Diagnosis and Management of Post–Liver Transplant Biliary Obstruction: 1,300 Patient Single-Center Experience

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BACKGROUND: Biliary tract obstruction (BTO) is a common complication after liver transplantation (LT) with high potential for morbidity. A comprehensive assessment of post-LT BTO, including patient and intraoperative characteristics predictive of postoperative obstruction, remains lacking. STUDY DESIGN: A prospectively collected database of all LTs performed at a single-center institution from 2014 to 2022 was analyzed. Diagnostic methods used in the evaluation of post-LT biliary obstruction were correlated with clinical data to identify high-yield diagnostic modalities. Subsequently, management strategies were analyzed to identify therapeutic approaches associated with optimal patient outcomes. RESULTS: Of 1,302 primary LT recipients, 137 (10.5%) experienced a posttransplant biliary obstruction event. The median time to post-LT BTO was 150 (68 to 275) days. One hundred nineteen obstruction events (86.9%) were attributable to anastomotic strictures, 11 (8.03%) to ischemic cholangiopathy, and 7 (5.1%) to T-tube or stent obstruction. On receiver operator characteristic analysis, gamma-glutamyl transferase demonstrated superior predictive power (area under the curve 0.80, 95% CI 0.69 to 0.91) in the detection of post-LT BTO as compared with total bilirubin (area under the curve 0.64, 95% CI 0.50 to 0.78) and alkaline phosphatase (area under the curve 0.57, 95% CI 0.41 to 0.72). History of coronary artery disease (odds ratio 4.26, p = 0.03) and postoperative hepatic artery thrombosis (odds ratio 6.01, p = 0.001) independently predicted stricture recurrence after an attempted stent-free trial. CONCLUSIONS: Obstruction of the biliary ductal system remains a common complication post-LT, with most cases occurring within 1 year of transplant. Gamma-glutamyl transferase demonstrates superior sensitivity and specificity in the detection of post-LT BTO and may be of significant diagnostic use. After an initial stent-free trial, several key risk factors may identify patients who merit additional monitoring for stricture recurrence.

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