Percutaneous Choledochoscopy and Laser Biliary Stricturoplasty: A Case Series of Novel Management of Refractory Post-Liver Transplant Biliary Complications

W. E. Jackson¹, P. S. Trivedi², J. J. Pomposelli³, T. J. Pshak³

¹Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO, ²Division of Vascular and Interventional Radiology, University of Colorado, Aurora, CO, ³Division of Transplant Surgery, University of Colorado, Aurora, CO

Meeting: 2020 American Transplant Congress

Abstract number: C-155

Keywords: Bile duct, Liver grafts, Liver transplantation, Living-related liver donors

Session Information

Session Name: Poster Session C: Liver: Living Donors and Partial Grafts

Session Type: Poster Session

Date: Saturday, May 30, 2020

Session Time: 3:15pm-4:00pm

Presentation Time: 3:30pm-4:00pm

Location: Virtual

*Purpose: Anastomotic biliary strictures are a well-recognized complication after living and deceased donor liver transplant (LDLT and DDLT). Management focuses on utilizing endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC) with biliary drain (PTBD), or surgical revision, including retransplant. We report a case series of percutaneous choledochoscopy and laser biliary stricturoplasty to treat refractory biliary complications.

*Methods: We reviewed 4 patients with persistent post-transplant anastomotic biliary strictures despite ERC and PTC with serial dilation. In all cases, a PTBD was previously placed fluoroscopically and serially upsized to 16-18 French to allow passage of the Olympus HD flexible ureteroscope for choledochoscopy. A Holmium laser with 200 or 365 micron Moses laser fiber was used to incise the length of the stricture to the level of healthy tissue. A Whitaker test was performed to determine response to treatment prior to removal of the PTBD.

*Results: 4 patients with biliary complications were identified at our institution. Patients 1, 2 and 3 had right lobe LDLT with hepaticojejunostomy (HJ) while patient 4 had a DDLT with duct to duct (DD) anastomosis. Time since transplant ranged from 1 to 5 years. Patients 2 and 3 had documentation of early hepatic artery thrombosis (HAT) with surgical revision. Patients 1, 2, and 4 were found to have ischemic appearing strictures treated with Holmium laser. Patient 3 was found to have a large obstructing biliary stone at the HJ anastomosis without underlying stricture. This was treated through 3 procedures with lithotripsy in addition to basket extraction. A silk suture was visualized and believed to be the nidus and removed. All patients underwent cholangiogram and repeat choledochoscopy 4 weeks later to inspect the site for response to treatment. All passed the Whitaker test prior to removal of the PTBD. Patient 2 had a complication of malpositioned PTBD within the portal vein with hemobilia managed with replacement of PTBD and later removal.

*Conclusions: Percutaneous choledochoscopy and Holmium laser biliary stricturoplasty is a novel tool for management of refractory post liver transplant biliary complications after failed ERC and PTC. Long term follow up is needed to assess durability of treatment response.

Patient Characteristics
	1	2	3	4
Graft	LDLT	LDLT	LDLT	DDLT
Anatomy	HJ	HJ	HJ	DD
Year of Txp	2014	2018	2017	2009
HAT	no	yes	yes	no
Biliary stricture	anastomotic	anastomotic	surgical suture with biliary stone	anastomotic
ERC interventions	7	5	1	1
PTC dilations	4	7	8	3

To cite this abstract in AMA style:

Jackson WE, Trivedi PS, Pomposelli JJ, Pshak TJ. Percutaneous Choledochoscopy and Laser Biliary Stricturoplasty: A Case Series of Novel Management of Refractory Post-Liver Transplant Biliary Complications [abstract]. Am J Transplant. 2020; 20 (suppl 3). https://atcmeetingabstracts.com/abstract/percutaneous-choledochoscopy-and-laser-biliary-stricturoplasty-a-case-series-of-novel-management-of-refractory-post-liver-transplant-biliary-complications/. Accessed November 21, 2024.

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