Biliary complications are the most common type of complications after liver transplantation. Post-transplant anastomotic strictures tend to develop in the first year at a mean interval of 5–8 weeks.¹ The risk factors for developing post-transplant anastomotic strictures include living-donor liver transplantation, surgical techniques leading to ischemia and fibrosis, ABO incompatibility, small bile duct caliber, advanced recipient age, a prolonged warm and cold ischemia period, and cytomegalovirus infection.² Treatment for biliary strictures is mainly endoscopic, with success rates of 70%–100%; however, anatomic alterations due the nature of biliary anastomosis may preclude endoscopic management.³ Here, we report the sharp recanalization of a complete biliary obstruction using a vascular re-entry device in a child after liver transplantation, allowing the placement of an internal/external drain and subsequent biliary dilatation.

An 18-month-old boy with history of biliary atresia underwent liver transplantation with Roux-en-Y biliary anastomosis. The patient presented with a fever of 39.7°C, rigor, hypoactivity, and poor oral intake, and cholangitis was suspected. Laboratory tests showed leukocytosis, abnormal liver function, and Epstein-Barr virus infection (alanine aminotransferase, 70 U/L; aspartate aminotransferase, 119 U/L; alkaline phosphatase, 778 U/L; total bilirubin, 55 μmol/L; white blood cell count, 15.30; erythrocyte sedimentation rate, 27 mm/h). Initial abdominal ultrasonography and cross-sectional images revealed intrahepatic biliary duct dilatation and suggested an anastomotic stricture (Fig. 1).

Figure 1. (A) Axial T2-weighted magnetic resonance imaging and (B) magnetic resonance cholangiopancreatography images show abrupt cutoff of the biliary tree at the anastomosis with proximal intrahepatic biliary dilatation.

Percutaneous transhepatic biliary drainage was done, but failed to cross the anastomosis into the bowel despite several antegrade attempts in separate sessions.

Another attempt was performed using the transjejunal retrograde approach. Under ultrasound guidance, percutaneous jejunal access was obtained using a micropuncture kit; however, the stricture could not be crossed retrogradely (Fig. 2). Due to the anatomical orientation of the stricture, an Outback Elite Re-entry Catheter (Cordis Corp.) was used, off-label, to cross from the biliary system into the Roux-en-Y loop to create a neo-anastomosis (Fig. 3). The stricture was crossed successfully with a 0.014” wire, followed by balloon dilatation with a 6 mm × 4 cm balloon and insertion of a 6 Fr internal-external biliary drainage catheter. Multiple sessions of dilatation were done over the course of the following months, reaching an 8 mm balloon, and the catheter was upsized to 12 Fr followed by drain removal after documenting patency and free flow of contrast into the bowel (Fig. 4). The patient remains tube-independent with normal liver function at the age of 42 months.

Figure 2. Percutaneous transhepatic antegrade and transjejunal retrograde access demonstrated the short segment of anastomotic occlusion.

Figure 3. Orthogonal views show the Outback re-entry device during the puncture from the biliary system targeting the catheter in the jejunal loop.

Figure 4. A sheath cholangiogram at 6 months of follow-up, after several sessions of balloon dilatation, shows a patent neo-anastomosis with no evidence of significant stricture.

The case report was approved by the research committee and informed consent was waived.

Crossing a biliary stricture or occlusion can be challenging and may require additional techniques or tools to connect the biliary system to the bowel. Sharp recanalization with a 21G cannula or Rosch-Uchida needle set has previously been used to cross complete biliary obstructions.⁴ Radiofrequency wires have been described as a way to create a biliary neo anastomosis in five patients with complete biliary anastomosis occlusions.⁵ The procedure was technically successful in all patients without reported complications. The newly created anastomoses remained patent in all patients after 4–11 months of follow-up.⁵ Another report described the use of the magnetic compression anastomotic method to treat complete biliary obstruction after multiple failed endoscopic and percutaneous trials.⁶ This technique uses two opposing magnets introduced endoscopically and percutaneously to gradually compress the intervening tissue and create a narrow lumen, transforming the complete obstruction into a stricture that could be eventually stented.⁶ The Outback device is designed for re-entry into the true lumen during arterial subintimal recanalization procedures. The device allows advancing a 22G hollow needle through a side port toward the target with a maximum throw of 5–7 mm. This technique is particularly useful when occlusion is short and the target lumen is not aligned with the proximal lumen.

In conclusion, establishing access across a post-liver transplant anastomotic obstruction is paramount to allow future management with serial dilatation and to avoid surgical interventions. Re-entry devices may be considered when other tools and approaches fail to cross the obstruction.

None.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.