Search

Objective: Biliary strictures occur more frequently after liver transplantation for primary sclerosing cholangitis (PSC) than for other diseases. A hypothesized cause is recurrence of PSC in the liver graft. In our study, we compared cholangiographic features of biliary strictures after transplantation for PSC to those after transplantation for other diseases., Materials and Methods: A study group of 32 PSC grafts in adults with biliary strictures was compared with a control group of 32 non-PSC grafts with strictures. Both groups were matched for the type of biliary anastomosis (choledochojejunostomy) and for the time interval between transplantation and stricture diagnosis. We then performed a blind retrospective review of cholangiograms in these 64 cases to evaluate for features of PSC., Results: Location, number, and length of strictures and ductal dilatation were similar in the PSC and non-PSC groups. Mural irregularities of bile ducts were present in 15 of 32 (47%) PSC grafts compared with four of 32 (13%) in the control group (p=.005). Diverticulum-like outpouchings occurred in six of 32 (19%) PSC graft compared with one of 32 (3%) in the control group. An overall resemblance to PSC was observed in eight of 32 (25%) grafts in the PSC group compared with two of 32 (6%) in the control group., Conclusion: Mural irregularity and diverticulum-like outpouchings--findings suggestive of PSC--and an overall appearance resembling PSC occur more frequently in PSC transplants than in transplants for other diseases. These findings are consistent with the hypothesis that PSC may recur in liver transplants.

Objective: The occurrence of biliary strictures or bile duct necrosis in liver transplant recipients with hepatic artery stenosis has been well documented. This study was done to determine the prevalence and cholangiographic appearance of biliary complications in liver transplant recipients with hepatic artery stenosis and to determine if such complications occur with increased frequency compared with transplant recipients with patent hepatic arteries., Materials and Methods: The study population consisted of 33 patients (17 male, 16 female; 1-65 years old) with angiographically proven significant hepatic artery stenosis after liver transplantation. All patients had T-tube or percutaneous transhepatic cholangiography performed within 4 months of hepatic arteriography. A retrospective review of radiographs was done to determine the prevalence and appearance of biliary complications in the study group compared with a control group of 58 patients with angiographically patent hepatic arteries who had liver transplants during the same period., Results: Biliary complications were significantly more prevalent in patients with hepatic artery stenosis, with 22 (67%) showing cholangiographic abnormal findings compared with 16 (28%) in the control group (p = .001). The most significant abnormalities in patients with arterial stenosis were nonanastomotic biliary strictures seen in 16 (49%), compared with 13 (22%) in the control group (p = .04). Other findings (intraductal filling defects, anastomotic biliary stricture, and anastomotic bile leak) showed no statistically significant difference between the study and control groups., Conclusion: Biliary complications are significantly more prevalent in liver transplant recipients with hepatic artery stenosis. The most common complication seen on cholangiography was nonanastomotic biliary stricture.

Objective: Recent reports have shown that a high percentage of patients with transjugular intrahepatic portosystemic shunts (TIPS) have postprocedural shunt complications, including thrombosis of the stent, stenosis of the stent, or stenosis of the hepatic vein draining the stent. We did a prospective study to determine the utility of Doppler sonography as a screening technique for the detection of these complications., Subjects and Methods: From September 1991 to September 1992 we placed TIPS in 45 patients. After the procedure, patients were routinely evaluated with both Doppler sonography and angiography. The sonographic protocol consisted of insonation of the stent, portal vein, and hepatic vein to determine the presence of flow, peak velocity, and direction of flow. The angiograms were evaluated for stenoses of the stent or hepatic vein that caused an increase in the portosystemic pressure gradient greater than 15 mm Hg, increased intrahepatic portal venous filling, retrograde filling of the draining hepatic vein, or opacification of varices. The sonographic findings were statistically evaluated to determine if sonography could demonstrate the complications shown by angiography., Results: Adequate follow-up was obtained in 29 of the 45 patients. Sixteen of the 29 patients had shunt complications that consisted of one stent thrombosis, three stent stenoses, nine hepatic vein stenoses, and three concomitant stenoses of the stent and hepatic vein. Flow was not detected by sonography in the stent of the patient with thrombosis. There was a significant difference (p = .003) between the temporal change in peak stent velocity in patients with stenoses versus those without. Use of a change (increase or decrease) in peak stent velocity greater than 50 cm/sec from the post-TIPS baseline sonogram as the diagnostic criterion for the detection of shunt stenoses resulted in a 93% sensitivity and 77% specificity. Five patients with stenosis had reversed flow in the draining hepatic vein. Only one patient with a stenosis had a peak stent velocity less than 50 cm/sec., Conclusion: Our results suggest that Doppler sonography is an excellent noninvasive screening technique for the detection of complications of TIPS. We have found a temporal change in peak stent velocity greater than 50 cm/sec to be a more sensitive sonographic sign of TIPS stenosis than the previously reported low-velocity parameters. Our experience suggests that nearly all complications of TIPS can be detected by using three criteria: (1) no flow for thrombosis, (2) a temporal change in peak stent velocity greater than 50 cm/sec for stent and/or hepatic vein stenosis, and (3) reversed flow in the hepatic vein draining the stent for hepatic vein and, rarely, stent stenosis.

