Peroral cholangioscopy–guided stricture therapy in living donor liver transplantation

Anastomotic biliary strictures are common in patients that undergo living donor liver transplantation (LDLT).1-5 Most anastomotic strictures are effectively treated by the endoscopic insertion of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic treatment of biliary strictures requires passage of a guidewire through the stricture.1 The wire is then used to guide instruments for subsequent stricture dilatation and stent placement. In severe cases, when endoscopic placement of a guidewire cannot be accomplished, more invasive procedures such as transhepatic access or surgery may become necessary. In this report, we describe a new technique for successful guidewire placement in severe anastomotic strictures after failed placement by conventional means. ERCP, endoscopic retrograde cholangiopancreatography; LDLT, living donor liver transplantation. A 65-year-old woman who had undergone a right-lobe LDLT with duct-to-duct anastomosis 3 months earlier presented for an ERCP because of rising alkaline phosphatase and gamma-glutamyl transferase levels. The cholangiogram obtained during the ERCP showed a high-grade stricture at the anastomotic site (Fig. 1). The stricture could not be traversed with a guidewire (Jagwire, Boston Scientific, Natick, MA). An extraction balloon that was already in place was inflated and centered in the bile duct. The stricture was probed with the guidewire while the orientation and degree of inflation of the balloon were changed. The stricture still could not be passed. The balloon was then positioned close to the stricture, inflated, and slightly pulled down toward the ampulla to straighten and stretch the bile duct while probing with the guidewire was continued.6 However, this technique also failed to provide access to the donor ducts. The balloon was then exchanged with a rotatable sphincterotome (Autotome Rx, Boston Scientific). This sphincterotome has a rotating handle that is designed to change its tip orientation to facilitate cannulation. Probing with the guidewire through the sphincterotome at different tip orientations also failed. The guidewire was then exchanged for an angled tip hydrophilic guidewire (Hydra Jagwire, Boston Scientific), and the aforementioned sequence was repeated without success. We have good experience with passing severe strictures by spinning an angled tip hydrophilic wire while simultaneously exerting mild longitudinal force on the guidewire pushing it toward the stricture. This technique proved futile as well. After failure to traverse the stricture with conventional means, a cholangioscope (SpyGlass Direct Visualization System, Boston Scientific) was introduced into the bile duct, and a very small slit-like opening was visualized at the anastomotic site (see Supplementary Video 1). Under direct cholangioscopic guidance, a guidewire (Jagwire) was passed through the opening and placed in the donor duct, traversing the stricture (see Supplementary Video 1 and Fig. 2). The stricture was then dilated and stented with excellent bile and contrast drainage (Fig. 3). After a few days, repeat laboratory work-up showed normalization of the liver enzymes. A severe anastomotic stricture prevents the passage of a guidewire (arrow). An inflated balloon (arrowhead) is placed in the recipient duct for injection of contrast under pressure in order to visualize the donor ducts. The stricture is traversed with a guidewire under direct visual guidance by a cholangioscope. Appropriate positioning of the guidewire is confirmed by fluoroscopy. A stent is placed in the bile duct crossing the stricture with excellent drainage of contrast. Various refinements in surgical techniques and postoperative and immunosuppressive management have reduced the incidence of complications after liver transplantation. Biliary complications, however, continue to be a significant cause of morbidity after LDLT.5, 7 Nonsurgical techniques such as ERCP have in recent years attained a primary role in the treatment of posttransplant biliary strictures. The success of ERCP in these cases, however, depends on the ability to traverse the stricture with a guidewire. In the vast majority of cases, this is accomplished easily. In severe strictures, however, it can represent a time-consuming challenge and, in some reports, a failure rate as high as 20%.2 In these cases, a more invasive procedure such as transhepatic access or surgery may become necessary.2 The SpyGlass Direct Visualization System is a peroral cholangioscope with 4-way tip deflection that recently became commercially available. In contrast to traditional dual-operator cholangioscopes, the SpyGlass system allows a single endoscopist to operate both “mother and baby scopes.” In this case, we used this system to pass a guidewire under direct visualization through a severe stricture after failure to do so during ERCP. This technique can prove useful and time-sparing in selected cases when the severity of the stricture prevents guidewire placement by conventional methods. Supplementary material for this article can be found on the Liver Transplantation Web site ( http://www.mrw.interscience.wiley.com/suppmat/1527-6465/suppmat/ ). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.