A Common Language for Post-Transplant Anastomotic Biliary Strictures: Standardized Endoscopic Outcome Definitions and a Failure-Mode Roadmap.

Abstract

Background and Objectives: Anastomotic biliary stricture (AS) is the most frequent biliary complication after duct-to-duct liver transplantation (LT) and a leading indication for post-transplant endoscopic retrograde cholangiopancreatography (ERCP). Because inconsistent outcome definitions hamper cross-study comparisons, we also propose standardized outcome definitions and a minimum reporting dataset. Materials and Methods: This narrative review covers pathogenesis and risk factors, diagnosis and timing, balloon dilation and stenting, the management of treatment failure, procedure-related safety, and graft outcomes. Results: ERCP is the established first-line treatment and achieves durable resolution in most patients. Randomized evidence shows comparable resolution with multiple plastic stents (MPS) and fully covered self-expandable metal stents (FCSEMS), the latter reducing procedures and treatment duration at the cost of migration and possible recurrence. Evidence is weaker for recurrent or refractory strictures, sequential stent addition versus complete exchange, and Roux-en-Y anatomy or a completely obstructed anastomosis. We define technical success, treatment success, recurrence, refractory disease, and durable stent-free resolution, and organize advanced management as a roadmap matching four modes of endoscopic failure to salvage techniques. Conclusions: Endoscopic therapy is central to graft-preserving management of post-transplant AS; adopting these harmonized definitions should make outcomes comparable and rescue algorithms evidence-based.