Post liver transplant anastomotic biliary stricture (CASE H)

This 42 year old gentleman had undergone a non related living donor liver transplant at a foreign centre one year ago (March 2014). For the past 6 weeks he had been complaining of pruritus and clay coloured stools. Liver biochemistry revealed rising ALP and bilirubin levels. His MRCP showed a subtle anastomotic stricture (A: red arrow) and prominent intrahepatic biliary channels (A: blue arrows). Contrast injection on ERCP showed the stricture (B: red arrow0 but the guidewire kept going into a sharp bend (B: white arrow) and kept curling up on itself (C: white arrow). We were finally able to get our guidewire across (D: black arrows) whilst avoiding the bend. Our papillotome was then pushed up along a mightily curved path (E: black arrow). The track was first dilated using a 7 French graduated dilatation catheter (F1: black arrows show the catheter while the red arrow indicates the level of stricture). This was followed by a larger 8.5-10 French catheter (F2 & F3: black arrows. Note: Star Wars fans will notice the uncanny resemblance of this catheter's "mouth" to Greedo's). A 7 French stent of 15 cm length was planned to be deployed. This went south as we weren't able to push the stent beyond even the first curve of the hairpin (G: white arrows show the failed stent deployment proximal to the stricture). No fear! We went again with aching muscles and did a repeat dilatation of the track with our  10 French "Greedo" catheter (H: black arrows show the catheter snaking up and red arrow marks the stricture site). A 7 French stent of 12 cm length was deployed. 

Note: This exercise highlights the difficulty while traversing a stricture using  smaller 7 French stent as these are deployed directly over the guidewire without the assembly. No assembly means less stiffness and strength which in turns translates to the stent bending before rather than pushing through an area of resistance.

Fourth follow-up ERCP for post lover transplant anastomotic stricture (CASE A)

This 50 year old gentleman had come for his 4th follow up procedure after developing jaundice and recurrent fever. We removed his old plastic sent placed during his previous (3rd) ERCP http://ercp365.blogspot.com/2014/09/third-follow-up-ercp-for-post.html using a snare. Contrast injection outlined the anastomotic stricture (A: black arrow). We dilated the stricture using a TTS balloon inflated to 8mm (B: white arrows show the balloon assembly in place at the stricture site with the balloon inflated). A 10 French plastic stent of 12 cm length was placed. 

Second follow up ERCP for post transplant anastomotic biliary stricture (CASE D)

This 40 year old gentleman had undergone a living donor liver transplant in June 2013 at our centre. He had developed repeated episodes of fever and right hypochondrial pain along with rising bilirubin in December. He was diagnosed with an anastomotic biliary stricture (A: red arrow) . He then traveled abroad and underwent ERCP with placement of a plastic biliary stent of 7 French diameter and 12 cm length. Over the past two weeks, his bilirubin levels had increased and he had been having recurrence of his hypochondrial pain. We suspected a blocked stent. This was confirmed visually and the stent was removed (B1 & B2). Contrast injection outlined the stricture (C: red arrow). A 3cm TTS balloon of 10mm diameter was maneuvered to the stricture (D: black arrows) and inflated (E: white arrow shows the waist of the balloon during inflation). A 12 cm long 10 French plastic stent was placed (F: white arrows).

Follow up ERCP of a post liver transplant biliary stricture (CASE C)

This 54 year old gentleman had earlier undergone ERCP and stricture dilatation followed by plastic stent placement in December last year http://ercp365.blogspot.com/2013/12/post-liver-transplant-anastomotic.html. He had a 12 cm long 10 French plastic stent in situ. His bilirubin levels were rising and the ultrasound scan showed no pneumobilia. We found the stent to be blocked and removed it. A sweep of the bile duct with balloon extruded a large cast (A: white arrow). Following a clean sweep of the CBD (B), we placed a guidewire in the right anterior duct (C1 & C2: white arrow) and a second guidewire in one of the segment VIII ducts (C2: blue arrow). This was followed by TTS balloon dilatation with an 8mm diameter balloon of the segment VIII duct (D: white arrows) and of the site of anastomosis of anterior and segment VIII ducts with the main bile duct (E: white arrows). We then passed two plastic stents, both of 10 French diameter.  The shorter, 12 cm stent was placed in the right anterior duct (F: black arrows). The longer, 15 cm stent was placed in the one of the segment VIII branches (F: white arrows). 

