Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case L)

This 45 year old gentleman was undergoing ERCP for the second time. Earlier  a 7 French 12 cm had been placed in May of this year. He then developed pruritus and a rising alkaline phosphatase. His bilirubin levels remained normal. We removed the previously placed stent which was blocked. Contrast injection showed the strictured segment involving the posterior ductal branch of the graft and native bile duct (A: White arrow). This segment was dilated with a 6mm diameter balloon of 40 mm length. A thicker, 10 French stent of 12 cm length was placed (C: Black arrows).

Second ERCP for post liver transplant anastomotic biliary structure (Case G)

This 65 year old gentleman last underwent ERCP for his biliary stricture three months earlier http://ercp365.blogspot.co.uk/2015/04/post-liver-transplant-anastomotic_76.html. We had placed a 10 French plastic stent of 12 cm length at that time. He now presented with pruritis, mildly raised bilirubin and markedly raised ALP levels. An ultrasound showed no pneumobilia and prominence of intrahepatic biliary channels. We pulled the old stent (A: White arrow & B) with a snare (A: Black arrow). Contrast injection outlined the stricture site (C: Black arrow). We dilated the track with a graduated dilatation catheter, size 7.5F  to 10 French (D: Black arrow shows the dilation catheter crossing the stricture site) and placed a 12 cm long stent of 10 French size (E:Black arrows), same as last time .

Second follow up ERCP for post liver transplant anastomotic stricture (CASE A)

This was a 50 year old gentleman who had undergone living donor liver transplant in June 2013. He underwent his first ERCP after developing an anastomotic stricture in February. An 8.5 French stent of 12cm length was placed after dilating the stricture with graduated dilatation catheters http://ercp365.blogspot.com/2014/02/post-transplant-anastomotic-biliary.html. We removed his previously placed stent. Contrast injection outlined a persistent stricture (A: Black arrow). We dilated the stricture using a 6 mm balloon of 3 cm length (B: White arrows). A 10 French plastic biliary stent of 15 cm length was placed (C1 & C2: White arrows).

Post transplant anastomotic stricture. This patient also had an intra-diverticular papilla.

This was a long drawn out affair. The first ERCP attempt at cannulation of CBD was unsuccessful due to the intra-diverticular position of papilla (1A: red arrow). We then planned a railroad technique, whereby the radiologist would do a percutaneous cannulation. That attempt was also unsuccessful (1B), due to a very tight stricture so the radiologist placed an external drain. In the second ERCP attempt, we were able to cannulate the Pancreatic duct but the CBD could still not be accessed. Our 3rd attempt was rewarded with success. The guidewire can be seen in the initial film curling up near the stricture (B: yellow arrow) with the external drain seen right above the stricture (B: green arrow). To the right (B: red arrow) a collection can be seen. Despite the external drain and stricture, the CBD was unusual in being dilated. We did a sphincterotomy (C: red arrow. Yellow arrow points to the diverticular lumen). A 10F x 12cm plastic stent was then placed across the stricture (D: red arrow & E).