World J Gastroenterol 2014 November 14; 20(42): 15916-15919
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
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DOI: 10.3748/wjg.v20.i42.15916
© 2014 Baishideng Publishing Group Inc. All rights reserved.
CASE REPORT
Interesting rendezvous location in a liver transplantation
patient with anastomosis stricture
Bulent Odemis, Erkin Oztas, Mehmet Yurdakul, Serkan Torun, Nuredtin Suna, Ertugrul Kayacetin
Bulent Odemis, Erkin Oztas, Serkan Torun, Nuredtin Suna,
Ertugrul Kayacetin, Department of Gastroenterology, Yuksek
Ihtisas Education and Research Hospital, 06100 Ankara, Turkey
Mehmet Yurdakul, Department of Radiology, Yuksek Ihtisas
Education and Research Hospital, 06100 Ankara, Turkey
Author contributions: Odemis B and Kayacetin E performed
endoscopic retrograde cholangiography; Yurdakul M performed
percutaneous transhepatic cholangiography; Oztas E, Torun S
and Suna N contributed equally to the writing of the manuscript.
Correspondence to: Erkin Oztas, MD, Department of Gastroenterology, Yuksek Ihtisas Education and Research Hospital,
Kizilay Str 4 Sihhiye, 06100 Ankara,
Turkey. [email protected]
Telephone: + 90-312-3061334 Fax: + 90-312-3124120
Received: March 19, 2014
Revised: June 3, 2014
Accepted: June 14, 2014
Published online: November 14, 2014
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Liver transplantation; Anastomosis stricture; Endoscopic radiologic rendezvous; Duodenal bulb
Core tip: An endoscopic-radiologic rendezvous technique may be used for stent application in the treatment of biliary strictures where previous endoscopic
retrograde cholangiopancreatography and percutaneous transhepatic attempts have failed. Recently, it
was reported that successful endoscopic-radiologic
rendezvous procedures were performed in the subhepatic space in patients with complete transections of
the common bile duct, especially secondary to surgical
injury. Herein, we report a modified rendezvous technique in the duodenal bulb as an extraordinary location
in a patient with a duct-to-duct complete anastomotic
stricture after liver transplantation.
Abstract
An endoscopic or radiologic percutaneous approach
may be an initial minimally invasive method for treating biliary strictures after living donor liver transplantation; however, cannulation of biliary strictures is
sometimes difficult due to the presence of a sharp or
twisted angle within the stricture or a complete stricture. When an angulated or twisted biliary stricture
interrupts passage of a guidewire over the stricture, it
is difficult to replace the percutaneous biliary drainage
catheter with inside stents by endoscopic retrograde
cholangiopancreatography. The rendezvous technique
can be used to overcome this difficulty. In addition to
the classical rendezvous method, in cases with complete transection of the common bile duct a modified
technique involving the insertion of a snare into the
subhepatic space has been successfully performed.
Herein, we report a modified rendezvous technique in
the duodenal bulb as an extraordinary location for a
patient with duct-to-duct anastomotic complete stricture after liver transplantation.
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Odemis B, Oztas E, Yurdakul M, Torun S, Suna N, Kayacetin
E. Interesting rendezvous location in a liver transplantation
patient with anastomosis stricture. World J Gastroenterol 2014;
20(42): 15916-15919 Available from: URL: http://www.wjgnet.
com/1007-9327/full/v20/i42/15916.htm DOI: http://dx.doi.
