Management issues in post living donor liver transplant biliary strictures

Figure 1 Types of biliary anastomoses and corresponding biliary reconstructions[54]. A: Single duct anastomosis; B: Double duct - minimum distance between two donor ducts, requires ductoplasty with recipient CBD; C: Double duct - two donor duct are far away, requires two separate duct anastomosis or a hepaticojejunostomy; D: Single duct to duct reonstruction; E: Double duct to duct reconstruction using right and left hepatic ducts; F: Double duct to duct reconstruction using cystic and CHD; G: Mixed type using duct to duct and hepaticojejunostomy. CHD: Common hepatic duct; CBD: Common bile duct.

Figure 2 Anastomotic stricture - single duct anastomosis. A: Magnetic resonance cholangiopancreatography shows stricture at the anastomotic site of a single duct anastomosis; B: Endoscopic retrograde cholangiopancreatography (ERCP) in the same patient shows the stricture; C: ERCP in same patient shows guide wire negotiated across the stricture.

Figure 3 Anastomotic stricture - double duct anastomosis. A: Magnetic resonance cholangiopancreatography image shows stricture across both RASD as well as RPSD ductal anastomosis; B: Endoscopic retrograde cholangiopancreatography (ERCP) image shows guide wire negotiated across RPSD in this patient; C: ERCP image shows guidewire negotiated across RASD in this patient.

Figure 4 Anastomotic stricture - ductoplasty. A: Magnetic resonance cholangiopancreatography image of a ductoplasty of RASD and RPSD to common hepatic duct; B: Endoscopic retrograde cholangiopancreatography (ERCP) image shows stricture at ductoplasty site; C: ERCP image shows guide wire across one ductal system.

Figure 5 Anastomotic stricture - cystic duct anastomosis (endoscopic retrograde cholangiopancreatography failed, patient underwent percutaneous transhepatic biliary drainage).

Figure 6 Cystic duct anastomosis after dilatation. This patient developed stricture again and underwent a hepaticojejunostomy.

Figure 7 Timeline of biliary complications after transplant.

Figure 8 Protocol for endoscopic intervention (please see text also). ERCP: Endoscopic retrograde cholangiopancreatography.

Figure 9 Balloon dilatation of biliary stricture. A: Endoscopic retrograde cholangiopancreatography (ERCP) images show stricture at the anastomotic site; B: ERCP image showing balloon dilatation of the stricture; C: Successful obliteration of the waist of stricture after balloon dilatation.

Figure 10 Rendezvous procedure. A: Endoscopic retrograde cholangiopancreatography opacified only RASD; B: RPSD accessed via percutaneous transhepatic biliary drainage; C: Rendezvous procedure being performed.