*Purpose: We evaluated the quality of endoscopic intervention for biliary complications after liver transplantation in a diverse urban center.

*Methods: A retrospective chart review of liver transplant recipients from 2015-2018 were included. Exclusion criteria included age >18, pre-transplant biliary complications including strictures, leaks, primary biliary cirrhosis, primary sclerosing cholangitis, and previous cholecystectomy. Background information included age, race, and donor type (deceased brain death (DBD), deceased cardiac death (DCD), and living donor transplant (LDT)). 1^st and 2^nd ERCP data included biliary complications. Analysis was performed using chi-square and Fisher’s exact tests.

*Results: 320 patients received a liver transplantation over the course of academic years 2015 (Y1, n=36), 2016 (Y2, n=29), and 2017 (Y3, n=29) respectively. 63.8% were male, 72.3% Caucasian, with mean age 57.4 years (range 23-71). Donors were 7.4% LDT, 78.7% DBD, and 13.8% DCD. ERCP was performed on an average of 1.97 months from transplant and an average of 2.96 times per patient. Patients undergoing ERCP for Y1 was 35.6%, Y2 23.2%, and Y3 31.5% of total transplantations (p=0.111). Initial ERCP showed abnormal findings in 90.2% including strictures (76.1%), biliary sludge (28%), stones (16.1%) and bile leak (7.5%). 80% required a follow up ERCP, with 65.8% having persistence of initial findings requiring repeat treatment. 28.6% of patients with bile leak who underwent repeat ERCP had persistent leak. Presence of biliary complications did not significantly increase mortality. Death among patients receiving ERCP was 8.5% versus 8.0% of those not needing ERCP (p=0.871). Repeat biliary surgery was needed in 4.3% (p=0.054), 42.9% (p=0.008), and 20% (p=0.081) of patients with strictures, bile leak and stones on initial ERCP respectively. Death among patients with stricture, bile leak and biliary stones was 4/66 (6.1%), 1/7 (14.3%), and 0/15 (0%) respectively. There was no statistical difference between Y1, Y2 and Y3 for overall positive findings on initial ERCP (p=1.000), strictures (p=0.980), bile leak (p=0.886) or stones (p=1.000). There was a trend towards increased bile leak among patients with history of intraoperative thrombectomy versus those without (20% vs 7.5%). There were no differences between LDT, DCD and DBD for overall positive findings on initial ERCP (p=0.814), strictures (p=0.167), bile leak (p=0.575) or stones (p=0.167).

*Conclusions: Initial ERCP when indicated, had a high likelihood of positive findings. Treatment on ERCP was most likely to be needed for patients with a stricture. Biliary complications did not significantly impact death. ERCP alone was able to resolve the biliary issue in the vast majority of patients with abnormal findings.

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