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DOI: 10.1055/a-2493-3614
A novel approach to managing biliary anastomotic stricture following orthotopic liver transplantation after failure of endoscopic retrograde cholangiopancreatography technique


Biliary stricture is the most common complication after liver transplantation, accounting for ~40% of all biliary complications [1] [2]. These complications remain a major cause of morbidity and, in severe cases, mortality. Endoscopic treatment is the first-line treatment for benign biliary stricture [3]. The success rate of endoscopic treatment of anastomotic stricture is 58%–76% in patients with living-donor liver transplantation [4] [5]. Here, we show a novel approach to managing biliary anastomotic stricture following orthotopic liver transplantation after failure of the endoscopic retrograde cholangiopancreatography (ERCP) technique, even with direct cholangioscopy.
We report the case of a 54-year-old patient who presented with progressive jaundice after undergoing liver transplantation for hepatocellular carcinoma. Contrast-enhanced abdominal computed tomography revealed a biliary anastomotic stricture, with a dilated common bile duct (CBD) measuring 21 mm ([Fig. 1]). A classic ERCP was performed, during which retrograde cholangiography revealed truncation of the CBD, with nonvisualization of the upper part of the CBD and intrahepatic bile duct. Attempts to pass through the stricture under fluoroscopy with a 0.035-inch straight guidewire were unsuccessful. Subsequent direct cholangioscopy with guidewire also failed after several attempts ([Fig. 2]). Classic rendezvous technique of percutaneous transhepatic biliary drainage and ERCP was unsuccessful in passing through the stricture ([Fig. 3]). Finally, percutaneous transhepatic cholangiography was performed and a rigid guidewire was inserted through the stricture under ultrasound guidance ([Fig. 4], [Video 1]). The stricture was then dilated using a 6-mm balloon, followed by placement of a 10 × 80 mm self-expanding covered metal stent under ERCP ([Fig. 5]).















The use of percutaneous transhepatic cholangiography for selective cannulation represents a novel approach to the therapeutic management of complex biliary stricture. This technique is particularly beneficial for cases where ERCP and classic rendezvous techniques have failed, allowing surgical treatment to be avoided.
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Publication History
Article published online:
14 January 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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