Post transplant anastomotic biliary stricture occurring 7 months after surgery (CASE A)

This 50 year old patient had undergone a living donor liver transplant seven months ago. His latest liver enzymes showed a raised alkaline phosphatase and gamma glutamyl transferase. A liver biopsy showed mild rejection. His MRCP films showed an anastomotic stricture (A: white arrow). On ERCP, we kept going into the pancreatic duct (B: white arrows). We thus decided to leave our guidewire there and go for the CBD with the second wire. This was successful (C: white arrows show the second guidewire in the CBD while black arrows show the first wire in the pancreatic duct). Contrast injection showed a sharp cutoff at the level of anastomosis (D: white arrow). Our standard 0.035 inch guidewire just couldn't negotiate this stricture and we decided to use a thinner 0.025 inch glide wire. This wire was maneuvered across successfully (E: white arrow). Repeat contrast injection showed a picture very similar to the MRCP film (F: white arrow marks the site of anastomotic narrowing and black arrows show the dilated intrahepatic channels). We dilated the stricture with a 9 French graduated dilatation catheter (G: black arrow) and placed a 12 cm long plastic stent of 8.5 French diameter. He will be followed up with serial ultrasounds and LFTs with a second ERCP due in a few months. 

Third follow-up ERCP for post transplant anastomotic biliary stricture

This 37 year old hospital nurse had undergone living donor liver transplant for Hepatitis C related liver disease. She had developed an anastomotic biliary stricture for which we had done two ERCPs previously, one in September http://ercp365.blogspot.com/2013/09/post-liver-transplant-anastomotic_10.html (single 12 French plastic stent passed) and second in December (Two 10 French plastic stents placed). The latest ultrasound suggested blocked stents. This was confirmed visually (A). Both the stents were removed with snare (B). Contrast injection showed the narrowing in the anastomotic site (C: white arrow). We decided to use a 3cm long, 10mm diameter TTS balloon rated at 90 psi (D) for stricturoplasty. The balloon was inflated in the stricture area (E1 to E3: white arrows). We then swept the CBD with a balloon to clear any sludge. An occlusion cholangiogram showed successful treatment of the stricture (F: white arrow). Although we were thinking pre procedure of placing three stents, the stricturoplasty results made us decide against it. No stents were placed and the patient will now be followed with serial bilirubin levels and ultrasound scans.

Anastomotic biliary stricture developing 3 weeks after living donor liver transplantation

A 54 year old gentleman with liver cirrhosis secondary to Hepatitis C. He received a right lobe graft from his nephew. This stricture was noted three weeks post transplant. The stricture was evident ton cholangiogram during ERCP (A: white arrow). A 12cm plastic stent of 10 French diameter was placed (B &  C: white arrows). There was a lot of sludge coming out of the stent and we suspect that the stent may get blocked sooner rather than later.

A 40 year old patient with cirrhosis of the liver and biliary stricture

This 40 year old patient had cirrhosis of the liver and a biliary stricture. He had undergone extensive workup for his liver and biliary disease, save for a liver biopsy. His tumor markers were normal, and so was his colonoscopy. He had earlier undergone ERCP with stent placement seven months ago. His latest MRCP showed dilated intrahepatic biliary channels (A & B: green arrows) and a stricture at the level of junction of the common hepatic and cystic ducts (A & B: white arrow). We placed a 10 French plastic stent of 10cm length. He has been admitted for further workup. A liver biopsy is on the cards.

Cirrhosis of liver with biliary stricture

The patient was a 50 year old lady who had a history of pruritus and liver disease. Viral serology, metabolic profile and autoimmune profiles were normal. Lately she developed recurring jaundice with raised ALP. MRCP showed a distal CBD stricture. On ERCP, intrahepatic channels were poorly outlined on dye injection-the "pruned biliary tree"(red arrow). The CBD showed distal tapering (red arrow). We did a sphincterotomy. That was sufficient to drain the biliary system. The negative shadows in the CBD were only air bubbles (green arrow).

Obstructive jaundice secondary to hilar mass

This was a middle aged lady with a large right ovarian mass and obstructive jaundice caused by a mass lesion in the hilar region. She was extremely obese and couldn't lie prone. We did the procedure in the left lateral position. Initial contrast injection showed a sharp cutoff at tue levelcof cystic duct (A: green arrow). The guidewire was passed beyond the stricture followed by contrast injection which outlined a dilated left system with no contrast going into the right system (B: green arrow). We dilated the stricture with a 9F dilatation catheter followed by placement of a 10F x 12cm plastic stent (C & D: green arrow).

When ERCP and MRCP differ

This was a 50 year old gentleman who had been referred after an MRCP showed a stricture below the hilum (A: green arrows) and fine tapering in the lower end of CBD (A: red arrows). When we did a cholangiogram the CBD was dilated with no stricture below the hilum (B: green arrow), however the lower CBD stricture was as it had been reported in the MRCP (B: red arrow). We passed a 10F x 10cm plastic stent to drain the biliary system (C: green arrow).