Prior sphincterotomy can impact the type of biliary complications following liver transplantation with duct-to-duct anastomoses.

It is unknown whether having undergone a sphincterotomy before liver transplantation (LT) affects biliary complications post-LT in patients undergoing duct-to-duct anastomoses. We performed a nested matched case-control study among 5950 adult LT recipients from 3 centers who underwent duct-to-duct biliary anastomosis (January 2010-December 2023). Patients who underwent ERCP with sphincterotomy unrelated to the etiology of cirrhosis (i.e., excluding primary sclerosing cholangitis, extrahepatic cholangiocarcinoma, or prior LT) were matched 3:1 to controls by age, sex, and graft type (deceased donor vs. living donor). Outcomes included post-LT biliary complications and infections (cholangitis or extrahepatic). Conditional logistic regression was performed. A total of 64 patients with pre-LT sphincterotomy were matched to 192 controls. The most frequent indication for ERCP before LT was choledocholithiasis. Overall, biliary complications occurred in 25% versus 28.1% (matched OR 0.85, 95% CI 0.45-1.62; p =0.63), with comparable 1-year (18.8% vs. 22.4%) and 5-year (25% vs. 25.5%) incidence. There was an increased risk of choledocholithiasis (12.5% vs. 4.7%; matched OR 3.55, 95% CI 1.13-11.18; p =0.03) and cholangitis (12.5% vs. 3.1%; matched OR 4.47, 95% CI 1.45-13.78; p =0.009) in the sphincterotomy group. Anastomotic strictures (15.6% vs. 21.4%, p =0.32), non-anastomotic strictures/ischemic cholangiopathy (6.2% vs. 5.2%, p =0.8), and bile leaks (7.8% vs. 4.7%, p =0.3) were similar between both groups. A longer ERCP-to-transplant interval was associated with a significant time-dependent increase in overall biliary complications and anastomotic strictures (both p <0.01; particularly beyond 2.3 y), but not in cholangitis, choledocholithiasis, or bile leaks. For sphincterotomy performed <0.2 years before transplant, anastomotic strictures were at or below those of controls. Five-year graft and patient survival were not different. Pre-transplant sphincterotomy was associated with increased risk of developing choledocholithiasis and cholangitis following liver transplant, without any difference in biliary strictures or bile leaks.