Rendezvous Technique for Biliary Stricture After Adult Right-Lobe
Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis.
Authors: Jin Hyoung Kim, Gi-Young Ko, Kyu-Bo Sung
A 53-year-old woman admitted to our hospital on April 2nd 2006, due to the elevation of LFT. She had underwent right-lobe living donor liver transplantation on May 11th 2005. Biliary stricture at duct-to-duct anastomosis was found on CT.
Cannulation of the stricture between anterior segmental duct and common bile duct (CBD) was successfully performed using ERCP and subsequent plastic stent was placed. However, there was remained stricture between posterior segmental duct and CBD(Fig.1). Cannulation of the remained stricture was failed via endoscopic approach at that time. However, the patient’s symptoms were improved and thus she was discharged.
However, she admitted to our hospital again one week later, because of recurrent symptoms. Percutaneous transhepatic biliary drainage (PTBD)of posterior segmental duct was performed for this patient. 4 days later, cannulation of stricture between posterior segmental duct and CBD was tried via percutaneous route, but it failed because of tight, complete obstruction (Fig 2). Thereafter, cannulation of the stricture was tried for 20 times during 1 year using PTBD route, but it failed. We then planned to cannulate the stricture using rendezvous technique using PTBD route and ERCP. First, the stricture between posterior duct and CBD was successfully cannulated using ERCP (Fig 3). Second, a snare through the PTBD route successfully captured and pulled the guide wire through the stricture to complete cannulation of the stricture (Fig 4). After successful cannulation of the stricture, subsequent balloon dilation was performed (Fig 5). After improvement of stricture, the PTBD tube was finally removed on March 24th 2008. The patient had no further symptoms for 32 months after PTBD tube removal.
Lateral fluoroscopic image shows successful cannulation of stricture and guide-wire (arrows) into the posterior segmental bile duct.
Snare (arrow) captures the cannulated guide-wire from ERCP.
- Rendezvous technique is clinically effective to cannulate severe stricture at duct-to-duct anastomosis after living-donor liver transplantation.
- Endoscopic assistance is useful adjunctive method that provide retrograde approach when the passage of a wire is not feasible with ante-grade approach.
- Intervention may provide the chance of cure for even the old stricture (more than 1 year) at duct-to-duct anastomosis after living-donor liver transplantation.