Management issues in post living donor liver transplant biliary strictures

Abstract

Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.

Keywords: Biliary complications; Biliary strictures; Endoscopic retrograde cholangiopancreatography; Living donor liver transplant; Percutaneous transhepatic biliary drainage.

Figure 1

Types of biliary anastomoses and corresponding biliary reconstructions[54]. A: Single duct anastomosis; B: Double duct - minimum distance between two donor ducts, requires ductoplasty with recipient CBD; C: Double duct - two donor duct are far away, requires two separate duct anastomosis or a hepaticojejunostomy; D: Single duct to duct reonstruction; E: Double duct to duct reconstruction using right and left hepatic ducts; F: Double duct to duct reconstruction using cystic and CHD; G: Mixed type using duct to duct and hepaticojejunostomy. CHD: Common hepatic duct; CBD: Common bile duct.

Figure 2

Anastomotic stricture - single duct anastomosis. A: Magnetic resonance cholangiopancreatography shows stricture at the anastomotic site of a single duct anastomosis; B: Endoscopic retrograde cholangiopancreatography (ERCP) in the same patient shows the stricture; C: ERCP in same patient shows guide wire negotiated across the stricture.

Figure 3

Anastomotic stricture - double duct anastomosis. A: Magnetic resonance cholangiopancreatography image shows stricture across both RASD as well as RPSD ductal anastomosis; B: Endoscopic retrograde cholangiopancreatography (ERCP) image shows guide wire negotiated across RPSD in this patient; C: ERCP image shows guidewire negotiated across RASD in this patient.

Figure 4

Anastomotic stricture - ductoplasty. A: Magnetic resonance cholangiopancreatography image of a ductoplasty of RASD and RPSD to common hepatic duct; B: Endoscopic retrograde cholangiopancreatography (ERCP) image shows stricture at ductoplasty site; C: ERCP image shows guide wire across one ductal system.

Figure 5

Anastomotic stricture - cystic duct anastomosis (endoscopic retrograde cholangiopancreatography failed, patient underwent percutaneous transhepatic biliary drainage).

Figure 6

Cystic duct anastomosis after dilatation. This patient developed stricture again and underwent a hepaticojejunostomy.

Figure 7

Timeline of biliary complications after transplant.

Figure 8

Protocol for endoscopic intervention (please see text also). ERCP: Endoscopic retrograde cholangiopancreatography.

Figure 9

Balloon dilatation of biliary stricture. A: Endoscopic retrograde cholangiopancreatography (ERCP) images show stricture at the anastomotic site; B: ERCP image showing balloon dilatation of the stricture; C: Successful obliteration of the waist of stricture after balloon dilatation.

Figure 10

Rendezvous procedure. A: Endoscopic retrograde cholangiopancreatography opacified only RASD; B: RPSD accessed via percutaneous transhepatic biliary drainage; C: Rendezvous procedure being performed.