Novel Treatment for Complex Bile Leakage After Liver Transplantation

Summary

Bile leakage is a common complication after liver transplantation that significantly affects patients' prognosis. The protocol presents a new method of combining endoscopic retrograde cholangiopancreatography (ERCP), branch choledochoscope, and percutaneous transhepatic cholangioscopy (PTCS) for treating complex bile leakage after liver transplantation.

Abstract

Bile leakage is a common complication after liver transplantation that may usually be cured with endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangial drainage (PTCD), percutaneous transhepatic cholangioscopy (PTCS)and surgery. We report a novel treatment for biliary leakage lasting 9 months after liver transplantation, during which ERCP, PTCD, PTCS, and surgical therapy were in vain. We have used a new method of multi-endoscopic treatment. First, ERCP and peroral single operator cholangioscopy are used to place a plastic stent as a marker at the distal end of the bile leakage site. Second, PTCS is performed through the PTCD tube. During the operation, the proximal end of the bile leakage site is located by the plastic stent and B ultrasound, and the continuity of the biliary tract is temporarily reconstructed through the guide wire and urinary catheter. Third, a double-headed guidewire is placed, the urinary catheter is removed, the stents are placed, and biliary continuity is reconstructed. In conclusion, we have found a new method combining ERCP, peroral single operator cholangioscopy, and PTCS to treat complex bile leakage after liver transplantation.

Introduction

Liver transplantation has become a standard of care in patients with end-stage liver disease. After liver transplantation, approximately 1/3^rd of patients are affected by biliary tract complications, and these result in significant morbidity and decreased patient survival, which is called the Achilles heel of liver transplantation¹. Biliary leakage is the second most common complication after liver transplantation, with an incidence of 2%-21%^2,3,4. Approaches commonly used for treating biliary complications involve endoscopic retrograde chol....

Protocol

The study conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University. The informed consent was obtained from the patient.

1. Preoperative preparation

1. Instruct the patient to fast for 6-8 h before ERCP. Administer Pethidine 1 mg/kg, Anisodamine 20 mg, Midazolam injection 1 mg, Flurbiprofen 100 mg intravenously, and tetracaine hydrochloride orally. When the pharyngeal reflex disappeared, Local anesthesia plus sedation and analgesia were deemed successful.

2. Plastic stent placement

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Results

We describe a new method combining ERCP, peroral single operator cholangioscopy, and PTCS to treat complex bile leakage after liver transplantation. To reconstruct biliary continuity, we placed a 7F x 7 cm double pigtail bile duct in the left hepatic duct (Figure 5C) and an 8.5 F x 12 cm bile duct plastic stent in the right hepatic duct (Figure 5D), using a combination of multiple endoscopes.

Discussion

In the study, we have found a new method of combining ERCP, peroral single operator cholangioscopy, and PTCS for the treatment of complex bile leakage after liver transplantation. The key steps of this method were as follows: first, under the peroral single operator cholangioscopy, the end of the bile leakage was identified, and a plastic stent was placed. Secondly, under the guidance of B-ultrasound, the common hepatic duct strictures were observed and dilated, and the plastic stent was exposed. During these two importa.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Biliary stent	Boston Scientific	M00533560	7 F*7 cm
Branch choledochoscope	Leinzett	LAN-EP-2612
Disposable electric snare	Boston Scientific	M00562320
Disposable sphincterotomy knife	Boston Scientific	M00545170
Electronic choledochoscope	Olympus	/
Electronic duodenum mirror	Olympus	/
Guidewire	Boston Scientific	M00556140
Guidewire guided the dilated balloon catheter	Boston Scientific	M00558600
Integrated biliary stent	Boston Scientific	M00539210	7 F*7 cm
Integrated biliary stent	Boston Scientific	M00539280	8.5 F*12 cm