Prior sphincterotomy can impact type of biliary complications following liver transplantation with duct-to-duct anastomoses

BACKGROUND: It is unknown whether having undergone a sphincterotomy prior to liver transplantation (LT) affects biliary complications post-LT in patients undergoing duct-to-duct anastomoses. METHODS: We performed a nested matched case-control study among adult 5,950 LT recipients from 3 centers with duct-to-duct biliary anastomosis (01/2010-12/2023). Patients who underwent ERCP with sphincterotomy unrelated to etiology of cirrhosis (i.e., excluding PSC, extrahepatic cholangiocarcinoma, or prior LT) were matched 3:1 to controls by age, sex, and graft type (deceased donor vs. living donor). Outcomes included post-LT biliary complications and infections (cholangitis or extra-hepatic). Conditional logistic regression was performed. RESULTS: 64 patients with pre-LT sphincterotomy were matched to 192 controls. Indication for ERCP prior to LT in most cases was choledocholithiasis. Overall biliary complications occurred in 25% vs 28.1% (matched OR 0.85, 95% CI 0.45-1.62; p=0.63), with comparable 1-year (18.8% vs. 22.4%) and 5-year (25% vs. 25.5%) incidence. There was increased risk of choledocholithiasis (12.5% vs. 4.7%; matched OR 3.55, 95% CI 1.13-11.18; p=0.03) and cholangitis (12.5% vs. 3.1%; matched OR 4.47, 95% CI 1.45-13.78; p=0.009) in the sphincterotomy group. Anastomotic strictures, (15.6% vs. 21.4%, p=0.32), non-anastomotic strictures/ischemic cholangiopathy (6.2% vs. 5.2%,p=0.8) and bile leaks (7.8% vs. 4.7%,p=0.3) were similar between both groups. A longer ERCP-to-transplant interval was associated with a significant time-dependent increase in overall biliary complications and anastomotic strictures (both p<0.01; particularly beyond 2.3 years), but not in cholangitis, choledocholithiasis, or bile leaks. For sphincterotomy performed <0.2 years before transplant, anastomotic stricture were at or below those of controls. Five-year graft and patient survival was not different. CONCLUSIONS: Pre-transplant sphincterotomy was associated with increased risk of developing choledocholithiasis and cholangitis following liver transplant, without any difference in biliary strictures or bile leaks.