Post-OLT Anastomotic Strictures with Apparent Total Occlusion: Looks Are Deceiving

Abstract

Purpose: Post-orthotopic liver transplant (OLT) strictures are diagnosed and managed by endoscopic retrograde cholangiopancreatogram (ERCP) and managed with dilation and stenting. We describe a series of cases of anastomotic strictures with apparent total occlusion that were successfully managed non-operatively. Methods: We reviewed all ERCPs done at a single tertiary care hospital between December 2008 and November 2011, and identified patients who were post-OLT and had total obstruction at the biliary anastomosis on ERCP. Total obstruction was defined as no contrast flowing proximal to the anastomosis on balloon occlusion injection and inability to pass a guide wire (Jag, glide). A total of 6 patients were found to meet our criteria. Data was collected regarding age, sex, date of transplant, indication for ERCP, bilirubin levels, PTC findings, findings on follow up ERCPs and need for surgical revision. Results: The indication for ERCP in all patients was abnormal liver enzymes and dilated ducts on imaging. The total bilirubin at the time of diagnosis ranged from 1.5 to 5.2 mg/dl (only one patient had total bilirubin >2 mg/dl.). The time of diagnosis was from 7 months to 7 years after OLT. All six patients underwent percutaneous transhepatic cholangiogram (PTC) within one day to two weeks of ERCP. PTC revealed total occlusion in 1 patient and high grade obstruction at the level of the biliary anastomosis in 5 patients. All patients had external biliary drainage established at initial PTC. Four of the patients could be managed by internalization of biliary drain by subsequent PTC, rendezvous ERCP and maximal parallel stent placement or fully covered self-expanding metal stent placement. One patient failed endoscopic management because of difficult ERCP and required hepaticojejunostomy. One patient had PTC and is awaiting repeat ERCP. The mean number of ERCP per patient was 3.3 and PTC was 4.3, with a single patient requiring 8 ERCP and 12 PTC due to recurrent stones and bile leak. Conclusion: Patients with apparent total occlusion on ERCP had only modest elevation of bilirubin indicating that these patients did not have a true total occlusion. We believe that dilatation of the donor bile duct may cause tortuosity at the anastomotic site which acts as a valve-like mechanism preventing passage of contrast or guidewire through the anastomosis. This does not preclude endoscopic management. ERCP with dilation and stent placement is possible once decompression is achieved via PTC.