Objective: The purpose of this study was to determine the prevalence and types of biliary strictures seen in liver allografts transplanted for primary sclerosing cholangitis and other end-stage liver diseases and to determine if such strictures occur more often in the allografts transplanted for primary sclerosing cholangitis than in the others., Materials and Methods: During a 10-year period, 643 liver transplantation patients (687 allografts) with choledochojejunostomy biliary anastomoses underwent 1728 cholangiographic studies. Three hundred six cholangiograms were obtained in 100 transplant recipients who had primary sclerosing cholangitis (112 allografts) and 1422 cholangiograms were obtained in 543 recipients who had other liver diseases (575 allografts). We retrospectively reviewed all cholangiograms of transplant recipients who had primary sclerosing cholangitis and 909 cholangiograms of the recipients who had other liver diseases and a diagnosis of biliary strictures, possible biliary strictures, or duct irregularity based on radiologic reports. The presence, number, and locations of strictures were recorded. The remaining 513 cholangiograms of recipients with other liver diseases without strictures were not reviewed. Biliary strictures were classified as intrahepatic (including bifurcation), anastomotic, and nonanastomotic extrahepatic., Results: Cholangiograms showed intrahepatic biliary strictures in 105 allografts (15%), anastomotic strictures in 105 allografts (15%), and nonanastomotic extrahepatic biliary strictures in 17 allografts (2%). Intrahepatic biliary strictures were diagnosed in 27% (30/112) of the allografts transplanted for primary sclerosing cholangitis and in 13% (75/575) of the allografts transplanted for other end-stage liver diseases (p = .0005). Anastomotic strictures developed in 18% (20/112) of the allografts transplanted for primary sclerosing cholangitis and in 15% (85/575) of the others (p = .381). Nonanastomotic extrahepatic strictures were seen in 6% (7/112) of the allografts transplanted for primary sclerosing cholangitis and in 2% (10/575) of the others (p = .008)., Conclusion: Intrahepatic and nonanastomotic extrahepatic biliary strictures are significantly more common in patients who have liver transplantation for primary sclerosing cholangitis than in patients who receive allografts for other end-stage liver diseases. However, strictures at the choledochojejunostomy anastomosis occur with equal frequency in both groups of patients.

Objective: Cadaveric kidneys from donors less than 5 years old, previously considered inferior graft material, are now being successfully transplanted en bloc into children and adults. On the basis of our experience with 132 patients, we describe the general principles of the procedure and review the spectrum of normal and abnormal imaging findings in patients who have undergone this promising transplantation procedure., Materials and Methods: Paired cadaveric kidneys obtained from donors less than 5 years old (mean age, 24 months) were transplanted en bloc to 132 patients (mean age, 37 years) at our institution between 1981 and 1991. All available medical, surgical, pathologic, and imaging records were retrospectively reviewed to define the surgical technique, 1-year survival rate of the graft, appearance of the transplant on postoperative imaging studies, and the prevalence of and imaging findings caused by vascular, urinary, infectious, and neoplastic complications after transplantation. Complications were confirmed by a definitive imaging study, surgical exploration, or study of a pathologic specimen., Results: Paired donor kidneys were transplanted en bloc extraperitoneally into the recipient's right or left iliac fossa, with intact portions of the donor aorta and inferior vena cava anastomosed to the recipient's external iliac artery and vein. One-year graft survival was 70% during the first 8 years of the study and 78% during the last 2 years. Postoperative imaging, particularly sonography and scintigraphy, clearly depicted the normal individual kidneys, urinary collecting systems, and en bloc vasculature. Postoperative complications were vascular (arterial stenoses and thromboses, venous thromboses, and pseudoaneurysms) in 18%, urinary (obstruction and anastomotic leak) in 11%, infectious (caliceal fungal balls) in 1%, and neoplastic (posttransplant lymphoma) in 1%. The complications involved one kidney in 60% of the patients and both kidneys in 40%. The imaging findings caused by these complications were similar to those caused by complications occurring after transplantation of single cadaveric kidneys; however, their detection was more difficult because of the complexity of the en bloc graft., Conclusion: Because of the shortage of available donor organs, en bloc renal transplantation will most likely become increasingly popular. Familiarity with the imaging appearance of the normal transplant and of posttransplantation complications will allow radiologists to perform effective postoperative imaging evaluations.

