Single operator cholangioscopy in liver transplanted patients. Registry of the BASALT study group

Aims Single-operator cholangioscopy (SOC) recently raised as a valuable procedure to assist treatment of biliary complications after liver transplantation (LT) and ERCP failure, as reported in single-centre case series.

Methods Registries of the Endoscopic Centers (Biliary Anastomotic Stricture After Liver Transplantation – BASALT Study Group) working with the Liver Transplantation Centers were reviewed on a national basis in Italy.

Results Since 2019 among seven Centers performed 26 SOCs in 23 LT patients (18 M, mean age 59) after a mean time of 24 (1-180) months after liver transplantation; 19% of the patients had a T-tube assisted biliary anastomosis which has been already removed at the time of endoscopic therapy. SOC was needed following a median of 1 (range 1-2) failed ERCPs. Fifteen LT patients (65%) complained biliary obstructive symptoms. In 16 cases SOC was considered to pass a severe anastomotic stricture (AS) or non anastomotic stricture (NAS) in two, in two to treat biliary stones, in one to check for filling defects (Cast Syndrome), in three to assist stenting in major anastomotic leaks or remove migrated stent in two. Success was achieved in 18 (69%) cases, i.e. 77% in anastomotic stricture, 60% in non anastomotic stricture, 100% in stones, 66% in major leak, 50% in stent removal. Second-line treatment was successful in 5/8 cases by ERCP (1) or percutaneous rendez-vous (4). Overall, SOC was successful in 73% of cases as a first-line and in 50% as a second-line during a percutaneous rendez-vous procedure. Further third-line treatment by magnetic compression anastomosis technique was successful in two patients. SOC failure in first-line occurred in 7 cases (3 AS, 2 NAS, 1 removal of metallic stent, 1 leak). Adverse events occurred in 11% first-line SOC, i.e. mild pancreatitis, cholangitis and a type 2 Stapfer’s perforation treated with fully covered SEMS, and in 28% of second-line percutaneous rendez-vous, i.e. two cholangitis. Patients with AS underwent plastic multistenting (PMS) in 12 and fully covered SEMS in 4. Stricture recurrence occurred in one patient after SEMS, successfully treated by PMS. Overall clinical success was achieved in 91% (21/23) LT patients. Hepatico-jejuno anastomosis was needed in two patients for severe AS after SOC failure and AS recurrence.

Conclusions In cases of major biliary complications after LT, SOC was successful after failed ERCP in most cases, limiting the surgical rescue therapy to a very minority. In severe anastomotic stricture managed with SOC, PMS should be considered the optimal treatment.

Publication History

Article published online:
27 March 2025