First ERCP for post liver transplant anastomotic biliary stricture (CASE N)

This 54 year old gentleman had recently undergone living donor liver transplant at our centre. He had presented with fever, chills, pruritus and a raised ALP level. His MRCP showed a short stricture at the anastomotic site (A: white arrow). We were greeted with a bulging ampulla on ERCP (B). Contrast injection highlighted the stricture ( C & D: white arrow). We dilated the track with a 7 French graduated dilatation catheter (D: black arrow) followed by placement of a 7 French plastic stent of 12 cm length (E:black arrows. White arrow shows the upper end of the stent assembly). This was rewarded with a gush (F: white arrow) of white (hence infected) bile.

Third (fourth, actually) ERCP for post liver transplant anastomotic biliary stricture (Case J)

This 56 year old gentleman had undergone biliary stenting previously http://ercp365.blogspot.com/2015/04/post-transplant-anastomotic-biliary.html. Following this he developed pruritus and disturbed transaminases and a repeat ERCP with stent removal and extension of sphincterotomy was done last month. The CBD was clean and free of any stones/sludge (A: White arrow). His liver enzymes became disturbed again and he developed pruritus. Contrast injection showed poor filling of the right ductal system (B: White arrow). No attempts at dilatation were made as our papillotome had easily traversed the strictured site and we placed a thicker 10 French stent of 12 cm length (C: White arrows) as opposed to the 7 French stent placed in the ERCP before last (see link above).

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.

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

This 22 year old lady had undergone her second ERCP for an anastomotic biliary stricture less than month earlier http://ercp365.blogspot.com/2015/09/second-follow-up-ercp-for-post-liver.html when we had placed a 7 French 12 cm plastic biliary stent. She had developed cholangitis and pruritus soon after and her ultrasound did not show any pneumobilia. We suspected the sludge ball proximal to the previously deployed stent to be the culprit (Refer to images in the link above). We removed her blocked stent (A). Contrast injection again highlighted the narrowed anastomotic segment (B: Black arrow). A stent assembly was then manoeuvred across this site (C: Black arrow) and a wider 10 French plastic stent of 12 cm length was deployed (D1 & D2: Black arrows).

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).

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.

Post liver transplant anastomotic biliary stricture (CASE F)

This 40 year old gentleman had undergone a living donor transplant at a foreign centre 7 months ago. He had been compounded with issues including acute cellular rejection and CMV infection. About three months ago he developed cholelithiasis. He underwent ERCP and stone extraction followed by placement of a 7 French 15 cm stent (A1: black arrow shows the stricture site. This may well be a case of sharp angulation of a main graft duct. A2: black arrows indicate the stent). He presented to us with ascites, a right pleural effusion, rising bilirubin levels. His biopsy showed only cholestasis. MRCP indicated a narrowed anastomotic site (B: white arrows shows the site of anastomosis. Red and blue arrows show a sub hepatic collection and a prominent cystic duct stump, respectively). On ERCP contrast injection initially showed a cutoff area (C: black arrow). Further contrast outlined the whole biliary tree (D: red arrows shows the anastomotic site with obvious sharp angle of the main graft duct with the native duct). A 12 cm long stent of 7 French diameter was placed (E: white arrows mark the stent).

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.