To better understand changes in the size of the extrahepatic bile duct after liver transplantation, we retrospectively studied the luminal diameter of the extrahepatic bile duct on serial cholangiograms in 40 liver transplant recipients with choledochocholedochostomy biliary anastomoses and without biliary complications. Forty operative and 105 postoperative cholangiograms were reviewed. The average interval between operative and last postoperative cholangiogram was 5 weeks (range, 1-17 weeks). The mean diameter of the donor common hepatic duct increased from 5.5 +/- 2.1 mm to 6.3 +/- 2.4 mm (p = .015). The mean diameter of the native common bile duct increased from 5.1 +/- 1.4 mm to 6.8 +/- 2.4 mm (p less than .001). The diameter of the donor common hepatic duct increased by 3 mm or more in six patients (15%); the diameter of the native common bile duct increased by 3 mm or more in nine (23%). Increased diameter of the native common bile duct was associated with T-tube migration into the duct in four cases. The size of the extrahepatic bile duct on cholangiograms is stable or increases slightly in most liver transplant recipients. Mild increases unassociated with a specific cause of obstruction or hepatic dysfunction do not portend biliary obstruction and are clinically benign.

Vascular complications associated with renal transplants are a significant cause of graft dysfunction. The most common complications are arterial and venous stenoses and thromboses and intrarenal and extrarenal arteriovenous fistulas and pseudoaneurysms. Although angiography is the imaging gold standard for the diagnosis of these disorders, Doppler sonography, scintigraphy, and occasionally CT are capable of detecting them. An awareness of the different imaging appearances of each complication will aid in their early detection and treatment. In this review, we present this information and provide a perspective on the relative roles of these techniques in the detection of vascular complications from renal transplants.

Biliary obstruction in liver transplants is most commonly due to stricture at the biliary anastomosis. The native common bile duct typically is normal. We retrospectively studied 28 patients with choledochocholedochostomy anastomoses who had marked native and donor extrahepatic bile duct dilatation associated with clinical evidence of biliary obstruction. Operative cholangiograms were compared with postoperative cholangiograms obtained a mean of 50 weeks (range, 2-246 weeks) later. Mean caliber of the native common bile duct increased from 7.5 +/- 2.0 mm on operative cholangiograms to 14.8 +/- 3.9 mm on postoperative cholangiograms (p less than .001). Mean caliber of the donor common hepatic duct increased from 5.9 +/- 1.3 mm on operative cholangiograms to 12.8 +/- 3.8 mm on postoperative cholangiograms (p less than .001). Dilatation of the cystic duct remnant was seen in 15 patients. All patients had surgical revision to choledochojejunostomy with improved results of liver function studies in most cases. Diffuse dilatation of native and donor extrahepatic bile ducts may develop in liver transplant recipients. Typical features include native and donor extrahepatic ducts greater than 12 mm in diameter and a dilated cystic duct remnant on postoperative cholangiography in a patient with otherwise unexplained hepatic dysfunction.

Percutaneous transluminal angioplasty was performed on 45 patients with vascular stenoses after vein bypass surgery. In 25 cases, the angioplasty catheter was introduced by direct puncture of the vein graft. The procedure was successful and reoperation was avoided in all but one of these cases. There were no complications. The experience has shown that in selected postoperative patients, direct puncture of the graft is safe and greatly facilitates performance of the angioplasty.

