Endoscopic retrograde cholangiography in post–orthotopic liver transplant population with Roux-en-Y biliary reconstruction

Abstract

Endoscopic retrograde cholangiography (ERC) is a well-established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post-orthotopic liver transplantation (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux-en-Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux-en-Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end-stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable-stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time-consuming in OLT patients with Roux-en-Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery. Liver Transpl 13: [1168][1169][1170][1171][1172][1173] 2007. © 2007 AASLD.Received July 31, 2006; accepted March 16, 2007. Biliary complications after liver transplantation are an important cause of early and late postoperative morbidity and mortality. 1-5 The Roux-en-Y biliary reconstruction is considered the method of choice when liver transplantation is performed for intrinsic biliary disease and for patients with primary sclerosing cholangitis (PSC) because the reported rate of biliary complications is higher and the graft and patient survival worse in the latter patient population when choledochocholedochostomy is performed. 6 Percutaneous transhepatic cholangiography and surgical repair have been the primary management approaches for biliary complications after orthotopic liver transplantation (OLT) with Roux-en-Y reconstruction because the Roux-en-Y surgical bypass has routinely been considered to preclude endosc...

Endoscopic management of biliary strictures after liver transplantation

“…PTC is most often reserved for patients in whom ERCP is unsuccessful and in patients with Roux-en-Y hepaticojejunostomy or choledochojejunostomy. While an inherent limitation of ERCP is the problem of access in patients with Rouxen-Y reconstructions, in high volume centers with experienced endoscopists, newer approaches of ERCP can be successfully performed using the variable stiffness colonoscope, double balloon enteroscope, single balloon enteroscope, and spiral overtube [61][62][63][64] . The characteristic cholangiographic appearance of an anastomotic stricture is that of a thin, short, localized, isolated narrowing in the area of the biliary anastomosis.…”

Successful endoscopic treatment of biliary cast syndrome in an orthotopic liver transplant patient with a Roux-en-Y anastomosis via balloon enteroscopy

“…1,2 The endoscopic management of post-LT biliary disorders in patients with a biliary enteric anastomosis is technically difficult because reaching the anastomosis requires negotiating the relatively long-length Roux-en-Y anastomosis. Chahal et al 3 described successful endoscopic management of a variety of biliary disorders in transplant patients with Roux-en-Y anatomy. This study was published prior to the utilization of balloon enteroscopes.…”

Endoscopic Retrograde Cholangiography of a Hepaticojejunostomy Using Double Balloon Enteroscopy

“…The success rate in post-orthotopic liver transplant population is 71% [11]. A pediatric colonoscope is generally used.…”