Anastomotic biliary stricture after liver transplantation

Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.

In this authoritative lecture, Dr. Benoît Gallix looks into the following issue: which imaging technique for which patient?

In this key lecture, Dr. Eduardo Houghton reviews percutaneous cholecystostomy.

In this authoritative lecture, Dr. Mariano Gimenez looks into the management of benign biliary stricture.

There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.

In this authoritative lecture, Dr. Dong Ki Lee covers the use of magnets in total benign biliary strictures (BBS).

Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.

Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.

In this authoritative lecture, Dr. Eduardo Houghton looks into the percutaneous treatment of biliary lithiasis.