Endoscopic management of post-liver transplant biliary complications

Abstract

Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.

Keywords: Bile leak; Biliary; Biloma; Cast; Complications; Endoscopic retrograde cholangiography; Endoscopy; Liver transplant; Management; Stone; Strictures.

Figure 1

Different management strategies for biliary strictures. A: Post-LT anastomotic biliary stricture (as seen on ERC); B: managed with balloon dilatation only; C: Post-LT anastomotic biliary stricture (as seen on ERC); D: Managed with balloon dilatation; E: MRCP image of the same stricture; F: Long segment biliary stricture due to global hypotension post-LT; G: Dilatation performed with biliary balloon; H: Followed by placement of two plastic stents; I: Due to inadequate effect with two stents, sequential therapy strategy adopted with placement of three stents; J: Fluoroscopic image of three stents in right posterior and anterior hepatic and left hepatic ducts; K: Final cholangiogram suggesting a much improved bile duct diameter. ERC: Endoscopic retrograde cholangiography; LT: Liver transplantation.

Figure 2

Diffuse non-anastomotic intra-hepatic biliary structuring seen in a donation after cardiac death liver transplant patient, not amenable to endoscopic therapy.

Figure 3

Management strategies for bile leak and biloma. A: Bile leak from split surface of the liver in a patient with split-liver transplant; B: Managed successfully with endoscopic plastic stent placement; C: In a separate patient, bile leak successfully managed by placement of a fully covered metal stent; D: In yet another patient, intrahepatic biloma, which becomes apparent on occlusion cholangiogram.

Figure 4

Management of common bile duct filling defects. A: Common bile duct (CBD) filling defect seen proximal to mid-CBD stricture in a post-liver transplantation patient; B: Successful removal of stone after dilatation the stricture; C: Endoscopic image of successfully extracted stone and sludge in this case.

Figure 5

Rare cause of Hemobilia. A: Hepatic artery pseudoaneurysm fistulizing to the common bile duct, resulting in hemobilia; B: Managed with intravascular stent placement by interventional radiology.

Figure 6

Don’t forget the native disease. Recurrence of native disease can mimic biliary complications, hence appropriately investigated with magnetic resonance cholangiopancreatography (A) and/or endoscopic retrograde cholangiography (B). This patient was transplanted for primary sclerosing cholangitis, and had disease recurrence involving the intra-hepatics few years later.