When hepatic artery thrombosis occurs after liver transplantation, another transplantation is required to ensure the patient's survival. Because of the importance of establishing this diagnosis, we reviewed the results of duplex sonography in 37 angiographically or surgically proved cases of hepatic artery thrombosis after liver transplantation. There were 20 children and 17 adults. Ten of the 20 children had angiographically documented hepatopetal arterial collaterals. Such collaterals were not seen in the adult patients. This subset of patients was evaluated separately to determine if intrahepatic arterial blood flow reestablished by collaterals after hepatic artery thrombosis was a cause of false-negative Doppler studies. Thirty-four (92%) of the 37 cases of hepatic artery thrombosis were correctly identified by Doppler. A Doppler pulse was not identified in any of the children with arterial collaterals. We conclude that duplex sonography is sensitive in detecting hepatic artery thrombosis after liver transplantation. Furthermore, the presence of blood flow in hepatopetal arterial collaterals does not cause false-negative examinations.

In 14 patients, 16 episodes of occluded Hickman catheters were evaluated by contrast venography. In 13 instances, a fibrin sheath occluding the distal catheter was observed. A mechanical problem was responsible for occlusion in three catheters. Low-dose streptokinase effectively restored lumen patency in 12 catheters (92%) occluded by a fibrin sheath.

We retrospectively reviewed the results of real-time sonography in 41 patients in whom biliary complications after liver transplantation were documented by percutaneous transhepatic cholangiography. Abnormalities included bile duct stricture (26 cases), occluded internal biliary stent (six cases), common duct redundancy with resultant functional biliary obstruction (three cases), bile leak (three cases), choledocholithiasis (two cases), and an abscess in a cystic duct remnant (one case). Sonography was abnormal in 22 of the 41 cases (sensitivity, 54%). Bile duct dilatation was the positive sonographic finding in 19 (86%) of the 22 abnormal examinations. In the remaining 19 patients, sonography was normal. Sonography is not a reliable test for the early detection of biliary abnormalities after liver transplantation. Percutaneous transhepatic cholangiography should be performed in patients with suspected biliary complications after liver transplantation.

During a 5-year period, 416 long-term double-lumen central venous catheters were inserted into 288 patients. In these patients, 106 catheter venograms and nine upper extremity venograms were performed. All studies were reviewed retrospectively to determine the nature and prevalence of noninfectious catheter-related complications, to evaluate the efficacy and safety of streptokinase therapy, and to determine if catheter venography should be performed before streptokinase therapy is started. Noninfectious complications occurred in 66 (23%) patients. Complications that resulted in catheter malfunction included deposition of fibrin around the catheter tip (formation of a fibrin sheath) in 44 (57%) instances, a constricting suture in six, abutment of the catheter tip against the venous wall in eight, catheter leak in two, and migration of the catheter completely out of the vein in three. Venous thrombosis developed in 11 patients. Treatment with low doses of streptokinase successfully relieved catheter obstruction due to a fibrin sheath in 27 (87%) of 31 instances. No bleeding complications occurred. Five patients had malpositioned catheters in the azygous, axillary, or internal jugular veins. By use of a deflector wire or snare inserted via the femoral vein, all five were relocated successfully into the superior vena cava. Recognition of noninfectious complications associated with use of long-term catheters is important for institution of appropriate therapy, which in many instances obviates removal of the catheter. Formation of a fibrin sheath in only 57% of cases of catheter malfunction provides an argument for performing catheter venography before streptokinase therapy is started. Low-dose streptokinase therapy for long-term central venous catheters occluded by a fibrin sheath is safe and efficacious.

Rejection, the leading cause of liver allograft dysfunction, is usually detected by liver biopsy. The purpose of this study was to determine if there are angiographic findings that correlate with this posttransplantation complication. In a retrospective study, the angiograms of 35 patients with histologically proven allograft rejection were reviewed. The examinations were done because of suspected posttransplantation vascular complications. Abnormal hepatic arteriograms were observed in 30 (86%). Eleven (37%) of the 30 had hepatic artery thrombosis (all had acute rejection). Nineteen (63%) of the 30 had varying degrees of intrahepatic arterial narrowing (14 had acute and five had chronic rejection). Additional findings in patients with acute rejection included stretching of the intrahepatic arterial tree (five cases) and slow flow, poor peripheral arterial filling, and a decrease in the number of intrahepatic arteries (10 cases total). Intrahepatic branch vessel stenoses and occlusions were seen in four patients with chronic rejection. We conclude that there is good correlations between the angiographic findings and histologic evidence of rejection. Although angiography is not advocated as a test for transplant rejection, detection of certain findings raises the possibility of rejection.

