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Digital cholangioscopic evaluation of a post–liver transplantation stricture

      A 65-year-old man underwent a donation after brain death liver transplantation for alcoholic liver cirrhosis and experienced progressively deteriorating liver function test results 4 to 5 months after transplantation, with an episode of acute cholangitis. He was cytomegalovirus negative, and Doppler US confirmed patent hepatic vessels with preserved portal venous flow. Intrahepatic biliary dilatation was noted on US, and MRCP confirmed an anastomotic stricture (Fig. 1A ).
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      Figure 1A, Stricture at the duct-duct anastomosis (arrow). B, Guidewire bouncing off the anastomotic stricture (arrow) at ERCP. C, View of the anastomotic stricture at cholangioscopy (arrow). D, Guidewire being inserted across the anastomotic stricture under cholangioscopic control. E, Guidewire being exchanged under cholangioscopic control to perform dilatation of the anastomotic stricture. F, Guidewire access across the anastomotic stricture on fluoroscopic view. G, Stent inserted across the anastomotic stricture.
      Attempted ERCP failed because guidewire access across the stricture was not possible (Fig. 1B). The Spyglass DS endoscope (Boston Scientific, Natick, Mass) was used to access the stricture, which was identified as a pinhole anastomotic stricture (arrow) (Fig. 1C and Video 1, available online at www.VideoGIE.org). A sphincterotomy was not performed to preserve the biliary sphincter, and careful flushing of the duct was carried out with continuous low-pressure suctioning through the Spyglass DS endoscope. The stricture was crossed with a wire (Fig. 1D-F), dilated, and stented (Fig. 1G); subsequently, normalization of the patient’s liver function test results occurred, and the patient experienced symptomatic improvement (resolution of abdominal pain and itching). The Spyglass DS endoscope facilitated a visual inspection of the anastomotic stricture, which was noted to be smooth and fibrotic, in keeping with an ischemic stricture.
      Management of post-transplantation ductal strictures can be challenging, and cholangioscopy can play an important role in the management of complex anastomotic strictures.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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