Successful Treatment of Severe Anastomotic Stricture of a Choledochojejunostomy After Living Donor Liver Transplantation With Transhepatic Cholangioscopy-Guided Balloon Dilatation T. Shimizu, T. Urahashi, Y. Ihara, Y. Kaneda, A. Miki, Y. Sanada, T. Wakiya, N. Okada, N. Yamada, and K. Mizuta ABSTRACT Anastomotic stricture of the choledochojejunostomy is a common complication after living donor liver transplantation. Most anastomotic strictures can be treated by percutaneous transhepatic cholangiodrainage and/or double balloon endoscopy. However, in severe cases and/or in small infants, neither of these is possible. Our new technique, cholangiography accompanied by cholangioscopy, enabled successful guidewire placement and balloon dilatation in cases with severe anastomotic stricture.
A
NASTOMOTIC stricture of the choledochojejunostomy is a common complication after living donor liver transplantation (LDLT) [1e4]. Most anastomotic strictures can be treated by percutaneous transhepatic cholangiodrainage (PTCD) and/or double balloon endoscopy (DBE) [5e8]. However, in severe cases, guidewire placement cannot be accomplished, and in small infants, DBE is not possible. We herein describe a new technique that enabled successful guidewire placement and balloon dilatation in cases with severe anastomotic stricture observed during choledochojejunostomy. METHODS Selection of Patients We performed this new method in 3 pediatric cases of severe anastomotic stricture of choledochojejunostomy after LDLT. PTCD was performed in all patients under cholangiography (Fig 1), but guidewire placement was difficult because it was twisted at the anastomosis, and the anastomotic stricture was worsened thereafter. The patient body weight and postoperative period at the time of PTCD were 10 to 14 kg and 90 to 322 days, respectively, and the DBE approach was not successful because of small body weight.
Fig 1. Complete obstruction was revealed.
Technical Information The PTCD approach was performed under direct transhepatic cholangioscopic guidance under general anesthesia. Cholangiography showed severe biliary stricture or complete obstruction, and cholangioscopy revealed traces of the anastomosis, such as a dimple (Fig 2). Under direct transhepatic cholangioscopic guidance, we attempted guidewire placement. ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 999e1000 (2014)
From the Department of Surgery, Jichi Medical University, Tochigi, Japan. Address reprint requests to Dr. Tetsuichiro Shimizu, Jichi Medical University, Department of Surgery, 3111-1 Yakushiji, Shimitsuke, Tochigi 3290498, Japan. E-mail: shimitetsu@hotmail. co.jp 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.10.045 999
1000
Fig 2. Cholangioscopy revealed traces of the anastomosis, such as a dimple.
RESULTS
Under direct cholangioscopic view, the caudal edge of a guidewire was passed through the trace of the anastomosis and inserted into the Roux-en-Y elevated jejunum (Fig 3). The anastomosis was dilated with a balloon catheter. A PTCD tube was then put in place. All patients demonstrated a satisfactory improvement by this method, and the PTCD tube could be successfully removed. DISCUSSION
Anastomotic stricture is one of the most common complications in choledochojejunostomy after LDLT. PTCD is the first-choice treatment for dilatation, but in some cases the PTCD approach is difficult. Kawano et al reported on the rendezvous penetration method. They approached from both sides of the anastomosis, PTCD cholangiography from the bile duct side and DBE from the elevated jejunum side. The Yamauchi method is a treatment using magnetic compression. This is also effective for anastomotic stricture after choledochojejunostomy. However, both could not be accomplished when the approach from the jejunum side was not successful. Reoperation has a relatively high risk for small infants with liver dysfunction after several laparotomies. This procedure safely and effectively treats severe biliary-enteric anastomotic stricture in small infants after LDLT, with minimal tissue invasion. However, we should be aware of the risk of iatrogenic perforation because we have
SHIMIZU, URAHASHI, IHARA ET AL
Fig 3. Guidewire passed through the anastomosis.
no information regarding the elevated jejunum side of the anastomosis. REFERENCES [1] Soejima Y, Taketomo A, Yoshizumi T, et al. Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution. Liver Transpl 2006;12:979e86. [2] Egawa H, Inomata Y, Uemoto S, et al. Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 2001;25:1300e7. [3] Seo JK, Ryu JK, Lee SH, et al. Endoscopic treatment for biliary stricture after adult living donor liver transplantation. Liver Transpl 2009;15:369e80. [4] Iwamoto H, Hama K, Nakamura Y. Biliary complications after 52 adult living donor liver transplantations: a single-center experience. Transplant Proc 2008;40:2539e41. [5] Roumilhac D, Poyet G, Sergent G, et al. Long-term results of percutaneous management for anastomotic biliary stricture after orthotopic liver transplantation. Liver Transpl 2003;9:394e400. [6] Haruta H, Yamamoto H, Mizuta K, et al. A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation. Liver Transpl 2005;11:1608e10. [7] Kawano Y, Mizuta K, Hishiwaka S, et al. Rendezvous penetration method using double-balloon endoscopy for complete anastomosis obstruction for hepaticojejunostomy after pediatric living donor liver transplantation. Liver Transpl 2008;14:385e7. [8] Tsukui D, Yano T, Nakazawa K, Osawa H, et al. Rendezvous technique combining double-balloon endoscopy with percutaneous cholangioscopy is useful for the treatment of biliary anastomotic obstruction after liver transplantation. Gastrointest Endosc 2008;68:1013e5.
