by the peribiliary vascular
plexus, a network of capillaries arising
from the terminal arterial branches

12. Types/Classification
Broadly divided into
Anastomotic Strictures (AS)
Non- Anastomotic Strictures (NAS)
The 2 types of strictures cannot be compared
as they have inherent differences in their
pathology, time to presentation, treatment, and
response to treatment

13. Types/Classification
NAS account for 10% to 25% of all stricture
complications after orthotopic liver transplantation,
with an incidence of 1% to 19%;
These are often multiple, longer and occur earlier
than anastomotic strictures.
AS, on the other hand, are isolated, are localized to
the site of the anastomosis, and are short in length.
Their reported incidence in the modern literature is
4% to 9%.

14. Types/Classification
Ling Classification- Based on
endoscopic pictures after LT.

17. Pathogenesis and Risk Factors
Anastomotic Strictures-EARLY
Ischemia and Fibrosis secondary to
suboptimal surgical technique
Small Caliber of bile ducts
Size mismatch
Inappropriate suture material
Tension at anastomosis
Excessive use of electrocautery

18. Pathogenesis and Risk Factors
Anastomotic Strictures- LATE
Ischemia at the end of donor or recipient
duct
Use of T-Tube??
LDLT vs DDLT
Duct to Duct anastomosis vs
hepaticojejunostomy

19. Pathogenesis and Risk Factors
Non-Anastomotic Strictures (NAS)
Moench et al. proposed a classification
NAS secondary to macroangiopathy
NAS secondary to microangiopathy
(preservation injury, prolonged cold and warm
ischemia times, donation after cardiac death, and
prolonged use of vasopressors in the donor)
LATE- Immunogenicity (chronic rejection, ABO
incompatibility, autoimmune hepatitis, and pri-
mary sclerosing cholangitis
Hepatitis C and cytomegalovirus

20. Non-Anastomotic Strictures (NAS)
Further Classifications
Buis et al. Have
suggested a classification
of the involved
intrahepatic zones A t o
D
Hilar bifurcation(zone A),
ducts between the first
and second-order
branches(B),
between second and third
order branches (C)
and in the periphery of
the liver(D)

22. Risk Factors in LDLT
Presence of Bile leaks- an important predictor-
Bile induced inflammation
Hwang et al- showed small duct size as risk
factor- not confirmed in subsequent studies
Multiple duct anastomosis
Recent meta-analysis showed older donor age
and presence of bile leaks in post operative
period as the only statistically significant risk
factors.
Use of UW solution- increased ischemia of
biliary arteries.
Increased Cold Ischemia time >11.5 hours

23. Presentation
Patients may be asymptomatic at presentation,
with elevations of serum aminotransferases,
bilirubin, alkaline phosphatase and/or gamma-
glutamyl transferase levels.
A high index of suspicion must be maintained,
as pain may be absent in the transplant setting
because of immunosuppression and hepatic
denervation
A recent report of 15 patients highlighted the
use of serum bilirubin >1.5 mg/dL as a better
indirect marker of biliary stasis in living donor
liver transplantation (LDLT) than alkaline
phosphatase, which is overly sensitive

24. Diagnosis
Liver ultrasound (US) with Doppler
evaluation of the hepatic vessels.
Lack of correlation between the ducal
dilatation on the ultrasound and the
cholangiographic and clinical features.
It is not clear why the donor bile ducts
do not respond to distal obstruction by
displaying the same degree of
proportional dilation as non transplanted
livers

25. Diagnosis
99-technetium labeled iminodiacetic acid
identifies strictures with 75% sensitivity
and 100% specificity.
MRCP is currently considered an
optimal noninvasive diagnostic tool for
the assessment of biliary complications
after orthotopic liver transplantation.
Cholangiography is considered by all to
be the gold standard.

26. MANAGMENT
AS
Endoscopic treatment consists of identification of
the opening of the stricture followed by
cannulation by the guidewire, balloon dilatation of
the stricture, and subsequent placement of plastic
stents.
Balloon dilation alone without stent placement is
only successful in approximately 40% of cases.
Balloon dilation with additional stent placement
appears to be more successful with a durable
outcome in 75% of patients with anastomotic
strictures

27. MANAGMENT
AS
Replaced by larger stents every 3 month to
prevent the complication of clogging, cholangitis,
or stone formation.
Dual or multiple stents, by providing greater
dilatation, have shown better results than single
stents
Most patients with anastomotic strictures require
ongoing ERCP sessions every 3 month with
balloon dilation of 6 to 10 mm and multiple stents
of 7 Fr to 10 Fr repeated for 12 to 24 months.

29. MANAGMENT
AS
An increasing number of stents can be used
at each session to achieve a maximum
diameter.
The treatment is usually completed in 1 year
with an average of 3 to 4 stent exchange
sessions
Endoscopic treatment success rates in AS
after LDLT appears significantly less than AS
for DDLT at 37% to 71%

30. MANAGMENT
AS
There is some experience in temporary placement
of covered self-expanding metal stents to reduce
the need for repeated stent exchanges but long
term results not identified.
In the few situations when endoscopic access to
the AS is not obtainable, as in Roux-en-Y
reconstructions,- Combined approach
A percutaneous transhepatic route followed by
“rendezvous” endoscopy
Surgical revision and biliary reconstruction with the
formation of a hepaticojejunostomy is indicated
when endoscopic or percutaneous treatment fails.

31. MANAGMENT
NAS
Management of patients with NAS is difficult,
and any generalized treatment
recommendations are difficult to make.
Accumulation of biliary sludge and casts
renders therapy particularly difficult because
of rapid stent occlusion.
NAS are more resistant to endoscopic
treatment, the results of endoscopic
approaches have been particularly
disappointing in the context of NAS in LDLT

32. MANAGMENT
NAS
The average success rate in LDLT varies from
25% to 33%
Endoscopic therapy of non-anastomotic strictures
typically consists of extraction of the biliary sludge
and casts and balloon dilation of all accessible
strictures followed by placement of plastic stents
with replacement every 3 month.
Patients with NAS may required early
retransplantation, endoscopic therapy appears to
play a more prominent role as a bridge to liver
retransplantation

33. ENDOSCOPY PROTOCOL

35. FUTURE DIRECTIONS
SPYGLASS Direct Visualization System
Peripheral cutting balloons may be more
effective in benign biliary stricture not
responsive to standard measures
Self-expanding stents made of
bioabsorbable material may offer several
advantages compared to the plastic and
self-expanding metal stents
Bioabsorbable stents can be impregnated
with pharmaceutical compounds, such as
antimicrobial and antineoplastic agents

36. Thank You….