An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Abstract

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

Keywords: Anastomotic leak; Biliary tract diseases; Cholangiopancreatography, endoscopic retrograde; Choledocholithiasis; Liver transplantation.

Fig. 1.

Cholangiogram of an anastomotic stricture (AS) in a 50-year-old man after living-donor liver transplant. (A) AS on a balloon-occluded cholangiogram. (B, C) Double guide wires inserted through the biliary stricture and balloon dilatation (4 mm at 10 atm). (D) Four plastic stents inserted through the AS of the transplanted liver.

Fig. 2.

The rendezvous technique in a 47-year-old man with failed guide wire access across an anastomotic stricture (AS) after living-donor liver transplant. (A, B) Percutaneous transhepatic cholangiogram showing a high-grade stricture at the biliary anastomosis site and the guide wire inserted through the transhepatic tract. (C, D) Endoscopic retrograde cholangiopancreatography view of the guide wire passed through the ampullary orifice from the percutaneous tract. (E, F) Plastic stents inserted through the AS.

Fig. 3.

Magnetic compression anastomosis in a 62-year-old man with a biliary stricture after living-donor liver transplant. (A) Endoscopic retrograde cholangiopancreatography (ERCP) showing the guide wire failing to pass through the anastomotic stricture. (B) After a percutaneous transhepatic biliary drainage (PTBD) catheter was inserted and the tract was dilated to 18 Fr, pneumatic dilatation was performed across the ampullary orifice. (C) A magnet was delivered via ERCP through the common bile duct, while another was inserted via the PTBD tract. (D) Fluoroscopy showing complete approximation of the magnets.

Fig. 4.

Bile leakage in a 74-year-old man after a deceased-donor liver transplant. (A) Cholangiogram showing bile leakage along the T-tube tractwith the T-tube in situ. (B, C) Cholangiogram showing T-tube tract leakage after the T-tube removal as well as sphincterotomy and nasobiliary catheter across the leakage site. (C) Repeat cholangiogram 2 weeks later demonstrating no evidence of bile leakage.

Fig. 5.

Biliary stones and intrahepatic duct dilatation in a 59-year-old woman with anastomotic stricture (AS) after a living-donor liver transplant. (A) Computed tomography showing high-attenuation material at the hepatic hilum. (B) Cholangiogram showing an intraductal filling defect suggestive of a stone within the AS. (C, D) Balloon dilatation of the AS after stone removal and plastic stent insertion.

Fig. 6.

Hemobilia in a 49-year-old woman after a living-donor liver transplant. (A) Running down of bloody bile at the ampullary orifice 2 days after the operation. (B, C) Cholangiogram showing an amorphous filling defect and a large blood clot on the retrieval balloon sweeping. (D) Sphincterotomy and nasobiliary catheter in the intrahepatic bile duct.

Fig. 7.

Intrahepatic duct (IHD) stone and foreign bodies in a 65-year-oldman after a living-donor liver transplant. (A, B) Percutaneous transhepatic cholangioscopy image showing multiple intrahepatic stones. (C, D) Non-absorbable suture material that could act as a nidus for IHD stones as well as an indwelling catheter removed using forceps.