CT scans of liver transplants may show periportal areas that are lower in attenuation than adjacent portal veins and liver. These areas appear as low-density rims that surround or parallel the portal vein and its intrahepatic branches as well as the immediate subhepatic portal area. In order to determine the value of periportal low attenuation as an indicator of rejection, we reviewed the CT scans of 37 liver transplant patients with biopsy evidence of either acute rejection (12 patients) or nonspecific change without rejection (25 patients). Low-attenuation areas around peripheral portal branches were identified in six of 12 patients with rejection and in four of 25 patients with nonspecific change (sensitivity, 50%; specificity, 84%; accuracy, 73%). The correlation between peripheral periportal low attenuation and rejection was statistically significant (p less than .05). Periportal low attenuation in a central location was seen in eight of 12 patients with acute rejection and in 14 of 25 patients with nonspecific change (sensitivity, 67%; specificity, 44%; accuracy, 51%). The correlation was not statistically significant. Low-attenuation areas were evident on scans obtained either with or without IV contrast enhancement. Periportal low-attenuation areas are commonly seen on CT scans of liver transplants. Peripheral areas correlate with acute rejection, but other factors probably contribute to their occurrence. Central areas do not correlate with acute rejection. Low sensitivity and relatively low accuracy limit the usefulness of peripheral periportal low attenuation as a sign of acute liver allograft rejection.

Hepatic artery thrombosis after liver transplantation is a devastating event requiring emergency retransplantation in most patients. Early clinical signs are often nonspecific. Before duplex sonography (combined real-time and pulsed Doppler) capability was acquired in October 1984, 76% of all transplants in this institution referred for angiography with a clinical suspicion of hepatic artery thrombosis had patent arteries. In an effort to reduce the number of negative angiograms, CT, real-time sonography, and pulsed Doppler have been evaluated as screening examinations to determine which patients need angiography. Of 14 patients with focal inhomogeneity of the liver architecture detected by CT and/or real-time sonography, 12 (86%) had hepatic artery thrombosis, one had slow arterial flow with hepatic necrosis, and one had a biloma with a patent hepatic artery. In 29 patients undergoing duplex sonography of the hepatic artery, six (21%) had absence of a Doppler arterial pulse. All six had abnormal angiograms: Four had thrombosis, one had a significant stenosis, and one had slow flow with biopsy-proven ischemia. Of 23 patients with a Doppler pulse, two had hepatic artery thrombosis at surgery. However, real-time sonography demonstrated focal inhomogeneity in the liver in both cases. Our data demonstrate that pulsed Doppler of the hepatic artery combined with real-time sonography of the liver parenchyma currently is the optimal screening test for selecting patients who require hepatic angiography after liver transplantation. A diagnostic algorithm is provided.

Radiographic assessment of the biliary tract is often essential in patients who have undergone liver transplantation. T- or straight-tube cholangiography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangiography all may be used. A total of 264 cholangiograms in 79 adult liver transplant patients (96 transplants) was reviewed. Normal radiographic features of biliary reconstructive procedures, including choledochocholedochostomy and choledochojejunostomy, are demonstrated. Complications diagnosed by cholangiography included obstruction, bile leaks, and tube problems, seen in eight, 24, and 12 transplants respectively. Stretching and incomplete filling of intrahepatic biliary ducts were frequently noted and may be associated with rejection and other conditions. Transhepatic biliary drainage, balloon catheter dilatation of strictures, replacement of dislodged T-tubes, and restoring patency of obstructed T-tubes using interventional radiologic techniques were important in avoiding complications and additional surgery in selected patients.

