Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients

Abstract

Aim: To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients.

Materials and methods: We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed.

Results: Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2-3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis).

Conclusions: Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.

Keywords: Biliary tract; cholangiopancreatography; endoscopic retrograde; liver transplantation; stricture.

Figure 1

Diagram showing included and excluded patients in the study

Figure 2

Diagram showing approach to the management of biliary strictures in LDLT recipients

Figure 3 (A-E)

A 10.5-year-old male post kasai procedure for biliary atresia underwent LDLT (Left lobe) and hepatico-jejunostomy. He developed anastomotic site stricture after 34 months (A, arrow). Stricture crossed (B, arrow) and graded balloon dilatation done using 6 mm and 8 mm angioplasty balloon (two sessions) (C, D, arrows). Check cholangiogram 2 weeks after the last dilatation shows no residual narrowing and free flow of contrast across anastomosis (E, arrow)

Figure 4 (A-F)

A 10-year-old male with Wilsons disease underwent LDLT (Left lobe), developed anastamotic site stricture with biliopleural fistula after 7.5 months. Initially stricture (A, D arrow) with biliopleural fistula (A, D arrowhead) was treated with ERCP plastic stent (B, arrowhead). However, leak persisted (B, arrow). NBCA was injected percutaneously into fistula (C, arrow) through left duct approach. Follow-up MRCP 48 month later shows significant decrease in stricture (E, arrow). Chest radiograph taken 78 months later shows no significant changes in the lungs (F)

Figure 5 (A-F)

A 44-year-old female with fulminant hepatic failure underwent LDLT (right lobe), developed stricture at two anastomotic sites after 13 months. Anterior (A, arrow) and posterior sectoral ducts (B, arrow) separately punctured. The strictures crossed and graded dilatation done using 4 mm and 7 mm balloons (C, posterior duct stricture; D, arrow anterior duct stricture) and internal-external drainage catheters placed (E, arrow, arrowhead). One month later covered metallic were deployed in both anterior (F, arrow) and posterior duct (F, arrowhead) anastomotic strictures

Figure 6 (A-D)

A 17-year-old male with Fulminant hepatic failure (Yellow phosphorus poisoning) underwent LDLT (right lobe). He developed anastomotic site stricture with leak at 8 months (A, arrow). Initial attempts to cross the stricture by ERCP failed. Stricture crossed (B, C, arrow) and plastic stent deployed across the stricture site (D, arrow) percutaneously

Figure 7 (A-D)

A 42-year-old female with autoimmune hepatitis underwent LDLT (right lobe) with two duct-duct anastomosis. Patient developed stricture with leak at anastomotic sites after 3.2 months (A, arrow, arrowhead). Repeated attempts to cross the stricture by the percutaneous approach (B, arrow, arrowhead) and ERCP (C, arrow, arrowhead) failed. External drains placed in both systems (D, arrow, arrowhead). Patient probably developed spontaneous bilioenteric fistulae. Follow-up for 60 months was uneventful