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 [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.

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• References

• 1 Safdar K, Atiq M, Stewart C. et al. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol 2009; 3: 183-195
• 2 Bukhari MA, Haito-Chavez Y, Ngamruengphong S. et al. Rendezvous biliary recanalization of complete biliary obstruction with direct peroral and percutaneous transhepatic cholangioscopy. Gastroenterology 2018; 154: 23-25
• 3 Gupta K, Aparicio D, Freeman ML. et al. Endoscopic biliary recanalization by using a needle catheter in patients with complete ligation or stricture of the bile duct: safety and feasibility of a novel technique (with videos). Gastrointest Endosc 2011; 74: 423-428
• 4 Martins FP, De Paulo GA, Macedo EP. et al. Endoscopic biliary recanalization with a needle-knife in post liver-transplant complete anastomotic stricture. Endoscopy 2012; 44: 304-305