Subscribe to RSS
DOI: 10.1055/a-0896-2360
A novel way to avoid reoperation for biliary strictures after liver transplantation: cholangioscopy-assisted guidewire placement
Publication History
Publication Date:
04 June 2019 (online)
Biliary tract complications after liver transplantation remain a major therapeutic issue significantly affecting graft and patient survival [1]. Strictures of the bile duct account for about 40 % of biliary complications after liver transplantation [2]. Today, endoscopic retrograde cholangiography (ERC) has widely replaced surgery and percutaneous techniques as the treatment of choice for such patients [3]. However, highly fibrotic strictures of the anastomotic region frequently preclude passage of the guidewire. In these cases, percutaneous transhepatic cholangiography (PTC), endoscopic ultrasound-guided biliary drainage, or indication for resection of the stenosis-bearing extrahepatic biliary segment with subsequent biliodigestive anastomosis are applied, all of which are associated with increased morbidity.
We present here three patients with late fibrotic strictures of the anastomotic region after deceased donor liver transplantation ([Table 1]). ERC revealed high grade stenosis that was impossible to pass despite various ERC maneuvers, including use of hydrophilic guidewires, occlusion balloons, and rotatable sphincterotome ([Fig. 1]). Using single-operator cholangioscopy (SpyGlass DS direct visualization system; Boston Scientific), the pin-sized orifice could be identified in all cases ([Fig. 2]). Only direct visual guidance allowed placement of a 0.025-inch hydrophilic guidewire through the stricture in two patients ([Fig. 3]). In one patient, pre-dilation of the stricture by means of biopsy forceps allowed subsequent guidewire placement ([Fig. 2 b]). Gradual mechanical dilation and stent placement were achieved in all three cases, avoiding alternative more invasive and riskier procedures. Consequently, direct cholangioscopy resulted in a therapeutic success in all three cases after failure of standard ERC.
Video 1 Cholangioscopy-assisted guidewire placement in a patient with biliary stricture after liver transplantation.
Quality:
From our experience we conclude that single-operator cholangioscopy (SpyGlass) seems to be a useful therapeutic option in patients with highly fibrotic strictures post-liver transplantation. No procedure-related complication occurred. No further interventions, in particular PTC or surgery, with associated morbidity were needed.
Endoscopy_UCTN_Code_TTT_1AR_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
-
References
- 1 Duffy JP, Kao K, Ko CY. et al. Long-term patient outcome and quality of life after liver transplantation: Analysis of 20-year survivors. Ann Surg 2010; 252: 652-661
- 2 Sauer P, Chahoud F, Gotthardt D. et al. Temporary placement of fully covered self-expandable metal stents in biliary complications after liver transplantation. Endoscopy 2012; 44: 536-538
- 3 Houben P, Gotthardt DN, Radeleff B. et al. Complication management after liver transplantation. Increasing patient safety by standardized approach and interdisciplinary cooperation. Chirurg 2015; 86: 139-145