Planned and Unplanned Repeat ERCP After Endoscopic Therapy for Anastomotic Biliary Strictures Following Liver Transplantation: A Retrospective Cohort Study

Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for post-liver transplantation anastomotic biliary strictures. However, repeat ERCP may represent either planned staged treatment or unexpected biliary deterioration. We evaluated the burden, patterns, triggers, adverse events, and endoscopic outcomes of planned and unplanned repeat ERCP. Methods This single-center retrospective cohort study screened 113 post-liver transplantation patients who underwent ERCP between January 2019 and March 2026. After 33 patients were excluded, 80 eligible consecutive patients with anastomotic biliary strictures were included. Repeat ERCP was classified as planned or unplanned. The primary outcome was any repeat ERCP. Secondary outcomes included unplanned repeat ERCP, reasons for unplanned intervention, adverse events, and final endoscopic status. Results During a median follow-up of 39.2 months, 34 patients (42.5%) underwent at least one repeat ERCP. Seventy repeat sessions were recorded, including 56 planned and 14 unplanned sessions. Unplanned repeat ERCP occurred in 12 patients (15.0%) and was triggered by stent dysfunction (n = 5), cholangitis (n = 4), de novo biliary stones (n = 2), or recurrent jaundice (n = 1). Documented stent-free resolution was confirmed in 35 patients (43.8%), whereas 12 patients (15.0%) remained on ongoing endoscopic therapy. Post-ERCP pancreatitis occurred in 10 patients (12.5%); no bleeding or perforation occurred. No variable was independently associated with repeat ERCP in the full-cohort model. In an exploratory plastic-stent subgroup analysis, post-ERCP pancreatitis and biliary stones at index ERCP were associated with a higher hazard of repeat ERCP. Conclusions Repeat ERCP was common, but most repeat sessions were planned components of staged treatment. Unplanned repeat ERCP was mainly related to stent dysfunction, cholangitis, and biliary stones. Planned and unplanned repeat ERCP should be reported separately when assessing endoscopic treatment burden.