Anastomotic biliary strictures after liver transplantation can be treated using several endoscopic strategies. One of the best approaches adopted is a sequential multistenting protocol where an additional plastic stent is placed across the stricture at each endoscopic retrograde cholangiopancreatography (ERCP) session without removing the previous ones. The aims of this study were to evaluate the incidence and the potential risk factors associated with cholangitis during the multistenting protocol.

We conducted a retrospective study at a single tertiary liver transplant center, reviewing data from patients who had undergone liver transplantation and were diagnosed with biliary strictures and treated with ERCP. The diagnosis of cholangitis was based on the Kyoto criteria. Patients with at least one episode of cholangitis were compared with those who did not. Data collected included patient demographics, hospitalization, rectal swab, presence of choledocholithiasis or stent migration, and timing of stenosis. The primary outcome was the incidence of cholangitis and secondary outcomes included the identification of potential risk factor

We analyzed data from 210 patients who underwent liver transplantation between June 2021 and May 2024. The median age was 59 years (SD 11), and the main indication was alcohol-related liver disease (24%, N = 49). Anastomotic biliary strictures occurred in 55 patients (26%) at a median of 4 months after transplant. These patients underwent a total of 220 ERCP as part of the sequential multistenting protocol, with a mean of four procedures per patient. Eighteen patients (32.7%) experienced at least one episode of cholangitis during the treatment period. The occurrence of choledocholithiasis was associated with cholangitis (p = 0.05; OR 3.8). Moreover, rectal swab colonization by multidrug-resistant (MDR) organisms showed a strong association (p = 0.005; OR 7.2)

Cholangitis represents a clinically events during the sequential multistenting protocol for post-transplant anastomotic strictures. A new onset of biliary stones and colonization by multidrug-resistant (MDR) organisms were predictors of cholangitis. These findings emphasize that Rectal swab colonization by multidrug-resistant organisms may represent an important predictor of cholangitis, suggesting that targeted pre-procedural antibiotic prophylaxis could help reduce its occurrence. Prospective studies would be needed to confirm these findings and to determine whether integrating rectal swab screening into routine management could improve outcomes.