*Purpose: Biliary strictures are associated with significant morbidity after pediatric liver transplantation. There are two main treatment options which are percutaneous transhepatic cholangiography (PTC) and stent placement or surgical revision. The optimal approach is still debated. We performed a cost effectiveness analysis comparing both therapies.

*Methods: We designed a Markov decision analysis model using TreeAgePro to simulate a cohort of patients treated for post liver transplant biliary strictures with 5 years of follow up. Transition probabilities were based on review of published literature on outcomes of pediatric patients with biliary complications. Treatment success was defined as absence of stricture recurrence for 12 months following intervention. Health utilities were estimated based on published literature and expert opinion. Cost variables defined using billing data from our institution. Willingness to pay (WTP) was set at $100,000/QALY. For each intervention we calculated cost and quality adjusted life years (QALYs), which were used to determine the incremental cost effectiveness ratio (ICER).

*Results: Stenting of biliary strictures provided 4.47 QALY over 5 years at a cost of $49,148 compared to surgical revision, which provided 4.56 QALY at the cost of $278,805 with an ICER of $655,500/QALY, which is well above our willingness to pay. Cost effectiveness estimates were most sensitive to changes in cost of surgery, success of stenting and health utility for surgery and stenting. Sensitivity analysis showed stent placement remained cost effective even when stent success rate was as low as 30%.

*Conclusions: Both stent placement and surgical revision result in similar QALYs but there are large cost differences. The current approach of treating biliary strictures first with stent placement by interventional radiology is cost effective compared to surgical revision using a WTP of $100,000.

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