Biliary Complications after Liver Transplant: Imaging Review and Minimally Invasive Management

Abstract With the advent of living donor liver transplant, the waiting list mortality of patients needing liver transplant has decreased. However, increased morbidity is observed, including higher rates of biliary complications (BCs). Strictures and postoperative leaks constitute the majority of the BCs. Various factors such as multiple biliary ducts anastomosis and small caliber ducts in the bile ducts increase the risk of biliary strictures. The lack of biliary dilation in the graft livers after liver transplant makes the recognition of biliary complications challenging and the diagnosis relies on abnormal liver function tests. Magnetic resonance cholangiopancreaticography provides a valuable means to assess the biliary anatomy prior to interventions by showing the level of stricture. While endoscopic retrograde cholangiopancreatography is considered the first modality to treat biliary strictures, those patients with proximal strictures and those with complex biliary anatomy with acute angulations between the donor and the recipient show poor response to endoscopic interventions. In such patients, percutaneous biliary interventions have success rates between 70 and 90%. Novel percutaneous biliary intervention techniques such as cholangioscopy-assisted laser incision and magnetic compression anastomosis are used to navigate difficult biliary strictures. Recently, biodegradable stents have been used to treat recalcitrant biliary strictures. In this review, we present the imaging features of common biliary complications following liver transplant and percutaneous biliary interventions in managing these complications.