Triamcinolone (TCN) injection was investigated for its potential benefit in the management of severe hilar bile duct strictures that were refractory ("defiant") to standard percutaneous or endoscopic management with balloon dilation (B-DIL). METHODS: 8 patients with severe, defiant strictures, (4 post-liver transplant (LTX), 4 postlap, chole (LAP)) were treated with submucosal injections via a sclerotherapy needle with 10% TCN in 0.5cc increments within the stricture segment, for a total of 50 to 100mg per stricture. A total of 21 injections were performed, ranging from one to five per patient. All strictures were located in either the right hepatic duct, the left hepatic duct, the common hepatic duct, or combinations of two or three ducts. LTX patients were treated via percutaneous catheter (PTC) or ERCP or combination procedure, whereas LAP patients were treated by ERCP only. B-DIL was then performed to 6, 8, or 10mm diameter for at least one minute at 12-14 atm pressure. Repeat cholangiography was conducted immediately afterward and at 3 week, 3 month, or 6 month intervals and stricture diameter measured Episodes of cholangitis, biliary obstruction, serum chemistries, and jaundice were followed. RESULTS: In the LTX group, all patients improved so that the previously placed PTC could be removed. 2 patients listed for retransplant were taken off the list. In the LAP group, TCN made the stricture more pliable and allowed the use of larger balloons, thus achieving a larger stricture diameter. There were no clinical failures in either group and there was only one complication of an asymptomatic trace bile duct leak in one patient. CONCLUSION: TCN injection is safe and improves the clinical outcome of B-DIL of defiant hilar bile duct strictures Successful endoscopic or percutaneous management can prevent the need for reconstructive biliary surgery in LAP patients or the need for retransplantation in LTX patients.