Background/Objectives: Data on the natural history and endoscopic treatment outcomes of recurrent anastomotic biliary stricture (RABS) after orthotopic liver transplantation (OLT) are limited. This study aimed to evaluate the incidence and outcomes of RABS after OLT. Methods: A retrospective single-center study on OLT patients who underwent successful endoscopic treatment of ABS was conducted. The incidence of RABS, risk factors for recurrence, and outcomes of repeat endoscopic therapy were recorded. Results: A total of 131 OLT patients with ABS underwent endoscopic treatment, of which 119 successfully completed an endoscopic treatment course. After a median follow-up of 51.5 months (IQR 18.5–86.25) from ABS resolution, 26/119 patients (22.7%) developed RABS. All patients with RABS underwent a second endoscopic treatment course; 24 patients received self-expandable metal stents and 2 received plastic stents. Re-treatment was successful in 21 patients (80.8%) after a median of 8.5 months (IQR 5.25–14.50) and a total of 62 ERCPs. Adverse events occurred in two patients (7.4%)—one bacteremia and one suprastenotic biliary stricture. After a median follow-up of 65.5 months (IQR 20.75–125.5) from stent removal, only one patient had a second recurrence, which was treated with a Roux-en-Y hepaticojejunostomy. Multivariate analysis showed that older age at ABS diagnosis (OR 1.1; 95% CI: 1.1–1.2 p = 0.04) was the only independent risk factor for recurrence. Conclusions: RABS affects more than 20% of patients after successful endoscopic treatment. A second endoscopic therapy with covered self-expandable metal stents is a safe and effective option and should be considered before more invasive options.

We present the case of a 73-year-old woman with no relevant medical history. She was admitted for a 3-month intermittent melena. The physical exam was unremarkable. Blood tests revealed anemia (hemoglobin 7.4 g/dL), raised urea (69 mg/dL), normal platelets and coagulation. Gastroscopy was performed with active oozing bleeding in the fundus and gastric body. Endoscopic fulguration of the potential lesions with holmium laser was performed. She was discharged with resolution of the symptoms and analytical improvement. However, the patient required hospitalization two weeks later due to recurrence of melena and anemia.

Aims Primary, technical success; Secondary, short (30 days) and long-term (symptom resolution without surgery/PTBD/indwelling stents) clinical success, and adverse events (AEs). Methods Retrospective cases series from tertiary-referral center. Among 770 consecutive OLT patients between 2001-2022, 142 underwent primary ERCP/PTBD of which 18 (16 male, median age=62) then had secondary i-EUS for biliary access after incomplete/failed therapy, either EUS-guided biliary drainage (EUS-BD) or EUS-directed trans-Enteric ERCP (EDEE). Results GI anatomy: native (n=13), Roux-en-Y hepaticojejunostomy (n=5). Prior approaches: Incomplete (successful cannulation) ERCP (n=9), failed ERCP cannulation (n=5), external PTBD and failed ERCP access (n=4). Biliary anatomy: disconnected (no contrast passage) anastomosis (n=9), anastomotic stricture (n=4), non-anastomotic stricture (n=4), migrated stent (n=1). 20 i-EUS procedures: EUS-BD (n=16), including 11 temporary anastomoses (8 hepaticogastrostomy, 3 choledochoduodenostomy) and 5 rendezvous; EDEE (n=4) with transjejunal ERCP through 15-mm LAMS. Overall, technical success was 94% (n=17), short-term clinical success 89% (1 early death in a critically ill patient with progressive sepsis despite successful drainage), long-term clinical success 78% (n=14; 1 unrelated late death with indwelling stent, 1 patient requiring surgery), and mild/moderate AEs 28% (2 cholangitis, 2 bacteremia, 1 LAMS misdeployement). Conclusions i-EUS is feasible & effective in select patients with complex post-OLT biliary disease. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims Primary, post-OLT anastomotic biliary stricture (ABS) recurrence; Secondary, time to and risk factors for recurrence and efficacy of a second endotherapy course. Methods Retrospective single-center cohort study including consecutive OLT recipients with choledocho-choledochostomy stricture and complete response to prior endotherapy using plastic, self-expandable metal stent (SEMS) or combined plastic and SEMS between Nov 2001-June 2021. Cox Regression was used to identify risk factors. Results Among 680 OLTs, 131 recipients presented ABS and were treated endoscopically; 119 recipients (90.8%) achieved ABS resolution (SEMS n=57 [47.9%], plastic [16%] and combined n=43 [36.1%]). At 55.5 month (IQR: 21.2-89.7) median follow-up after ABS resolution, 25 (21%) patients (median age 61.2 +/- 6.9 years) experienced recurrences. Median time to recurrence was 18 (IQR 7-27) months ([Fig. 1]). Cox-regression identified prolonged endoscopic treatment (>12 months) as protective against recurrence (HR 0.031, p=0,02). A second endotherapy course was attempted in 23 patients, EUS-guided drainage in one patient and follow-up without further intervention in another. ABS resolution was obtaiend in 18/23 patients who underwent ERCP treatment (21 SEMS, 2 plastic stent) after a median of 2.4 (+/-0.8) sessions and a median treatment time of 9 (IQR 6-13) months ([Fig. 2]). One patient experienced a second ABS recurrence, requiring surgical management. Conclusions Prolonged baseline ABS endotherapy protects against recurrence. A second endoscopic treatment course appears effective as definitive treatment of recurrent ABS. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany