Bile leak grade predicts time-to-healing and subsequent biliary stricture after liver transplantation

Background & Aims Biliary leaks after liver transplantation predispose to strictures, but leak-specific endoscopic strategies remain heterogeneous. We evaluated leak- and procedure-related predictors of time-to-closure and 12-month stricture. Methods Single-center retrospective cohort (Jan 2020–Jun 2024) of adults with radiologically confirmed leak treated by ERCP within 24 h. Leaks were graded (high vs low) and timed (early ≤ 4 weeks vs late). Primary outcome: days to closure (clinical–biochemical–radiologic composite). Secondary outcome: stricture ≤ 12 months. Results Thirty-four patients were analyzed. Median time-to-closure was 16 days (IQR 10–25); early leaks healed more slowly than late (21.1 vs 13.0 days; p = 0.01). High-grade leaks required more ERCPs. In multivariable models, high-grade leak and an ERCP interval ≥ 1 month predicted delayed closure, whereas an initial 10 Fr plastic stent was associated with faster healing in univariable analyses. Within 12 months, 18/33 (54.5%) developed strictures—all after high-grade leaks; after adjustment, timing and stent caliber were not significant. Conclusions Leak grade is the key determinant of both healing kinetics and stricture risk. A grade-based approach—early large-caliber (10 Fr) plastic stenting with close surveillance for high-grade leaks, minimalist single-stent therapy for low-grade—may reduce procedure burden and downstream biliary morbidity.