Endoscopy 2021; 53(12): E466-E467
DOI: 10.1055/a-1346-7555
E-Videos

Intracavity rendezvous procedure

Muhammad Farman
1  Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, UK
,
Pauline Kane
2  Department of Radiology, King’s College Hospital NHS Foundation Trust, London, UK
,
Stephen Gregory
2  Department of Radiology, King’s College Hospital NHS Foundation Trust, London, UK
,
Andreas Prachalias
1  Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, UK
,
Deepak Joshi
1  Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, UK
› Author Affiliations
 

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]).

Zoom Image
Fig. 1 Abdominal computed tomography demonstrates the intra-abdominal collection.
Zoom Image
Fig. 2 Endoscopic retrograde cholangiopancreatography shows contrast leakage at the biliary anastomosis.
Zoom Image
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.

Zoom Image
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.


Quality:
Zoom Image
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

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


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Muhammad Farman, MBBS, MRCPI
Institute of Liver Studies
King’s College Hospital NHS Foundation Trust
Denmark Hill
London
SE5 9RS
UK   

Publication History

Publication Date:
04 February 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Abdominal computed tomography demonstrates the intra-abdominal collection.
Zoom Image
Fig. 2 Endoscopic retrograde cholangiopancreatography shows contrast leakage at the biliary anastomosis.
Zoom Image
Fig. 3 Percutaneous transhepatic cholangiography shows contrast leakage at the biliary anastomosis with no delineation of the recipient duct.
Zoom Image
Fig. 4 Guidewire passed successfully across the anastomosis.
Zoom Image
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.