The T-Tube Approach to Biliary Strictures in Liver Transplant Recipients

Abstract

Nonanastomotic biliary strictures (BS) are challenging complications of liver transplantation (LT) with long-term patency rates of 25% after nonsurgical treatment (1, 2). We report on a novel approach in the management of early-onset, nonanastomotic BS by means of a radiology-assisted T-tube approach. This technique was employed in a LT recipient with a severe right hepatic duct stricture three months after LT. A 52-year-old male patient was transplanted for HCV-related cirrhosis with an ABO-compatible, 50-year-old cadaver graft. Cold ischemia time was 9h10′ and biliary reconstruction was over a T-tube (3). Three months after LT the patient was admitted to the hospital for the scheduled T-tube removal (3). His liver function tests (LFT) were elevated (total bilirubin 2.1 mg/dL; GGT 68 IU/L; alkaline phosphatases 337 UI/L), but no hepatic artery thrombosis was detected on Duplex US scan. On trans-tube cholangiography a severe stricture of the right hepatic bile duct was observed in close proximity to the biliary confluence and associated with a mild dilation of the left biliary duct (Fig. 1). Under fluoro-angiographic control, a hydrophilic, 150-cm long, 0.035′ guide wire with a 3-cm flexible tip (Terumo Radiofrequency Guide Wire M, Radiofocus, Terumo Europe, Leuven, Belgium) was introduced in the T-tube and oriented through its ascending branch up to the distal aspect of the stricture. The T-tube was removed and a 6-Fr dilator (Fascial Dilator, MediTech, Boston Scientific Corporation, Watertown, MA) was passed through the stricture. The flexible guide wire was removed and replaced with a PTFE-shafted, 145-cm long, 0.035′ stiff one (Amplatz Super Stiff, MediTech, Boston Scientific Corporation, Miami, FL). Cone-tipped dilators up to 10-Fr diameter were passed over the stiff wire to dilate the strictured duct. A hydrophilic, 8-Fr catheter (Flexima Regular APD All Purpose Drainage Catheter Set, MediTech, Boston Scientific Corporation, Watertown, MA) was placed with drainage holes on either side of stenosis (Fig. 2). The catheter was secured to the skin and left open for 12 hr. A control US scan 24 hr later confirmed proper placement of the catheter and the patient was dismissed 48 hr after the procedure. He was readmitted 1 month later for a scheduled cholangiography and the 8-Fr catheter was replaced by a 10-Fr one with no complications. This latter catheter was left in place for 1 month and removed under cholangiographic control. A magnetic-resonance cholangiography performed 1 month after stent removal did not disclose any stricture of the biliary tree and LFTs had returned to baseline. At a follow-up of 9 months post-LT the patient is alive without clinically evident relapse.FIGURE 1.: T-tube cholangiography showing a severe stricture of the right hepatic duct above the confluence and associated with a mild dilation of the left hepatic duct.FIGURE 2.: Percutaneous cholangiography showing proper positioning of the 8-Fr stent catheter.BS affect 9% to 15% of adult LT patients and their management varies according to type, location, and length of lesions and the availability of experienced radiologic or endoscopic teams (1, 2, 4). A recent survey reported that 67% of US centers favor the endoscopic or percutaneous approach with 2-year patency rates in excess of 70% (5). Nonsurgical management of nonanastomotic BS requires multiple interventions and yields patency rates of approximately 25% in the long term (1, 2, 4, 5). Better resultsare reported for early, extrahepatic, single strictures, and those not associated with ductopenic rejection or hepatic artery thrombosis (1, 2, 4, 5). The T-tube approach may represent a valid alternative in the management of early-onset, proximally-sited BS, as it spares patients rendezvous techniques, and larger series are strongly favored to validate its results in the long term. Paolo De Simone Lucio Urbani Luca Morelli Gabriele Catalano Laura Coletti Marcello Spampinato Franco Filipponi Liver Transplant Unit University of Pisa Cisanello Hospital Pisa, Italy Alessandro Campatelli General Surgery and Transplant Department University of Pisa Cisanello Hospital Pisa, Italy