Approach to Biliary Complications After Liver Transplantation: Current Evidence and the Emerging Role of Therapeutic Endoscopic Ultrasound

Background: Biliary complications represent the most frequent and clinically relevant adverse events after liver transplantation, contributing substantially to morbidity, graft dysfunction, and reduced patient survival. Methods: We performed a review of current evidence to explore the prevalence, etiology, diagnosis and treatment of biliary complications after liver transplantation, focusing on the emerging role of therapeutic endoscopic ultrasound. Results: The most common biliary complications include anastomotic and non-anastomotic biliary strictures and bile leaks, while gallstones, casts, and sphincter of Oddi dysfunction are less common. Diagnosis is based on a combination of clinical evaluation, laboratory tests, ultrasound and magnetic resonance cholangiopancreatography. Endoscopic therapy, in most cases, is the first therapeutic approach, followed by interventional radiology and, ultimately, surgery. In recent years, therapeutic endoscopic ultrasound has emerged as a promising, minimally invasive salvage option, particularly when conventional access is unfeasible or has failed. Conclusions: Early recognition and appropriate treatment of these complications are essential for preserving graft integrity and improving long-term outcomes. Although current evidence is still limited, therapeutic EUS could expand the therapeutic arsenal at highly specialized centers. Overall, a multidisciplinary approach is essential for the optimal diagnosis and management of biliary complications after liver transplantation.