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

Abstract

The endoscopic treatment of biliary cast syndrome after liver transplantation (LT) has been described; it has been performed only in patients with a duct-to-duct anastomosis. We describe the successful endoscopic removal of a biliary cast via balloon enteroscopy–guided endoscopic retrograde cholangiopancreatography in an orthotopic liver transplantation (OLT) patient with Roux-en-Y reconstruction. A 51-year-old man had undergone OLT 1 month previously for primary sclerosing cholangitis and cholangiocarcinoma. He was clinically well post-transplantation but was noted to have a progressive rise in his alkaline phosphatase level up to 984 U/L. Abdominal ultrasound showed prominent bile ducts in the left lobe. The endoscopic evaluation was undertaken to evaluate him for suspected stenosis of the biliary enteric anastomosis. LT, liver transplantation; OLT, orthotopic liver transplantation. In the endoscopy suite, with the patient supine and under monitored anesthesia care, a single balloon enteroscope (SIFQ180, Olympus Corp., Center Valley, PA) was passed into the enteroenterostomy and eventually up the afferent limb (Fig. 1). The choledochojejunostomy was identified as a pinpoint opening. An angled 0.035-inch hydrophilic wire, preloaded into a long-length stone retrieval balloon, was used to cannulate the biliary tree. Scout radiograph demonstrating the configuration of the balloon enteroscope when it reached the choledochojejunal anastomosis. A cholangiogram revealed a filling defect in both the right and left intrahepatic systems extending down to the level of the choledochojejunostomy, and it was consistent with a biliary cast (Fig. 2). The choledochojejunostomy was balloon-dilated to 8 mm. A stone retrieval balloon was passed into the peripheral right and left intrahepatic ducts, inflated, and withdrawn distally with removal of the cast (Figs. 3 and 4). A follow-up cholangiogram revealed no residual filling defects, and the biliary tree was without obvious ischemic changes (Fig. 5). The patient tolerated the procedure well without complications. Two and 5 months later, the patient underwent additional endoscopic procedures for cholangitis because of the subsequent development of ischemic strictures. Balloon dilation was performed during both sessions without the need for stent placement. Over the last 10 months after the initial removal of the cast, the patient has remained asymptomatic. Cholangiogram demonstrating intrahepatic and extrahepatic filling defects. Endoscopic image taken during the withdrawal of the cast from the bile duct into the jejunal lumen. Biliary cast after its removal from the patient. Follow-up cholangiogram after cast removal. No filling defects can be seen, and the biliary tree appears normal. To our knowledge, this is the first case of successful endoscopic treatment of biliary cast syndrome in an LT patient with a Roux-en-Y biliary anastomosis. In patients with a duct-to-duct anastomosis, endoscopic access to the biliary tree is straightforward, and biliary cast syndrome has been successfully managed endoscopically in such patients.1, 2 The failure of endoscopic treatment may necessitate percutaneous or surgical revision of the anastomosis and possibly retransplantation.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. Since that time, a number of authors have described successful biliary interventions using balloon enteroscopy in patients with postsurgical anatomy.4-6 However, none of these cases have been performed for the treatment of cast syndrome. In conclusion, successful endoscopic biliary interventions in LT patients with a Roux-en-Y anastomosis are increasingly feasible, especially with the use of balloon endoscopes.