Anastomotic strictures. While early experience with endoscopic therapy for anastomotic strictures revealed a significant rate of failures requiring surgical intervention [33,97], more recent studies support the primacy of ERC and percutaneous treatment by PTC with either stenting or dilation [2,57,64,98,99]. Reports indicate long-term success in more than 70% of patients [97,98,100]. Up to 75% of patients diagnosed with anastomotic strictures were shown to be stent-free 18 months after initial ERC , using the combination of endoscopic balloon dilation and stenting of anastomotic strictures (Fig. 3). However, as relapse rates of 30–40% were reported, there is a concern about the long-term effect of balloon dilation and temporary stent placement for late-appearing anastomotic strictures (usually after 3 months) [59,101]. Several reports stressed the necessity of long-term endoscopic stenting of anastomotic strictures with intercurrent endoscopic re-assessment . In selected cases, double or triple parallel stenting may be successful. (Fig. 3) With these treatment modalities, patient and graft survival rates similar to the ones of an uncomplicated control population after OLT were achieved.
Surgical revision and creation of a Roux-en-Y CJ is indicated when endoscopic or percutaneous treatment failed [1,3,37,60,68]. In some cases re-establishment of a CC is possible. Percutaneous transhepatic balloon dilation of anastomotic strictures has been shown in one study to have a 66% long-term success rate and is of special importance for the initial management of strictures affecting choledochojejunostomies [1,3,68]. Some centers prefer to leave percutaneous biliary drains across the stricture, maintaining the patency of the anastomosis and allowing easy access to the stricture for repeated treatment . Self-expanding metal stents have also been used in some centers [101,102]. They have been discussed controversially because of the high rate of stent occlusion and the obvious difficulties in the case of surgical conversion to CJ . Persistent Roux-en-Y CJ strictures often require surgical revision.
Nonanastomotic strictures. Nonanastomotic strictures are commonly classified as having less favorable prognosis and being less responding to conservative endoscopic or interventional therapy  than anastomotic strictures. Strictures that appear within the first 3 months were shown to be more amenable to endoscopic measures than those that developed later (Figs 4–6). A recent study of dilation and stenting of hilar and intrahepatic strictures achieved a success rate of only 28.6% compared with a 75% success rate with anastomotic strictures . Despite this dismal outcome, nonanastomotic strictures have primarily been treated using interventional endoscopic or transhepatic techniques [36,65,59]. However, frequent re-interventions and long-term antibiotic treatment are required in many patients when compared with patients having anastomotic strictures. Moreover, patients have a higher prevalence of concomitant choledocholithiasis and biliary casts, and successful endoscopic therapy takes longer . In selected cases, double or triple parallel stenting may be successful.
There are no randomized controlled trials comparing the risk/benefit ratio of the different endoscopic or percutaneous techniques. Both, PTC and ERC, are associated with characteristic limitations and risks. Anastomotic and nonanastomotic strictures after creation of a bilioenteric anastomosis are only accessible by PTC. Because the rate of reduced-size OLT and complex biliary reconstructions in LD-LTx is increasing, percutaneous treatment options will gain even more importance in the future. Their use is limited in patients with impaired liver function and thereby increased risk of bleeding complications. ERC provides direct access to the biliary system without invasive measures, provides direct access to ampullary dysfunction by treatment with sphincterotomy, however, is associated with a relevant risk of pancreatitis. Additionally, ERC cannot be used in recipients with bilioenteric anastomosis. PTC and ERC were reported to be associated with overall complication rates in 3.4% of PTC and 7% of ERC procedures . Recommendations regarding the use of both procedures often do not reflect scientific evidence, but rather individual experience and center policy. Early reports suggested that despite attempts at nonsurgical intervention, 25–50% of patients with nonanastomotic strictures die or undergo retransplantation for these complications [36,42,65]. Advances in endoscopic and percutaneous therapy of biliary strictures have improved these outcomes so that the overall patient survival does not differ from transplant recipients without stricture [64,65] as long as the indication for surgical reconstruction or retransplantation occurs in a timely fashion. Particularly patients with suspected recurrence of primary sclerosing cholangitis should be considered for retransplantation in due time.
A recent report by Schlitt et al . evaluated the feasibility, complication rate, and results of a reconstructive surgical approach that included resection of the hepatic bifurcation for the treatment of patients with hilar ITBL (Fig. 4) unrelated to vascular problems after OLT. All patients treated in this study either already had several endoscopic interventions or the biliary tree could not be approached adequately either after primary hepaticojejunostomy or because of extensive stenosis. Surgical reconstruction in 14 patients was accomplished by resection of the bifurcation and hepatojejunostomy. Clinical symptoms and biochemical parameters normalized or improved considerably in 88%. In three patients with more extensive biliary destruction, portoenterostomy with or without peripheral hepatojejunostomy was performed. Only one patient who underwent an additional peripheral hepatojejunostomy showed a considerable improvement for about 18 months. The other two patients required rapid retransplantation.
It may be concluded that the reconstructive surgical approach should be reserved to patients not responsive to repeat endoscopical interventions, with recurrent cholangitis, or those with restricted accessibility of the biliary tract by percutaneous or endoscopic methods. Because of the restricted availability of donor organs and the increased risk of a retransplantation, the option of retransplantation should be reserved for patients in whom no adequate surgical reconstruction can be accomplished. The latter group of patients comprise those suffering from intrahepatic ITBL not responding adequately to endoscopic or percutaneous therapy or not suitable for surgical reconstruction, patients with recurrent cholangitis resistant to conservative treatment, patients with frustraneous surgical reconstruction, and patients with progredient ITBL-associated cholestasis and liver insufficiency.
Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Medical treatment for intrahepatic strictures comprises ursodeoxycholic acid (UDCA) and antibiotics for stricture-induced cholangitis. There are no data proving benefitial effects of antibiotic prophylaxis. UDCA has often been used as a neoadjuvant to endoscopic retrograde cholangiopancreatography (ERCP) or supportive therapy in the setting of nonanastomotic stricture formation, common bile duct stones, and casts. UDCA and low fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone  or even analyzed the impact of supportive UDCA treatment. However, in selected patient populations, such as recipients with PSC, UDCA may be advocated for other reasons: patients with PSC are at greater risk of colonic cancer, which may be reduced by UDCA. Recent diagnosis of PSC and no UDCA treatment were predictors of malignancy after OLT .