Role of cholangioscopy and therapeutic options in complex anastomotic strictures after liver transplantation Primary author – Mateus Funari Co-authors – Bruno Hirsch, Antonio de Miranda Neto, Tommaso Franzini, Eduardo de Mourão Here are our disclosures. A 35-year-old male patient underwent a cadaveric donor liver transplantation for fulminant hepatitis B. He developed a hepatic artery thrombosis nine months after the transplantation, treated with endovascular stent. After one year, there was an increase of liver biochemical tests and suspicion of biliary anastomotic stricture on cross-sectional imaging. The liver biopsy revealed cholestatic pattern changes, then an ERCP was performed. It was not possible to pass the long, filiform and tortuous complex stricture with the guide wire. Using the cholangioscope, it was possible to place the 0.025-inch guide wire and dilate the stricture with an 8-mm balloon. Cholangioscopy revealed a pale and thin mucosa in the stenotic area with intense fibrosis, debris and sutures. A 10-inch by 10-cm straight plastic stent was placed. Here we can see the filiform segmental stricture. The axis was directed towards the cystic duct. Despite several attempts, it was not possible to overcome it. The cholangioscope was introduced and the position inside the CBD was confirmed with the fluoroscopy. During the cholangioscopy, we were able to confirm the axis was directed towards the cystic duct. Thus, we could shift the position of the guide wire towards the common hepatic duct. We can see the mucosa in this stenotic area with fibrosis and sutures. After manipulation with the guide wire, it is possible to see bile coming from the common hepatic duct. Despite using fluoroscopy, it was difficult to pass the 0.035 inch guide wire. After several attempts, it was possible to pass the 0.025 inch guide wire. After confirming its position inside the common hepatic duct, we could dilate the stricture up to 8 mm. He was able to overcome the stricture with the cholangioscope and access the graft's bioduct. We can observe the mucosa within the stricture with debris, clots, sutures and the laceration caused by the dilation. The procedure was finished after the deployment of the 10-franch straight plastic stent. The second ERCP was performed after 2 months. Fluoroscopy showed a slight improvement. It was possible to dilate the stricture up to 9 mm and place 3 8.5-franch by 10 cm straight plastic stents. The third ERCP was performed 6 months after the first procedure. Due to the tortuous complex stricture with important excess deviation between the donor and the recipient bioducts, a 10 by 60 mm fully covered self-expandable metal stent was placed. Here we can see the stent deployment. This is the final aspect. Finally, the last ERCP was performed 10 months after the beginning of the treatment. During the procedure, the SAMS wasn't identified due to migration. Another attempt to pass the guard wire through the stretcher was performed without success because of the important axis deviation, despite adequate flow of contrast into the duodenum. Due to the fluoroscopy findings, the patient's clinical condition and improvement in laboratory tests, it was decided to keep the patient without any stent at this moment. The patient presented clinical and biochemical improvement, remaining asymptomatic since the beginning of the treatment. Currently, he's under close multidisciplinary follow-up for over a year, with no need for further procedures. In some cases, cholangioscopy may help to assess and allow endoscopic treatment of complex biliary anastomosis strictures after liver transplant. In the reported case, it prevented the patient from percutaneous drainage, ensuring a better quality of life. In such complex strictures with axis deviation, the metal stent may be a better option than the plastic ones.

liver transplantation

biliary anastomotic stricture

cholangioscopy

guide wires

metal stents