Biliary tract complications are a source of morbidity and mortality after orthotopic liver transplantation (OLT). Since 1994 we have utilized the direct duct to duct anastomosis without T-tube drainage to avoid T-tube tract leaks. Biliary strictures occur most frequently at the choledochocholedochal anastomosis. We reviewed our experience with endoscopic, percutaneous, and surgical treatment of biliary anastomotic strictures after OLT during a 2.5 year period. Methods: 219 adult pts received OLT between 1/1/94 and 6/30/96. 23 pts (10.5%) developed biliary anastomotic strictures. Cholangiography was done with rising liver tests, symptoms, and a nondiagnostic liver biopsy. All pts were assessed pre- and post-"definitive" therapy for symptoms of biliary tract disease, graft function, and procedure-related complications. Complete response was defined as presence of a normal appearing anastomosis, normalization of liver tests, and resolution of symptoms. Data was analyzed using analysis of variance. Results: The mean age of pts was 50 years (range 35-65) 16M and 7F. Pts presented at a mean of 42 days (range 4-307); 91% within 3 months following OLT. There were no statistically significant differences in regards to sex, age, etiology of liver disease, warm ischemia time, presenting symptoms, or latency. Endoscopie retrograde cholangiopancreatography (ERCP) was performed in 20 pts; 15 of them for therapeutic purposes. 13 had stems placed; 8 with balloon dilation (BD), 5 with bougie dilation, and 5 required endoscopic sphincterotomy (ES), 1 pt was treated with balloon dilation alone and one with ES + BD. 7 of 13 pts underwent 1 stent exchange. Mean indwelling stent time was 48 days. A complete response was seen in 9/15 (60%) pts; 6/15 failed and were treated surgically. ERCP's were complicated by self-limited cholangitis (1) and pancreatitis (1). 9 pts had percutaneous transhepatic Cholangiography (PTC); 4 with external drainage alone; 5 were treated with an internal stent and BD, one of those was a surgical failure. 2 pts had a complete response and 3 required surgery. The PTC's were complicated by a biloma (1). 12 pts underwent surgical conversion to Roux-en-Y choledochojejunostomy (RYCJ); 10 had complete responses, 2 failed due to Roux obstruction and recurrent cholangitis. There were no deaths. Mean follow-up time was 13 months. There were no statiscally significant differences in outcome among the 3 treatment groups (p=0.58). Conclusions: 1) Endoscopie therapy is an effective and safe alternative to reconstructive surgery. 2) A trial of endoscopic therapy with dilation and stenting is warranted and justified as first-line treatment of anastomotic strictures complicating OLT. 3) Surgery is indicated for recurrent strictures, cholangitis, and failures of endoscopic or percutaneous therapy.