Anastomotic strictures are a frequent complication after liver transplantation [1]. The key step in endoscopic treatment is getting a guidewire through the stricture.
When strictures are critical, an intraductal cholangioscopy (IDC) system (SpyGlass)
can help with passage of the guidewire under direct visualization [2]. In very severe strictures, however, this may be insufficient to achieve guidewire
passage, even for small caliber guidewires.
We present a new technique that can help in advancing the guidewire in patients with
severe anastomotic stricture. Repeated biopsies of the anastomosis are taken, under
direct vision with IDC using biopsy forceps (SpyBite), until a passage for the guidewire
is cleared. We show this technique in four patients with anastomotic stenosis post-liver
transplantation ([Video 1]).
Video 1 Four liver transplant patients with critical anastomotic strictures are presented.
Intraductal cholangioscopy was performed in each case, with biopsies taken from the
anastomosis until the guidewire could be advanced and the endoscopic retrograde cholangiopancreatography
completed.
On endoscopic retrograde cholangiopancreatography (ERCP), a severe stenosis of the
anastomosis was observed in three of the patients and a complete stenosis in the fourth.
In none of the patients was it possible for the guidewire to be advanced through the
anastomosis, even under direct visualization with IDC, although many attempts were
made and different guidewires were employed. The IDC biopsy forceps were used under
direct visualization to take four to five biopsies of the anastomosis, until the orifice
of the anastomosis was of sufficient diameter for a guidewire to be advanced. Once
the guidewire could be passed through the anastomosis, ERCP was completed. No complications
associated with the technique were observed in any of the patients.
IDC-assisted biopsy of the biliary anastomotic stricture may be useful in advancement
of the guidewire in liver transplant patients with critical strictures.
Endoscopy_UCTN_Code_TTT_1AR_2AG
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