Post–orthotopic liver transplantation (OLT) anastomotic biliary strictures (ABS) are commonly treated with multiple plastic stents (MPS), but data on protocol performance and the role of endoscopic ultrasound (EUS) remain limited. We evaluated efficacy, safety and technical characteristics of an MPS protocol in ABS, focusing on patients with associated ischemic-type biliary lesions (ITBL).

This single-centre retrospective study included 28-OLT recipients with ABS treated with ERCP-guided MPS. Of the 31-screened patients, 3 were excluded as they didn’t fulfill the cholangiographic criteria for ABS. In a subset, linear EUS or transpapillary miniprobe EUS was performed before/after MPS.

Ten patients had completed the MPS protocol and 18 are still on treatment. Among completed, 2 had isolated ABS and 8 ABS+ITBL: overall, 35 ERCPs were performed (3.5 per patient; 38 minutes per session). A mean of 3.3 stents were placed, achieving a cumulative diameter of 29.6 Fr. Biliary clearance with stent removal was required in 40% of procedures (50% in ABS+ITBL, 0% in isolated ABS), and mechanical dilation in 40%. Adverse events included two mild–moderate postERCP pancreatitis and one moderate cholangitis. Resolution of ABS at the end of MPS, according to predefined cholangiographic criteria, was achieved in 90%. In five ABS+ITBL patients with follow-up (5.25 months), three maintained stricture resolution and two developed recurrence requiring retransplantation.

ERCP-guided MPS is an effective and safe strategy for post-OLT ABS, whereas concomitant ITBL identifies a more complex subgroup in which adjunctive EUS may help to identify anatomical alterations and to customize treatment.