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Percutaneous creation of biliary‐enteric neoanastomosis for anastomotic biliary occlusion following living donor liver transplantation

A 64-year-old man with history of primary sclerosing cholangitis underwent living donor liver transplantation at the age of 51 years. For creation of the hepaticojejunostomy, the 2 ducts of the right lobe graft were joined to form a single orifice and then anastomosed to the Roux limb. He did very well for many years. Approximately 12 years following the transplant, he began developing episodes of cholangitis, initially managed with intravenous antibiotics, and subsequently with rotating prophylactic antibiotics. He was then referred to our institution for definitive intervention. A magnetic resonance imaging scan revealed moderate intrahepatic biliary duct dilatation to the level of a tight stricture at the biliary-enteric anastomosis (Fig. 1A). In the preceding 6 months, he had developed 3 episodes of cholangitis, requiring hospital admission. He underwent an attempt at endoscopic retrograde cholangiopancreatography. However, the endoscope could not be advanced to the level of the hepaticojejunostomy. Percutaneous transhepatic cholangiogram was performed, confirming a severe anastomotic stricture that could not be crossed (Fig. 1B). An external biliary drain was left in place. A second attempt at crossing the stricture was made several days later that was also unsuccessful. A cone-beam computed tomography (CT) scan was performed in the interventional radiology suite that demonstrated the liver was closely apposed to a loop of jejunum from the prior hepaticojejunostomy (Fig. 2A). A decision was made to attempt creation of a neohepaticojejunostomy anastomosis between the biliary tree and the jejunum. The existing biliary drain was exchanged for a sheath over a wire. A R€osch-Uchida transjugular venous access system (Cook Medical, Bloomington, IN), typically used for creation of a transjugular intrahepatic portosystemic shunt, was employed. A curved 14-gauge guiding cannula was placed into the biliary tree, and a 5-Fr catheter was mounted on a sharp 0.038 in. stylet, which were passed through the liver and directly into the jejunum (Fig. 2B,C). The stylet was removed, and contrast injection confirmed successful passage into the bowel (Fig. 2D), with no evidence of leak. The patient was discharged home on the evening of the neoanastomosis creation on a 2-week course of ertapenem via an indwelling peripherally inserted central catheter (PICC). He received single doses of periprocedural antibiotics during subsequent dilatations but was no longer maintained on rotating antibiotics at home. The patient presented for serial evaluation and intermittent dilatation of the neoanastomosis 8 times over the following 8 months, to a maximum of 12mm (Fig. 3A,B) using low-profile Armada balloons (Abbott Laboratories, Abbott Park, IL). He tolerated the drain well. Once the neoanastomosis seemed robust, an external biliary drainage catheter was placed. After 4 weeks with the catheter clamped and repeat final cholangiogram (Fig. 3C) demonstrating a widely Abbreviations: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CT, computed tomography; IR, interventional radiology; MIP, maximum-intensity projection; MRCP, magnetic resonance cholangiopancreatography; PICC, peripherally inserted central catheter; SGOT, serum glutamic oxaloacetic transaminase; SGPT, serum glutamate pyruvate transaminase.