Benign biliary strictures are established complications after liver transplantation,
commonly occurring at the duct-to-duct anastomosis [1]. 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.
Fig. 1 Magnetic resonance cholangiopancreatography (MRCP) image showing a severe, short
localized stricture.
Fig. 2 Cholangiogram images showing: a a wire coiling at the level of the stricture prior to the needle knife procedure;
b no evidence of contrast extravasation after needle knife electrocautery of the complete
anastomotic stricture; c the appearance at follow-up 4 weeks after the procedure.
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 [2]. Gupta et al. used a specific needle knife for puncture that allowed a wire to pass
through the needle and stricture [3]. Recently, a standard needle knife has been used to cut and puncture these strictures
[4]. 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.
Endoscopy_UCTN_Code_TTT_1AR_2AG
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