A
NASTOMOTIC stricture of the choledochojejunostomy is a common complication after living donor liver transplantation (LDLT) [1e4]. Most anastomotic strictures can be treated by percutaneous transhepatic cholangiodrainage (PTCD) and/or double balloon endoscopy (DBE) [5e8]. However, in severe cases, guidewire placement cannot be accomplished, and in small infants, DBE is not possible. We herein describe a new technique that enabled successful guidewire placement and balloon dilatation in cases with severe anastomotic stricture observed during choledochojejunostomy. METHODS Selection of Patients We performed this new method in 3 pediatric cases of severe anastomotic stricture of choledochojejunostomy after LDLT. PTCD was performed in all patients under cholangiography (Fig 1), but guidewire placement was difficult because it was twisted at the anastomosis, and the anastomotic stricture was worsened thereafter. The patient body weight and postoperative period at the time of PTCD were 10 to 14 kg and 90 to 322 days, respectively, and the DBE approach was not successful because of small body weight.
Fig 1. Complete obstruction was revealed.
Technical Information The PTCD approach was performed under direct transhepatic cholangioscopic guidance under general anesthesia. Cholangiography showed severe biliary stricture or complete obstruction, and cholangioscopy revealed traces of the anastomosis, such as a dimple (Fig 2). Under direct transhepatic cholangioscopic guidance, we attempted guidewire placement. ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 999e1000 (2014)
From the Department of Surgery, Jichi Medical University, Tochigi, Japan. Address reprint requests to Dr. Tetsuichiro Shimizu, Jichi Medical University, Department of Surgery, 3111-1 Yakushiji, Shimitsuke, Tochigi 3290498, Japan. E-mail: shimitetsu@hotmail. co.jp 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.10.045 999
1000
Fig 2. Cholangioscopy revealed traces of the anastomosis, such as a dimple.
RESULTS
Under direct cholangioscopic view, the caudal edge of a guidewire was passed through the trace of the anastomosis and inserted into the Roux-en-Y elevated jejunum (Fig 3). The anastomosis was dilated with a balloon catheter. A PTCD tube was then put in place. All patients demonstrated a satisfactory improvement by this method, and the PTCD tube could be successfully removed. DISCUSSION
Anastomotic stricture is one of the most common complications in choledochojejunostomy after LDLT. PTCD is the first-choice treatment for dilatation, but in some cases the PTCD approach is difficult. Kawano et al reported on the rendezvous penetration method. They approached from both sides of the anastomosis, PTCD cholangiography from the bile duct side and DBE from the elevated jejunum side. The Yamauchi method is a treatment using magnetic compression. This is also effective for anastomotic stricture after choledochojejunostomy. However, both could not be accomplished when the approach from the jejunum side was not successful. Reoperation has a relatively high risk for small infants with liver dysfunction after several laparotomies. This procedure safely and effectively treats severe biliary-enteric anastomotic stricture in small infants after LDLT, with minimal tissue invasion. However, we should be aware of the risk of iatrogenic perforation because we have
SHIMIZU, URAHASHI, IHARA ET AL
Fig 3. Guidewire passed through the anastomosis.
no information regarding the elevated jejunum side of the anastomosis. REFERENCES [1] Soejima Y, Taketomo A, Yoshizumi T, et al. Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution. Liver Transpl 2006;12:979e86. [2] Egawa H, Inomata Y, Uemoto S, et al. Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 2001;25:1300e7. [3] Seo JK, Ryu JK, Lee SH, et al. Endoscopic treatment for biliary stricture after adult living donor liver transplantation. Liver Transpl 2009;15:369e80. [4] Iwamoto H, Hama K, Nakamura Y. Biliary complications after 52 adult living donor liver transplantations: a single-center experience. Transplant Proc 2008;40:2539e41. [5] Roumilhac D, Poyet G, Sergent G, et al. Long-term results of percutaneous management for anastomotic biliary stricture after orthotopic liver transplantation. Liver Transpl 2003;9:394e400. [6] Haruta H, Yamamoto H, Mizuta K, et al. A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation. Liver Transpl 2005;11:1608e10. [7] Kawano Y, Mizuta K, Hishiwaka S, et al. Rendezvous penetration method using double-balloon endoscopy for complete anastomosis obstruction for hepaticojejunostomy after pediatric living donor liver transplantation. Liver Transpl 2008;14:385e7. [8] Tsukui D, Yano T, Nakazawa K, Osawa H, et al. Rendezvous technique combining double-balloon endoscopy with percutaneous cholangioscopy is useful for the treatment of biliary anastomotic obstruction after liver transplantation. Gastrointest Endosc 2008;68:1013e5.
