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Needle knife recanalization of a complete post-transplant bile duct stricture
Benign biliary strictures are established complications after liver transplantation, commonly occurring at the duct-to-duct anastomosis . Severe anastomotic strictures may not be amendable to the gold standard endoscopic therapy.
A 65-year-old-man with a history of alcoholic cirrhosis who had undergone liver transplantation 1 year previously was referred for endoscopic retrograde cholangiography (ERCP) after outpatient laboratory evaluation revealed signs of cholestasis and magnetic resonance cholangiopancreatography (MRCP) revealed a complete anastomotic stricture ( [Fig.1]). ERCP was performed and confirmed these findings; in addition, difficulty was encountered while attempting to traverse the stricture with a 0.025-inch guidewire ([Fig. 2 a]). Cholangioscopy was performed, but manipulation with cholangioscopic biopsy forceps was unsuccessful. The guidewire was downsized to a 0.018-inch wire and the stricture was traversed; however, attempts to dilate the anatomic stricture with various dilating catheters were unsuccessful. A needle knife was then loaded over the guidewire, electrocautery was applied, and the stricture was recanalized successfully ([Video 1]). After this maneuver, there was no evidence of contrast extravasation, which would have suggested bile duct injury ([Fig. 2 b]). A follow-up ERCP 4 weeks later revealed improvement in the anastomotic stricture and a 0.035-inch guidewire was easily passed beyond the stricture ([Fig. 2 sc]). This allowed for routine biliary balloon dilation to 6 mm and placement of a 12-cm 11.5-Fr stent.
Video 1 Needle knife recanalization of a complete bile duct stricture following liver transplantation.
Bile duct recanalization has previously been achieved using a combined percutaneous and endoscopic approach . Gupta et al. used a specific needle knife for puncture that allowed a wire to pass through the needle and stricture . Recently, a standard needle knife has been used to cut and puncture these strictures . In our case, cholangioscopic guidance was first used to pass a wire, which allowed for a controlled cut using the loaded needle knife. This technique may be used as a minimally invasive alternative to surgical repair in short anastomotic strictures.
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19 February 2021 (online)
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