Clinical bottom line
Postoperative biliary strictures represent a challenging complication following hepatobiliary surgery or liver transplantation. Current evidence supports endoscopic management as the first-line approach for most benign strictures due to its minimally invasive nature and favorable safety profile. However, surgical reconstruction remains a critical option for refractory cases or complex strictures not amenable to endoscopic therapy. The choice between endoscopic and surgical approaches should be individualized based on stricture characteristics, patient comorbidities, and local expertise.
What the evidence shows
Benign biliary strictures after surgery or liver transplantation commonly result from ischemia, inflammation, or technical injury. Endoscopic therapy, primarily via balloon dilation and placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMS), has become the mainstay of treatment. Wang et al. (2026) provide a comprehensive overview of endoscopic management post-liver transplantation, highlighting success rates exceeding 70–80% with repeated sessions and stent exchanges. Emerging techniques such as cholangioscopy-guided interventions and biodegradable stents are under investigation to improve outcomes and reduce treatment duration.
Sato et al. (2022) emphasize that endoscopic approaches are favored due to lower morbidity compared to surgery, with most strictures responding to serial dilations and stenting. Ladna et al. (2022) further support this, noting that evidence-based protocols recommend endoscopic therapy as first-line, reserving surgery for cases with persistent or complex strictures, such as those involving the hepatic hilum or associated with bile duct injury.
Surgical options typically involve biliary-enteric anastomosis, such as hepaticojejunostomy, and are indicated when endoscopic therapy fails or is not feasible. Pappas et al. (2011) describe surgical repair as definitive but associated with higher perioperative risks and longer recovery. Corso et al. (2002) detail that surgery is particularly necessary in strictures complicated by recurrent cholangitis or when anatomical distortion precludes endoscopic access.
Caveats and uncertainty
Most evidence derives from observational studies, case series, and expert consensus rather than randomized controlled trials, limiting the strength of recommendations. Variability in stricture etiology, anatomy, and patient factors complicates direct comparisons between endoscopic and surgical outcomes. The optimal stenting strategy (plastic versus metal, number of stents, duration) remains debated, with ongoing trials needed to clarify best practices (Wang et al., 2026; Ladna et al., 2022).
Additionally, long-term data on stricture recurrence and quality of life after endoscopic versus surgical treatment are limited. Endoscopic therapy requires multiple procedures and close follow-up, which may not be feasible in all settings. Surgical reconstruction, while more invasive, may offer more durable resolution in selected patients but carries higher upfront risk (Pappas et al., 2011).
How this may change practice
Clinicians managing postoperative biliary strictures should prioritize endoscopic evaluation and therapy as the initial approach, especially in centers with advanced endoscopic expertise. Multidisciplinary collaboration involving surgeons, gastroenterologists, and interventional endoscopists is essential to tailor treatment plans.
Awareness of emerging endoscopic technologies and evolving stenting protocols may improve patient outcomes and reduce the need for surgery. However, surgeons should remain prepared to offer reconstructive surgery for refractory or complex strictures, recognizing that timely referral can prevent complications such as secondary biliary cirrhosis.
Future practice will benefit from standardized algorithms incorporating stricture characteristics and patient factors to guide therapy choice. Participation in clinical trials and registries is encouraged to strengthen the evidence base.