Endoscopic biliary recanalization with a needle-knife in post liver-transplant complete anastomotic stricture.

Biliary strictures are challenging situations in post liver-transplant patients, occurring in up to 15% after deceased orthotropic liver transplant (OLT) and 32% after living donor liver transplant [1]. Endoscopic treatment is established as firstline therapy for these patients, more recently using fully covered self-expandable metallic stents (FCSEMS) [2]. A 62-year-old man, who had received an OLT 9 months earlier due to hepatitis C, presented with jaundice, elevated liver enzymes and dilated intrahepatic ducts. During endoscopic retrograde cholangiopancreatography (ERCP), after failed attempts to pass a guide wire through the stricture (●" Fig.1a), a decision was made to puncture the stricture with a needleknife. The needle-knife was advanced through the papilla and, under fluoroscopy, the stricture was punctured by advancing the needle-knife with pure-cut current (●" Video1). The guide wire was then advanced and contrast injected to confirm the intraductal location. The FCSEMS was placed (●" Fig.1b). After 6 months the metal stent was removed, with stricture resolution shown by radiograph (●" Fig.1c), clinical and biochemical improvement (●" Table1). A 66-year-old woman with autoimmune hepatitis, who had undergone an OLT 29 months earlier, presented with jaundice, elevated liver enzymes, and dilated intrahepatic ducts. The guide wire could not be advanced through the stricture (●" Fig.2a). Needle-knife puncture of the stricture was performed, and a FCSEMS was placed (●" Fig.2b and ●" Video2) and then left in place for 6 months, with Fig.1 Retrograde cholangiogram. a Tight biliary anastomotic stricture. b Fully covered self-expandable metallic stent (FCSEMS) placed after stricture puncture. Note two stent compressions, one proximal at the stricture site and a distal one at the ampullary level; no sphincterotomy was performed. c Fluoroscopic view of stricture resolution after stent removal 6 months later.