Charting the biliary intervention path: Systematic insights into endoscopic versus percutaneous route in managing post-liver transplant complications

Biliary complications represent a major challenge following liver transplantation (LT), affecting up to 30% of recipients depending on donor type. These complications jeopardise graft survival through obstruction, infection, and ischemia. Gadour et al,[1] present a systematic review comparing the two principal interventional modalities—endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary procedures (PTBP) in managing post-LT biliary complications. The two procedures have long coexisted in a delicate balance of clinical preference, with their relative efficacy debated.[2] The systematic review under discussion, conducted in line with PRISMA 2020 standards, synthesizes evidence from 31 studies spanning 1997 to 2023, to examine these approaches through the lenses of efficacy, safety, and durability. In an era shaped by precision medicine and multidisciplinary care, this review provides timely clarity on when to reach for the endoscope or the needle. Within the current landscape of precision medicine and multidisciplinary care, this synthesis offers timely guidance on optimal intervention selection. ERCP demonstrates superior efficacy in managing bile leaks (71%–100%) and AS (65%–96%), reflecting its minimally invasive nature and capacity for rapid biliary decompression and biochemical recovery. Technical success rates for stenting bile leaks approach 94%–100%, particularly in duct-to-duct anastomoses. Non-anastomotic stricture (NAS), however, remains difficult to manage endoscopically, with success rates of only 12%–42%, largely owing to ischemic injury and limited ductal accessibility. PTBP—including percutaneous transhepatic cholangiography and biliary drainage—achieves success rates of 70%–90%, particularly valuable in NAS and pediatric populations requiring staged interventions.[3] PTBP serves as an essential salvage option when ERCP fails, with recovery rates up to 90%, albeit at the cost of external drainage and patient discomfort. The safety profiles of ERCP and PTBP differ considerably. Post-ERCP pancreatitis (PEP) occurs in 4%–10% of cases, particularly in patients with altered anatomy, while bleeding and cholangitis occur in up to 16% and 10.6%, respectively. PTBP avoids PEP but carries risks of hemorrhage (1.4%–11.1%) and sepsis (5%–22%), particularly in non-dilated ducts. Both procedures, however, maintain procedural mortality rates below 2%. In the long term, ERCP is associated with recurrence rates of 0%–32% for AS and 0%–16% for bile leaks, with plastic stents outperforming covered self-expanding metal stents (cSEMS). Conversely, NAS recurrence can reach 50%, frequently requiring retransplantation. PTBP exhibits recurrence rates of 20%–44%, though long-term patency of 70% at 3.5 years has been reported despite frequent re-interventions. Hybrid approaches combining ERCP and PTBP achieve over 90% success in selected cases, marking a collaborative evolution in interventional care.[4] Methodologically, the review exemplifies systematic precision. It was preregistered on PROSPERO (CRD420251108145) and employed a structured PICOS framework encompassing adult and pediatric cohorts and both living- and deceased-donor transplants. Quality assessment using the Newcastle–Ottawa Scale classified 40% of studies as high quality, 50% as moderate, and 10% as low to moderate. Thematic analysis by complication subtype and treatment modality revealed consistent advantages for plastic stents and noted variable ERCP outcomes for NAS. Despite its strengths, several limitations persist. Most included studies were retrospective cohorts rather than randomized controlled trials, introducing heterogeneity in populations, outcome definitions, and follow-up duration. Such variability complicates direct comparison and may bias efficacy estimates towards ERCP, which is often reserved for less complex cases. Uncertainty persists regarding the optimal stent type: plastic stents appear to reduce recurrence compared with cSEMS, yet evidence on newer bioengineered stents remains limited. Hybrid approaches yield promising >90% success rates but derive from small observational series lacking cost-effectiveness and quality-of-life data. The review’s temporal span (1997–2023) excludes recent innovations such as cholangioscopy and AI-assisted cannulation, which could alter contemporary practice relevance.[5,6] Clinicians should adopt an adaptive, patient-centered approach rather than a rigid algorithm. ERCP remains the first-line option for bile leaks and AS, given its high success and minimal invasiveness. PTBP should be reserved for NAS, complex hilar anatomy, or failed ERCP, providing transhepatic access to anatomically challenging regions. Intervention selection should prioritize anatomical feasibility and patient comorbidities. Pre-procedural imaging aids pathway optimization, while coagulopathy may favor ERCP, particularly in non-dilated ducts. High-volume centers consistently demonstrate superior outcomes, highlighting the need for procedural centralization and multidisciplinary collaboration. Effective stewardship of stent choice and prophylactic antibiotic use remains critical for optimizing outcomes.[7] This systematic review makes a substantive contribution to the contemporary understanding of post-transplant biliary management. It reaffirms ERCP as the intervention of choice for accessible lesions, underscores the indispensability of percutaneous trans-hepatic biliary procedures for salvage, and highlights the growing relevance of hybrid strategies. Despite inherent heterogeneity, its methodological thoroughness and analytical clarity provide clinicians with a pragmatic framework to navigate complex biliary scenarios. In an era of expanding transplant activity and persistent organ scarcity, precision-guided, team-based interventions remain central to graft longevity. The coming decade should priorities high-quality comparative trials and real-world data integration to refine biliary management algorithms and ensure optimal outcomes for every graft and patient.