A Novel Use of SpyGlass Cholangioscopy to Traverse and Manage a Completely Occlusive Post-Liver Transplant Anastomotic Stricture

Abstract

Anastomotic biliary stricture is a post-orthotopic liver transplantation (OLT) complication that is managed with endoscopic retrograde cholangiopancreatoscopy (ERCP). While ERCP is typically successful, failure can lead to surgical or percutaneous intervention. We present a novel technique to traverse a completely occlusive anastomotic biliary stricture using the second generation SpyGlassTM DS Direct Visualization (SDVS). SpyGlass allowed visualization of an angulated stricture, led to successful stent placement and prevented more invasive interventions. Therapeutic endoscopists can use SDVS to manage occlusive biliary strictures. A 56-year-old man with a history of OLT (hepatitis C, alcohol abuse) had elevated liver function tests and jaundice on presentation. Initial ERCP was notable for a post-OLT anastomotic stricture. A plastic stent was placed, but converted to a metal stent given the recalcitrant nature of the stricture. Repeat ERCP revealed the metal stent had migrated distally. Occlusion cholangiogram showed a blind stump with no contrast extending proximal to the anastomosis, suggestive of an occlusive stricture (Figure 1). Despite the use of multiple wires and devices, attempts to traverse the stricture proximally were unsuccessful. SDVS cholangioscopy showed significant fibrosis at the proximal end of the native duct. Although initial views suggested a blind stump, continued maneuvering revealed an occlusive, fibrotic, and severely angulated stricture (Figure 2). A guide wire was inserted through the cholangioscope and steered across the stricture into the intrahepatic ducts. The stricture was subsequently dilated and two plastic stents were placed across the stricture (Figure 3). Novel use of the SVDS cholangioscope averted any radiologic or surgical intervention. The management of post OLT anastomotic strictures with ERCP may be difficult or unsuccessful in patients with tight strictures. While Spyglass cholangioscopy has been predominantly used for diagnosis of indeterminate biliary strictures, this case presents a novel use of Spyglass in performing therapeutic ERCP for an occlusive biliary stricture. The most recent second-generation SVDS system provides superior image quality, allowing precise visualization and access beyond occlusive strictures. This is the first ever-reported case of using the second-generation SVDS cholangioscope to traverse an occlusive post-OLT anastomotic stricture and perform therapeutic biliary stenting.Figure: Blind stump, tight stricture.Figure: SpyGlassTM DS showing angulated stricture.Figure: Angulated stricture and common bile duct after dilation.