Real-Time 3D Imaging of Post-Transplant Biliary Stricture: A Novel Application of Existing Technology.

Complex biliary strictures in living-related liver transplant biliary strictures are challenging to manage and remain a major cause of morbidity and mortality (1). Anastomotic strictures can be found in up to 19% of patients, particularly in patients who undergo living donor liver transplantation (2). These are challenging to manage endoscopically, particularly in the setting of multiple ductal anastomoses. Even after successful endoscopic intervention, recurrence of the stricture is seen in 30% of patients (3) necessitating repeat interventions.

One of the challenges of endoscopic retrograde (ERCP) is the projection of a 3D structure on a flat fluoroscopy detector, with the limitation of overlapping biliary systems not visualized distinctly. This problem is heightened in living-related liver transplant strictures where the dual anastomosis necessitates selective biliary cannulation for stricture evaluation and therapy.

3D fluoroscopy is a new technique that has seen use primarily in the orthopedic, spinal, and neurosurgical fields (4). Its advantage lies in the ability to provide real-time 3D imaging that can aid in visualization of structures that may be difficult to appreciate from 2D projection imaging alone. We report the first use of a hybrid mobile 2D/3D C-arm system in ERCP for the navigation of difficult biliary anastomotic strictures.

A 68-year-old woman who previously underwent a living donor liver transplant 2 years earlier for cryptogenic liver cirrhosis with hepatocellular carcinoma. Biliary duct-to-duct anastomosis had been performed with the donor's 3-mm right posterior biliary duct to the recipient's right hepatic duct, and the donor's 2-mm right anterior biliary duct to the recipient's left hepatic duct. Postoperatively, the patient developed an early biliary leak that subsequently led to biliary anastomotic strictures involving both her right posterior and anterior sectoral ducts, requiring recurrent endoscopic intervention, biliary dilatation, and stenting. She underwent routine 3-monthly stent exchanges prophylactically to reduce the risk of stent occlusion and cholangitis. However, liver regeneration and hypertrophy made cannulation of the anterior sectoral duct challenging, and each endoscopic session required a prolonged procedure time of >1 hour.

Routine ERCP was performed for the patient under general anesthesia. Her existing biliary stents were removed. Balloon catheter cannulation allowed for engagement of her right posterior system, and a cholangiogram again demonstrated anastomotic strictures of her right anterior and posterior ducts (Figure 1). 3D spin fluoroscopy was then performed. 3D image reconstruction of her biliary system (Figure 2) enabled accurate visualization of her biliary anatomy and assisted with forward planning. Her right anterior system was then accessed with ease, after which biliary dilatation and double pigtail plastic stent insertion were successfully accomplished.

Figure 1.

Fluoroscopic image of the living donor liver transplant biliary anastomosis during endoscopic retrograde.

Figure 2.

3D image of the biliary tree for visualization of complex biliary stricture anatomy.

This is a novel application of this technology for biliary tree visualization. Although this does not replace high-quality preprocedure imaging and planning, augmenting conventional 2D fluoroscopy with 3D imaging helps visualization of complex biliary anatomy at the time of the procedure. This will be a useful tool to add to the existing armamentarium for management of difficult biliary strictures. Further research is required to determine its cost-effectiveness and the extent of its utility (see Video 1, Supplementary Digital Content 1, http://links.lww.com/AJG/C27).

CONFLICTS OF INTEREST

Guarantor of the article: Calvin Jianyi Koh, MBBS, FRCP, FASGE.

Specific author contributions: Study Concept and Design: C.J.K. Drafting of the manuscript: C.J.K. and C.S.K. Critical revision of the manuscript: C.J.K. and B.K.D.

Financial support: None to report.

Potential competing interests: None to report.