Second follow up ERCP for post liver transplant anastomotic biliary structure (Case I)

This 25 year old gentleman had undergone a previous ERCP for an anastomotic biliary stricture. http://ercp365.blogspot.com/2015/04/post-liver-transplant-anastomotic.html. He had developed jaundice with pruritus and fever. His ultrasound showed a blocked stent. On ERCP, the biliary and pancreatic duct stents were visible (A: Black arrow-biliary stent, white arrow-pancreatic stent). Both were removed (B: Black and white stents showing the pancreatic and biliary stents, respectively). Contrast injection identified the site of stricture (C: Black arrow). A 40mm long and 6mm wide (at maximum inflation ) stricture dilatation balloon was positioned across the site (D: Black arrow) and dilated successively above, at and below the site of stricture (E1, E2 & E3: White arrows show the inflated balloon above the stricture site, at the stricture site and below the stricture site, respectively). No stent was passed this time and the patient will be followed up in our outpatient clinic.

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

This 22 year old lady had undergone living donor liver transplant at our centre for hepatitis B related liver disease. She developed an anastomotic stricture shortly after her surgery and underwent an ERCP in April of this year (A 7 French stent of 15 cm length was initially placed after dilatation of stricture with graduated dilatation catheters but she developed GI bleeding the same day. On endoscopy done the next day, the distal end of the stent was seen to erode the opposite duodenal wall and cause ulceration. This was removed and a shorter stent of the same diameter but shorter 12 cm length was placed). Now, she had developed pruritus and fever. Her stent was removed (A). The next image shows her MRCP which was done prior to her first ERCP (B: White arrow shows the anastomotic stricture site and red arrow shows a collection next to the biliary tree). Contrast injection after stent removal showed the narrowed stricture area (C: Black arrow) and what appears to be a sludge ball above the stricture (C: White arrow). A stricture dilatation balloon of 40 mm length and 6 mm diameter was used to dilate the stricture ( D: Black arrow). A stent assembly was placed across the affected area (E: Black arrow) and a 7 French plastic stent of 12 cm length was deployed (F: Black arrows).

Second ERCP for post transplant anastomotic biliary stricture (CASE J)

This 56 year old gentleman underwent a living related transplant for liver cirrhosis secondary to Hepatitis C around March 2014. He had his first ERCP in December 2014 (an earlier attempt in October 2014 had been unsuccessful). Contrast injection identified a sharp L-shaped angulation of the left hepatic duct, crossing in front of the right duct (A: white arrows). The right duct was seen behind it (A: black arrow). A 7 French stent of 12cm length was deployed in the left duct after dilating the track with a nominal 7 French graduated dilatation catheter. He again developed burning of the soles of his feet and pruritis along with rising ALP. We decided to remove his stent. On ERCP, it was seen to have migrated inside the CBD (B: Black arrows). We retrieved it using a biliary balloon inflated next to it (C: black arrows show the stent and white arrow marks the balloon adjacent to the stent. D: a single balloon sweep had resulted in some pullout and straightening of the proximal sharply bent portion of the stent-compare with C. E: white arrow shows the retrieved stent). Contrast injection post stent retrieval resulted in clear outlining of the right duct (F: black arrow) however the left L-shaped duct was only marginally outlined (F: white arrow). A balloon assembly was positioned in the right ductal system (G: black arrow) which was then inflated with full obliteration of the waist (H: black arrow). Next we manoeuvred our guidewire into the L-shaped left duct (I: black arrow). Pushing the papillotome over the wire and injection of contrast now outlined the left duct in its sharply bent form (J: black arrows. Compare with A). A 7 French double pigtail stent of 12 cm length was deployed (K: black arrows. Note the marked coil in the proximal portion of the stent. Not quite the desired result but we'll keep an eye on him nevertheless to see how it drains). A collection of contrast was also noted (K: red arrows). This was possibly a result of balloon dilatation of the right system. Admission with antibiotics and an eye on the temperature charts is on the menu.

First ERCP for anastomotic biliary stricture following liver transplantation (CASE E)

This gentleman had recently undergone a live related liver transplant. His bilirubin levels started to rise along with his alkaline phosphatase. An anastomotic stricture was suspected and confirmed on MRCP (A: red arrow shows the strictured area along the left maim duct). A guidewire was passed into the left system (B: black arrows mark the guidewire in the left ductal system). A TTS stricture dilatation balloon was manoeuvred across the affected segment and inflated to 9mm (C: black arrows indicate the balloon in the stricture site. The balloon isn't clearly visible because we haven't mixed any contrast with the saline). Repeat contrast injection some improvement in ductal filling (D). We then placed a plastic stent of 10 French diameter and 12 cm length (E: black arrows mark the deployed stent). 

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. 

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

We last saw this 50 year old gentleman two and a half months earlier when we dilated his anastomotic stricture with a 6mm balloon and placed a 10 French stent http://ercp365.blogspot.com/2014/09/second-follow-up-ercp-for-post-liver.html. His bilirubin levels had started to rise and we expected a blocked stent. His ultrasound confirmed this with no pneumobilia. We removed his previous stent using a snare (A: White arrows mark the wires of the snare around the stent. Blue arrow marks the stent. A guidewire was manoeuvred across the stricture (B: Black arrow shows the level of the stricture on the guidewire). Contrast injection again confirmed the narrowing (C: Black arrows show the narrowing at the anastomotic site). We decided to go for a bigger balloon this time and an 8mm diameter balloon was placed across the stricture (D: White arrows). The balloon was inflated (E: White arrows show the inflated balloon with a "waist" formation at the specific point of concern). Following dilatation, repeat contrast injection showed adequate dilatation (F: Black arrows now show no narrowing).  A stent assembly was then placed (G: White arrows). A 10 French plastic stent of 15 cm length was deployed.

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).

Fifth follow-up ERCP for post transplant biliary stricture (CASE B)

This was this 24 year old's fifth follow up visit. We removed the stent placed in his last visit http://ercp365.blogspot.com/2014/09/fourth-follow-up-ercp-for-post.html. Contrast injection showed a persistent stricture (A: Black arrows). We used a 10mm stricture dilatation balloon of 3cm length to dilate the stricture (B & C: Black arrows show the inflated balloon and red arrow marks the "waist"of the balloon at the strictured segment in B). Marked improvement in the previously narrowed site of ductal anastomosis was noted (D: Black arrows).