Intracavity rendezvous procedure

Biliary complications are common after liver transplantation, and the vast majority of these can be managed endoscopically [1] [2]. We describe a case of a spontaneous bile leak after liver transplantation which eventually required an extraductal rendezvous to re-establish recipient and donor bile duct continuity.

A 47-year-woman underwent liver transplantation (donation after brain death, duct-to-duct anastomosis) for end-stage liver cirrhosis. Two weeks after transplantation she was diagnosed with a bile leak ([Fig. 1]). The patient initially had two endoscopic retrograde cholangiopancreatograms performed and both demonstrated a bile leak at the level of the biliary anastomosis. On both occasions it proved impossible to pass a guidewire into the donor duct ([Fig. 2]). A percutaneous transhepatic cholangiogram was performed, but the recipient duct could not be accessed ([Fig. 3]).

Fig. 1 Abdominal computed tomography demonstrates the intra-abdominal collection.

Fig. 2 Endoscopic retrograde cholangiopancreatography shows contrast leakage at the biliary anastomosis.

Fig. 3 Percutaneous transhepatic cholangiography shows contrast leakage at the biliary anastomosis with no delineation of the recipient duct.

A rendezvous procedure was undertaken. Endoscopically, a guidewire (450 cm, 0.018 inch; Terumo, Tokyo, Japan) was passed into the biloma. The guidewire was then snared with an Amplatz Goose Neck loop snare (6 Fr, 15 mm; ev3 Inc. Plymouth, Maine, USA) to establish access across the leak ([Fig. 4]; [Video 1]). The Terumo wire was then exchanged for a VisiGlide wire (450 cm, 0.025 inch; Olympus, USA). The donor:recipient duct anastomotic site was dilated with a dilatation balloon (6 mm, 4 cm; Hurricane RX, Boston Scientific, USA) before a fully covered self-expanding metal stent (8 mm, 4 cm; Kaffes stent, Taewoong Medical, Japan) was inserted over the guidewire across the anastomosis. Further contrast injection through the percutaneous route did not demonstrate a bile leak ([Fig. 5]). The patient was discharged home 2 days later without any complications.

Fig. 4 Guidewire passed successfully across the anastomosis.

Video 1 Rendezvous procedure in the biloma to re-establish donor:recipient duct continuity following spontaneous bile leak after liver transplantation.

Fig. 5 Fully covered self-expanding metal stent deployed across the anastomosis and contrast passed through the stent into the small bowel with no leakage.

An intracavity rendezvous procedure is a viable management solution in cases where endoscopic retrograde cholangiopancreatography and the percutaneous transhepatic approach have failed to resolve a bile leak after liver transplantation. A novel fully covered self-expanding metal stent (Kaffes stent) can be used to bridge the anastomotic area between the donor and the recipient duct.

Endoscopy_UCTN_Code_TTT_1AR_2AJ

Publication History

Article published online:
04 February 2021

• References

• 1 Kochhar G, Parungao JM, Hanouneh IA. et al. Biliary complications following liver transplantation. World J Gastroenterol 2013; 19: 2841-2846
• 2 Thuluvath PJ, Pfau PR, Kimmey MB. et al. Biliary complications after liver transplantation: the role of endoscopy. Endoscopy 2005; 37: 857-863