org/10.3748/wjg.v20.i42.15916
INTRODUCTION
Biliary strictures are not uncommon after living donor
liver transplantation (LDLT), and two-thirds of biliary
strictures can be treated by endoscopic retrograde cholangiopancreatography (ERCP). If ERCP fails, percutaneous transhepatic biliary drainage (PTBD) is recommended[1,2]. Although maintaining a PTBD catheter for
a long period is beneficial for treating biliary strictures, it
may be difficult for patients, especially in liver transplant
patients, due to the development of PTBD catheter-re-
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Odemis B et al . An interesting rendezvous location
A
B
C
D
E
F
Figure 1 Fifty-three-year-old-man was admitted to our clinic for removal of a percutaneous internal-external biliary drainage catheter and insertion of
stents via endoscopic retrograde cholangiopancreatography. A: Internal portion of the percutaneous transhepatic biliary drainage (PTBD) catheter (arrowheads)
and the balloon catheter extending from the papilla towards the common bile duct (CBD) (arrows) were observed separately on cholangiography; B: Despite several
attempts at simultaneous percutaneous transhepatic cholangiography, all attempts at advancing a guidewire (arrow) proximally through the papilla into the intrahepatic
bile ducts failed and the guidewire (arrowhead) could not be advanced into the CBD; C: The guidewire which was inserted transpapillarily was intentionally pushed
through the paracholedocal area at the level of the CBD stricture and spontaneously came out of the duodenal bulb. A snare was slowly introduced via the transhepatic route into the bulbus and the guidewire was caught by closing the snare under endoscopic visualization; D: The guidewire was pulled proximally all the way through
the percutaneous access (arrows); E: This was followed by a 5 and 7 mm balloon dilatation of the stricture (arrows). Another guidewire, which was inserted into the
duodenal bulb at the site of the PTBD’s internal orifice, is also shown in this figure (arrowhead); F: In the third month of follow-up, the stricture was almost completely
resolved, and the patient was then followed stent-free.
lated complications, such as leakage, pain, infection, and
accidental removal of the PTBD catheter. Therefore,
replacing PTBD catheters with inside stents is recommended. When an angulated or twisted biliary stricture
interrupts passage of a guidewire over the stricture, it is
difficult to replace the PTBD catheter with inside stents
by ERCP[3]. The rendezvous technique can be used to
overcome this difficulty. The rendezvous procedure is
classically performed after transhepatic advancement of
a guidewire through the papilla for subsequent ERCP[4,5].
In addition to this classical rendezvous method, in cases
with complete transection of the common bile duct
(CBD), a modified technique involving the insertion of
a snare into the subhepatic space has been successfully
performed[6,7]. Herein, we report a modified rendezvous
technique in the duodenal bulb as an extraordinary location in a patient with a duct-to-duct complete anastomotic stricture after liver transplantation.
CASE REPORT
A 53-year-old-man was admitted to our clinic for removal of a percutaneous internal-external biliary drainage catheter and insertion of stents via ERCP. He had
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a history of right lobe LDLT due to hepatitis B-related
cirrhosis and hepatocellular carcinoma three years ago.
After a short time, a duct-to-duct anastomotic stricture
developed. Because cannulation of the intrahepatic bile
ducts via ERCP was unsuccessful, an internal-external
biliary drainage catheter was inserted after balloon dilatation of the stricture via percutaneous transhepatic
cholangiography (PTC). The biliary drainage catheter
was kept in place, and the patient had undergone balloon dilatation of the stricture via a transhepatic route
five times in the previous seven months. After admission
to our clinic, ERCP was performed. At the beginning of
ERCP, the tip of the internal-external biliary drainage
catheter was protruding from the apex of the bulbus, an
astonishing endoscopic finding. Intrahepatic bile ducts
could not be opacified after a balloon (Anrei Medical
Co. Ltd Hangzhou, China) occluded cholangiography
obtained through the papilla, and all attempts at advancing a guidewire (0.035 inch VisiGlide, Olympus Europa
Holding GMBH Hamburg, Germany) proximally into
the intrahepatic bile ducts failed (Figure 1A, B). On a
simultaneous PTC, a guidewire could not be advanced
into the CBD despite several attempts (Figure 1B).
These findings indicated complete stenosis of the anas-
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Odemis B et al . An interesting rendezvous location
tomosis during the previous year; therefore, we resolved
these problems by performing a modified rendezvous
technique. A guidewire inserted through the papilla was
intentionally pushed strongly into the paracholedochal
space at the level of the stricture, which was then spontaneously advanced into the bulbus of the duodenum
alongside the biliary drainage catheter. Later, a snare
(Micro-Tech Nanjing Co. Ltd. Hamburg, Germany)
was slowly introduced via the transhepatic route into
the bulbus and the guidewire was caught by closing the
snare under endoscopic visualization (Figure 1C). The
guidewire was pulled proximally all the way through the
percutaneous access (Figure 1D). This was followed by a
5 and 7 mm balloon (Ventura biliary dilatation catheter,
Panmedikal, Gloucester, United Kingdom), dilatation of
the stricture (Figure 1E) and placement of an internalexternal biliary drainage catheter through the papilla.