Because the hepatic artery provides the only blood supply to the biliary tree of a liver allograft, posttransplantation arterial occlusion may result in a biliary complication. Cholangiograms were reviewed retrospectively in 31 transplant patients who had proved complete or partial occlusions of the hepatic artery (thrombosis in 29 and marked stenosis in two). Cholangiograms were abnormal in 26 (84%). The most common abnormality, seen in 16 patients, was nonanastomotic contrast leakage from the donor intra- or extrahepatic bile ducts. Strictures of the donor biliary tree occurred in 14 patients, four of whom also had a nonanastomotic bile leak. In 12 of the 14, the strictures were nonanastomotic. Other findings included poor filling of the intrahepatic bile ducts, generalized donor ductal dilatation and irregularity, and intraductal filling defects. Sixteen (89%) of 18 transplants with nonanastomotic contrast leakage had occlusions of the hepatic artery. Of 21 transplants with nonanastomotic strictures, 12 (57%) had occlusions of the hepatic artery. Only two (10%) of 20 transplants with biliary anastomotic strictures had arterial occlusion. We conclude that liver transplant recipients who exhibit nonanastomotic contrast leakage or nonanastomotic strictures on cholangiography should be evaluated for occlusion of the hepatic artery as the probable cause.

During the past 5 years, 104 angiographic studies were performed in 87 patients (45 children and 42 adults) with 92 transplanted livers for evaluation of possible vascular complications. Seventy percent of the studies were abnormal. Hepatic artery thrombosis was the most common complication (seen in 42% of children studied, compared with only 12% of adults) and was a major complication that frequently resulted in graft failure, usually necessitating retransplantation. In six children, reconstitution of the intrahepatic arteries by collaterals was seen. Three survived without retransplant. Arterial stenosis at the anastomosis or in the donor hepatic artery was observed in 11% of patients. Portal vein thrombosis or stenosis occurred in 13% of patients. Two children and one adult with portal vein thrombosis demonstrated hepatopetal collaterals that reconstituted the intrahepatic portal vessels. Uncommon complications included anastomotic and donor hepatic artery pseudoaneurysms, a hepatic artery-dissecting aneurysm, pancreaticoduodenal mycotic aneurysms, hepatic artery-portal vein fistula, biliary-portal vein fistula, hepatic vein occlusion, and inferior vena cava thrombosis.

We investigated the cholangiographic appearance of intrahepatic bile ducts in 56 liver transplants and correlated the findings with biopsy evidence of acute rejection and other histologic diagnoses. Mild to moderate narrowing, stretching, separation, and poor filling of the bile ducts were common. Narrowing was present in 69 (92%) of 75 studies and was at least moderate in degree in 14 (19%). Duct separation was seen on 39 (58%) of 67 cholangiograms and was usually mild but was more pronounced in 10 (15%). In 22 (25%) of 89 studies, 10 or fewer branch ducts were filled. Cholangiographic abnormalities were more marked in patients with biopsy diagnoses of moderate-severe and partially treated acute rejection than with findings of mild rejection or nonspecific histology. Portal tract cellular infiltration and edema, liver swelling and, possibly, loss of small bile ducts correlated with the radiologic changes. However, the severity of the radiographic changes varied in all histologic categories. Acute rejection contributes to intrahepatic duct narrowing, separation, and poor filling on cholangiography in liver transplants, but the cause of the changes is probably multifactorial. Cholangiography is limited as a test for rejection and other hepatic parenchymal abnormalities in individual patients, but it may provide evidence supporting the need for liver biopsy in the evaluation of hepatic dysfunction after transplantation.

Between February 1981 and June 1984, 15 patients with benign biliary strictures were treated with percutaneous transhepatic balloon dilatation. Three of these patients had received liver transplants. The treatment began with a course of balloon dilatation therapy, after which a stent catheter was left across the stricture. Six weeks later, after duct patency had been shown by cholangiography, the stent catheter was removed from all but two patients, both of whom had intrahepatic sclerosing cholangitis. After this procedure, six patients (40%), including two liver-transplant patients, were stricture-free after one treatment for periods ranging from 27 to 56 months, and were considered to be treatment successes. Nine patients (60%) suffered stricture recurrences. In eight of these patients, the stricture was heralded by symptoms of either cholangitis or jaundice; in one patient, who was on permanent catheter drainage, the stricture was discovered only on follow-up cholangiography. All successfully treated patients had only one stricture, while all patients with more than one stricture suffered recurrences. Our data also suggest a greater responsiveness for anastomotic strictures than for non-anastomotic strictures. Of the patients with recurrences, five had symptom-free intervals of 23 months or more (up to 31 months). The fact that strictures recurred after such long periods of time underscores the importance of long-term follow-up. In view of the number of patients helped, the favorable experience with post-liver-transplantation strictures, and the lack of any major complications in our series, percutaneous biliary balloon dilatation offers a viable alternative to surgical management of benign biliary strictures.