Endoscopic Management of Biliary Complications After Liver Transplantation

Biliary reconstruction has been described 35 years ago by Sir Roy Calne as the technical ‘Achilles heel’ of orthotopic liver transplantation (OLT). The name “Achilles' heel” comes from Greek mythology, which is a metaphor of a single vulnerable spot. This is because the potential detrimental effects of biliary complications on graft and patient survival. Biliary complications, which “plagued” the early experience of liver transplantation occurring in nearly one of every three transplant recipients (Moser & Wall, 2001), have been reduced dramatically due to the improvements in organ selection, retrieval, preservation, and implantation techniques. However, biliary complications still remain a common source of morbidity and mortality (Greif et al., 1994). Additionally, they significantly affect the recipients’ quality of life because they entail frequent readmissions, repeated imaging, invasive procedures, and even reoperation. All of them added to the financial and emotional toll suffer the patients (Sharma et al., 2008). Biliary leaks and strictures, either anastomotic or non-anastomotic, are the most frequent complications. Cystic duct obstruction due to mucocele, stones, sludge or casts, hemobilia and sphincter of Oddi dysfunction have also been recorded (Colonna et al., 1992; Greif et al., 1994). The surgical management used to be the standard of care for these conditions in earlier practice. However, the revolutionary progress in minimally invasive armamentarium, namely endoscopy and percutaneous radiologic interventional modalities, made it the current alternative first line of management displacing surgical intervention to be a second backup option (Sharma et al., 2008; Williams & Draganov, 2009). A living donor liver transplantation (LDLT) was first reported in 1988 by Raia in Brazil, followed by Nagasue in Japan in 1989. After the leading successful experience of right lobe living related liver transplantation (RL-LDLT) that has been reported by Hong Kong team in 1996, it rapidly evolved as a well-established practice in Asian countries. World wide organ shortage and promising results were alluring to other centers to consider (RL-LDLT) as a practical option. In this review we will shed more light on biliary complications related to right lobe living donor liver transplantation and their endoscopic management.