Two weeks later, the drainage catheter was removed and
two biliary plastic stents (Erdamed Biliary Stent, Istanbul, Turkey) were inserted into the right anterior and
posterior segments of the liver via ERCP. In the third
month of follow-up, the stricture was almost completely
resolved and the patient was then followed stent-free
(Figure 1F).
DISCUSSION
There have been no other reports in the literature regarding the misplacement of the internal portion of
the percutaneous internal-external drainage catheter
to the duodenal bulb, and this case was the first in our
clinic. In patients with liver transplantation, placement
of the PTBD catheter in the wrong location, such as the
duodenal bulb as in our case, can cause several complications, such as leakage, pain, infection, and accidental
removal of the PTBD catheter. Two alternatives can be
performed in such cases in which transpapillary cannulation of the intrahepatic bile ducts is not possible
because of complete stenosis of the anastomosis. The
first option is to accept the overall risks and to live with
the PTBD catheter, and the second is surgery. The rendezvous procedure is classically performed after transhepatic advancement of a guidewire through the papilla
for subsequent ERCP[5]. In a recent report, Fiocca et al[6]
performed a 100% successful endoscopic-radiologic rendezvous procedure in the subhepatic space in patients
with complete transection of the common bile duct. We
also successfully performed this technique in another
patient with a complete transection of the CBD due to
previous cholecystectomy[7]. This experience encouraged
us to perform the same endoscopic-radiologic rendezvous technique in the duodenal bulb. The procedure
was successful, and we avoided the possible risks that
may develop due to PTBD or surgery. We suggest that
the rendezvous technique can be performed as an initial
method for treating similar biliary complications after
liver transplantation.
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COMMENTS
COMMENTS
Case characteristics
A 53-year-old-man with a history of right lobe living donor liver transplantation
(LDLT) due to hepatitis B-related cirrhosis and hepatocellular carcinoma three
years ago was admitted to our clinic for removal of a percutaneous internalexternal biliary drainage catheter and with the complaint of pruritis.
Clinical diagnosis
The signs were scratch wounds on the skin secondary to pruritis, large abdominal scar due to previous liver transplantation and a percutaneous biliary drainage catheter on the abdomen.
Differential diagnosis
Stricture of the biliary anastomosis, biliary injury, ischemic cholangiopathy,
chronic rejection, posttransplantation disease recurrence.
Laboratory diagnosis
Hemoglobin: 11.5 g/dL; aspartate aminotransferase: 99 U/L; alanine aminotransferase: 87 U/L; alkaline phosphatase: 475 U/L; glutamyltransferase: 155
U/L; total bilirubin: 1.8 mg/dL; direct bilirubin: 1.4 mg/dL; other laboratory tests
were within normal limits.
Imaging diagnosis
The tip of the internal-external biliary drainage catheter was protruding from the
bulbus during endoscopic retrograde cholangiopancreatography (ERCP) and a
stricture blocking advance of the guidewire proximally was recorded on cholangiography.
Pathological diagnosis
Pathological examination was not performed.
Treatment
After passage between the proximal and distal segments of the bulbus was
achieved via the endoscopic-radiologic rendezvous method, balloon dilatation
of the stricture and placement of an internal-external biliary drainage catheter
through the papilla were performed.
Related reports
Biliary strictures are common in LDLT patients, and ERCP, percutaneous transhepatic cholangiography or, infrequently, surgical management is necessary
for treatment.
Experiences and lessons
This case report suggests that an endoscopic radiologic rendezvous technique
can be performed as an alternative method for treating biliary strictures in which
the conventional endoscopic and radiologic methods have failed after liver
transplantation, even if the rendezvous localization is the duodenal bulb. This
procedure should be considered before invasive management options, such as
surgery.
Peer review
The endoscopic radiologic rendezvous technique is a viable alternative method
for treating biliary strictures, especially in patients with liver transplantation.
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P- Reviewer: Sakai Y S- Editor: Gou SX
L- Editor: Webster JR E- Editor: Liu XM
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