Biliary Complications after Liver Transplant: Timeline, Spectrum, Management Algorithm, and Prevention

Biliary complications are the most common complications seen after liver transplantation (LT) with an incidence ranging between 10 and 15% and increasing in the setting of increased access to living donor liver transplant and utilization of marginal grafts. Among the biliary complications, the most common are anastomotic strictures, nonanastomotic strictures, and biliary leaks, which have a variable time of presentation posttransplant. The risk factors for the development of biliary complications include surgical techniques, type of grafts, prolonged ischemia, primary disease etiology, and associated post-LT complications. The approach to a diagnosis in an appropriate clinical setting involves a stepwise approach involving clinical history, assessment of risk factors, biochemical abnormalities, and appropriate imaging. Therapeutic options revolve around endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage, with surgical intervention being reserved in case of failure of these modalities. Preventive strategies with machine perfusion techniques are promising, while use of T-tubes for prevention of complications remains controversial.