With improved techniques and experience in endoscopic and percutaneous-transhepatic biliary procedures, the initial management of biliary complications after liver transplantation has become increasingly nonoperative in nature. Although no prospective randomized trials that formally compare nonoperative and operative therapy for post-transplant biliary complications have been performed, numerous case series and other descriptive studies have demonstrated that nonoperative therapies can be as effective as surgical therapy, and the less invasive nature of the endoscopic and percutaneous techniques make them the preferred initial therapy of choice in selected circumstances. Indeed, for small biliary leaks and early anastomotic strictures, nonoperative management has become the initial therapy of choice, with operative intervention being reserved for cases in which the endoscopic or percutaneous approach fails to resolve the underlying complication. Despite the increasing use of endoscopic or percutaneous treatment modalities to treat post-transplant biliary complication, operative intervention remains a potential definitive therapy for most complications and generally results in the most durable outcomes with the least need for reintervention. Operative intervention is still the treatment of choice for significant biliary anastomotic disruptions, massive biliary leaks, or any biliary complication that is associated with severe intraabdominal or systemic infection.
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