Predictors of biliary stricture resolution after living donor liver transplantation: Is biliary complexity the key factor?

Biliary complications remain a significant cause of morbidity following liver transplantation (LT). This study investigates factors and outcomes associated with unresolved biliary strictures (BS) in living donor (LDLT) recipients after endoscopic retrograde biliary drainage (ERBD) or percutaneous transhepatic cholangiodrainage (PTCD). This retrospective study analyzed 1110 adult ABO-compatible recipients with duct-to-duct biliary anastomosis. Exclusion criteria included malignant strictures, isolated bile leaks, and bilomas. Patients were categorized into complete resolution (CR) and non-complete resolution (NCR) groups, and their perioperative factors and outcomes were compared. Among 123 cases of anastomotic BS treated with ERBD or PTCD, NCR was observed in 59.3 % (73/123), while CR occurred in 40.7 % (50/123) over a median follow-up of 7.77 years. Patients in the NCR group experienced 13 patients of biliary cirrhosis and had shorter overall survival. Significant risk factors for NCR included Model of End-Stage Liver Disease (MELD) score (p = 0.021, HR = 2.61), Child-Pugh Grade C (p = 0.031, HR = 2.77), recipient operation time (p = 0.039, HR = 2.168), blood loss (p = 0.032, HR = 2.375), stricture diameter (p = 0.011, HR = 3.882), and PTCD (p = 0.020, HR = 11.760). No significant difference was observed in survival rates between the groups. The complexity of biliary anatomy is not a primary determinant of BS non-resolution following LDLT in an experience transplant center. Instead, factors such as the severity of underlying liver disease and the operative duration/blood loss negatively impact BS outcomes. These findings indicate that optimizing intraoperative management to minimize hypoperfusion in high-risk patients is crucial for improving BC outcomes.