Introduction
Biliary leaks are a well-recognized complication following liver transplantation (LT). Despite advancements in ERCP techniques, there remains variability in treatment success, Considering the peculiarities of this patient group, characterized by specific post-surgical anatomy, variations in endoductal pressure, and immunosuppressive therapy. This study was conducted to identify predictive factors influencing the healing of biliary leaks and the development of post-leak strictures, with the goal of refining management strategies and enhancing patient outcomes.
Aims & Methods
A retrospective analysis was performed on 34 LT patients who developed biliary leaks and were managed with ERCP within 24 hours from diagnosis. Variables included: the type of biliary stricture (anastomotic vs. non-anastomotic), presence of clinical symptoms (pain, fever, jaundice), time interval between multiple ERCPs to reach leak healing, characteristics of the stents (number, diameter in French, and length in cm), and leak parameters (high-grade vs. low-grade, early vs. late leak onset). Statistical analyses included Chi-square and Fisher's exact tests for categorical variables, Student's t-test and Mann-Whitney U test were used for continuous variables. The significance threshold was p<0.05.
Results
Among 34 patients with post-liver transplant biliary leaks, the overall healing rate was 94.1% (32/34). Early leaks (≤4 weeks) had longer healing times than late leaks (>4 weeks) (21.1 vs. 13.0 days). Strictures developed in 54.5% of patients (18/33). All strictures occurred in high-grade leaks: 66.7% in early high-grade and 60.0% in late high-grade groups. No strictures were observed in any low-grade leak, regardless of timing.
Based on cholangiographic appearance, high-grade leaks (visible before full biliary opacification) accounted for all strictures and often required multiple ERCPs. Low-grade leaks (visible only after full opacification) never led to strictures and typically healed after a single procedure. Notably, no strictures occurred in low-grade leaks, regardless of timing, while all strictures developed in patients with high-grade leaks, both early and late.
Shorter healing times were associated with the presence of symptoms, use of 10 Fr vs. 7 Fr stents, and intervals <1 month between ERCPs. In contrast, use of multiple stents, pre-existing NAS, and early high-grade leaks were linked to prolonged healing courses or non-resolution with standard ERCP strategy. The Kehr tube showed no significant impact.
| Leak Timing | Leak Output | Stricture Rate (%) |
| Early (≤ 4 weeks) | High Output | 66.7 |
Early (≤ 4 weeks)
| Low Output | 0 |
| Late (> 4 weeks) | High Output | 50 |
| Late (> 4 weeks) | Low Output | 0 |
Conclusion
Leak grade and timing are key predictors of post-transplant biliary leak healing. High-grade leaks, especially when early, were associated with delayed recovery and the need for multiple ERCPs, while low-grade leaks followed a consistently favorable course. Faster healing was also observed in symptomatic patients, with the use of 10 Fr stents and short ERCP intervals (<1 month). Strictures occurred exclusively in high-grade leaks, further supporting the prognostic relevance of cholangiographic grading. Incorporating leak grade and timing into early ERCP decision-making can accelerate healing, reduce complications, and significantly improve post-transplant outcomes.
References
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