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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
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10.1055/a-2384-9303
E-Videos-2024-06-5156-EV
E-Videos
Recanalization of occluded biliary intestinal anastomosis through utilizing percutaneous transhepatic cholangioscopy for a 2-year-old patient after liver transplantation
Chen Rui Dr.
Zhang Jingyi Prof.
Chen Tianhao
Zhang Jie Dr.
http://orcid.org/0009-0008-0970-1491
Zhou Rongxing MD
1 34753 Division of Biliary Surgery, Department of General Surgery, West China Hospital of Sichuan University, Chengdu, China
2 34753 Research Center for Biliary Diseases, West China Hospital of Sichuan University, Chengdu, China
3 34753 Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
Correspondence Rongxing Zhou, MD Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University37 Guo Xue XiangChengdu, Sichuan, 610041P.R. Chinarongxingzhou@126.com
04 9 2024
12 2024
1 9 2024
56 Suppl 1 E770E771
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/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
National Natural Science Foundation of China 10.13039/501100001809 22004088 Science & Technology Support Project of Sichuan Province2023YFS0183
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pmc A 2-year-old girl with a history of liver transplantation for biliary atresia was admitted with recurrent fever and jaundice. Magnetic resonance cholangiopancreatography ( Fig. 1 ) showed a stricture of the bilioenteric anastomosis. Two attempts at percutaneous transhepatic cholangiography drainage (PTCD) failed ( Fig. 2 ). Percutaneous transhepatic cholangioscopy (PTCS) was therefore applied to provide direct visualization of any intraductal lesions or confirm a benign stricture, which is generally observed as having a smooth mucosal surface, tapered luminal narrowing, short stricture segment, and the absence of neovascularization 1 ( Video 1 ).

Fig. 1 Magnetic resonance cholangiopancreatography showed a stricture of the biliary intestinal anastomosis (yellow arrow).

Fig. 2 In both percutaneous transhepatic cholangiography drainage (PTCD) procedures, the guidewire failed to pass through the anastomosis due to severe narrowing.

The recanalization of occluded biliary intestinal anastomosis was successfully performed under the direct visualization of percutaneous transhepatic cholangioscopy (PTCS) for the 2-year-old patient after failed percutaneous transhepatic cholangiography drainage (PTCD).

Video 1

To minimize the patient’s radiation dose exposure, ultrasound was used instead of interventional radiography to evaluate the intrahepatic bile ducts. The guidewire was inserted through the PTCD sinus, followed by sequential dilation of the tract until a 16-Fr sheath could be placed. A rigid cholangioscope was inserted under the guidance of the guidewire, and the completely obstructed bilio-enteric anastomotic site was then directly visualized after clearing the hepatolithiasis ( Fig. 3 ). The guidewire was passed through the anastomosis after repeated attempts. Balloon dilation was performed repeatedly until significant dilation of the anastomosis was achieved ( Fig. 4 ). The intraoperative cholangiography confirmed the disappearance of the occluded biliary intestinal anastomosis, with good transition of contrast medium from bile ducts to bowel ( Fig. 5 ). Finally, a 16-Fr bile drainage tube was placed through the anastomosis to support and drain. There were no postoperative complications and the patient was discharged 3 days after surgery.

Fig. 3 The obstructed anastomosis (yellow dashed circle) was observed under the direct visualization of the rigid cholangioscope.

Fig. 4 The balloon was used to repeatedly dilate the narrow tracts until there was a noticeable dilation at the anastomotic site. a The balloon was placed through the anastomosis. b The pressure of the balloon was maintained at 8 bar for 1 minute for continuous expansion. c The originally narrow anastomosis showed significant dilation after multiple expansions.

Fig. 5 The intraoperative cholangiography confirmed the disappearance of the occluded biliary intestinal anastomosis, with good transition of contrast medium from bile ducts to bowel.

Anastomotic stricture is a common complication after liver transplantation 2 . PTCD has become the preferred choice for most patients given the changes in anatomical structure 3 . Compared with PTCD, PTCS has the advantages of operating under direct vision and reducing the radiation exposure 4 , and it has been widely used in adults with biliary-enteric anastomotic strictures 5 . This study demonstrated that PTCS might also be a safe and feasible minimally invasive treatment for anastomotic stricture following pediatric liver transplantation.

Endoscopy_UCTN_Code_TTT_1AR_2AG

Endoscopy E-Videos https://eref.thieme.de/e-videos

E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .

Conflict of Interest The authors declare that they have no conflict of interest.
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References

1 Haber ZM Srinivasa RN Lee EW Percutaneous transhepatic cholangioscopy interventions – updates J Clin Gastroenterol 2023 57 879 885 10.1097/MCG.0000000000001891 37428081
2 Hsiao CY Ho CM Wu YM Biliary complication in pediatric liver transplantation: a single-center 15-year experience J Gastrointest Surg 2019 23 751 759 10.1007/s11605-018-04076-x 30632007
3 Monroe EJ Shin DS Young VA Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques Pediatr Radiol 2022 52 570 586 10.1007/s00247-021-05212-7 34713322
4 Yan KL Gomes AS Monteleone PA Management of biliary stricture in pediatric liver transplantation patients: long-term outcomes Liver Transplant 2021 27 1788 1798 10.1002/lt.26095
5 Nam K Lee SK Song TJ Percutaneous transhepatic cholangioscopy for biliary complications after liver transplantation: a single center experience J Hepatobiliary Pancreat Sci 2016 23 650 657 10.1002/jhbp.388 27474863
