Endoscopic retrograde cholangiopancreatography versus percutaneous transhepatic radiological procedures in the management of post-liver transplantation biliary complications: A systematic review

Abstract Background: Biliary complications, including anastomotic strictures (AS), non-anastomotic strictures (NAS), bile leaks, and biliary stones, affect 10%–30% of liver transplant recipients, causing significant morbidity. The optimal choice between endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic radiological procedures (PTRPs) for managing these complications remains debated. Methods: This systematic review, conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines, analyzed 31 studies published from 1997 to 2023, to compare the effectiveness and safety of ERCP and PTRPs in managing post-liver transplant biliary complications. Results: ERCP showed high efficacy for bile leaks (71%–100% success) and AS (65%–96% success), but lower efficacy for NAS (12%–42%). PTRPs excelled in managing complex strictures (70%–90.6% success) and, as salvage therapy, achieved 100% success in pediatric cohorts. Safety-wise, ERCP risks included pancreatitis (4–10%) and bleeding (2.6%–16%), while PTRP risks involved hemorrhage (1.4%–11.1%) and sepsis (5%–22%). Long-term outcomes varied: ERCP provided durable results for AS (0%–32% recurrence) but high recurrence for NAS (33%–50%). PTRPs maintained 70% patency at 3.5 years, despite frequent reinterventions (43%–53%). Plastic stents showed lower recurrence rates than metal stents (7.7% vs. 30.3%). Hybrid approaches combining ERCP and PTRPs achieved over 90% success in complex cases. Conclusion: ERCP remains preferred for bile leaks and accessible AS, while PTRPs benefit complex strictures or as salvage therapy. Individualized management considering anatomical factors, complication subtypes, stent selection, and institutional expertise is crucial for improving graft survival. Hybrid strategies may be particularly advantageous in difficult cases, highlighting the need for a tailored approach in post-liver transplantation biliary complication management.