Post transplant anastomotic site leakage

Well a refreshing break from all the anastomotic strictures that we had been dealing with earlier!

This 52 year old gentleman had undergone live related transplant in February this year at our centre. He he recently developed right upper quadrant pain. He was a febrile. His labs showed raised ALP and GGT. The ultrasound detected a collection in the sub hepatic area and epigastrium. On MRCP a large collection was seen in at the anastomotic site confirming a leak (A: red arrow shows the leak and white arrow marks the anastomotic site). Contrast injection on ERCP initially showed a sharp cutoff at the site of anastomoses (B: black arrow). Further contrast injection and guide wire progression showed both the leak and the graft biliary channels. Our guide wire kept going into the leak site rather than the channels proximal to the leak (C: white arrow shows the guidewire going into the collection and red arrow indicates our desired guidewire path). Finally we were successful (we got one of our interventional radiologists to manipulate the guidewire rather than our regular assistant. He decided to use his own glide wire for the purpose. These IR guys can work miracles with a wire) and our wire went past the leak and into a graft biliary channel (D: blue arrow shows a significant link in the wire at the leakage site and black arrow shows it in the graft duct). Further manipulation of the wire improved the link (E &F: white arrows. The black arrow in F shows a now smooth wire track on which would ride our stent assembly). A 7 French stent of 12 cm length was deployed (G: black arrows show the stent and blue arrow indicated the level of leak, now properly bridged by the stent).