ERCP-NEEDLE KNIFE RECANALIZATION OF A NEAR COMPLETE COMMON BILE DUCT STRICTURE

Video Transcription

Needle knife recanalization of a near-complete common bile duct stricture.  These are our disclosures.  A 65-year-old male with a history of alcoholic cirrhosis status post liver transplantation one year prior, presented for routine care post-transplant.  His laboratory workup revealed an elevated alkaline phosphatase and GGT. The rest of his laboratory workup was unremarkable.  The patient underwent an MRCP, which revealed a focal signal loss and narrowing in the extrahepatic common bile duct.  There was no evidence of intrahepatic biliary ductal dilatation.  The patient was referred for ERCP. Under general anesthesia in the prone position, the bile duct was successfully cannulated and contrast was injected,  which revealed a single localized stenosis in the upper third of the main bile duct. Despite several attempts, the 0.025 guide wire could not traverse the stricture.  A biliary sphinctrotomy was performed to allow further interventions, and a single-operator cholangioscope was inserted into the bile duct.  This revealed a very tight and asthmatic stricture. Attempts were made to directly traverse the stricture with the wire, but this was unsuccessful.  Cholangioscopic forceps was also used in an effort to recanalize the stricture, but this was also without success.  The 0.025 guide wire was downsized to a 0.018 wire, which subsequently traversed the stricture.  Next, a 3 mm tapered dilating catheter and a 4 mm dilating balloon was used in an attempt to dilate the tight and asthmatic stricture. However, this was unsuccessful.  The decision was then made to proceed with needle-knife electrocautery of the stricture over the guide wire.  This allowed the needle-knife to traverse and recanalize the tight and asthmatic stricture.  Occlusion balloon cholangiogram was performed, and there was no evidence of any leaks. A 10 French by 12 cm plastic stent was subsequently placed.  Biliary and asthmatic strictures are common complications after liver transplant.  We demonstrate the successful use of wire-guided needle-knife recanalization of a near-complete biliary and asthmatic stricture.  This technique may be used as a minimally invasive alternative to surgical repair.

Video Summary

In this video, a needle-knife recanalization procedure is demonstrated on a 65-year-old male with a history of alcoholic cirrhosis and a liver transplant. The patient had elevated liver enzyme levels and an MRCP showed a focal narrowing in the common bile duct. During the ERCP procedure, attempts were made to traverse the stricture using a guide wire and cholangioscope, but they were unsuccessful. Eventually, a smaller guide wire successfully traversed the stricture, and a needle-knife electrocautery was used to recanalize it. A stent was then placed to prevent future strictures. This technique could be an alternative to surgical repair for similar cases. No credits were provided in the transcript.

Asset Subtitle

Honorable Mention

Keywords

needle-knife recanalization procedure

alcoholic cirrhosis

liver transplant

common bile duct

ERCP procedure