First ERCP for post transplant anastomotic stricture (CASE M)

This 60 year old gentleman had undergone live related liver transplant a couple of months ago. He had developed anastomotic stricture along with a large collection that was also contributing to obstruction by extrinsic compression upon the biliary confluence and proximal CBD (A: MRCP images. White arrows show the dilated intrahepatic biliary channels and red arrow shows the collection in the sub-hepatic space). A drain was placed to treat the collection. We initially attempted an ERCP but getting across the stricture was unsuccessful due to the combined effect of a tight stricture and extrinsic compression. Since the patient was showing signs of cholangitis, quick drainage was mandatory. We asked the interventional radiologist to place a percutaneous transhepatic biliary drainage (PTBD) catheter over a guidewire. We would then utilise the guidewire to do a railroad endoscopic biliary stenting. On ERCP, the guidewire was grabbed with a snare and the wire was pulled through the channel of the scope. Contrast injection outlined the biliary tree and stricture (B: White arrow shows the PTBD catheter. Red arrow shows the abdominal catheter used to drain the collection also seen in A. Blue arrow shows the guidewire which has now been pulled into the scope. Black arrow shows the dilated intrahepatic duct in the graft). A stent assembly was then placed over the guidewire (C: Black arrows). A 7 French diameter stent of 12 cm length was then deployed (D1 & D2: Black arrows mark the deployed stent. Blue are shows the PTBD catheter. Red arrow marks the abdominal drain in the subhepatic space. White arrow shows the injected contrast which has decreased in size after stent placement-compare D1 with D2).