Choledochoscopy in the diagnosis and management of biliary complications after orthotopic liver transplant (OLT)

The most commonly reported complications after OLT include anastomotic stricture, papillary dysfunction, and ductal stones. There are no data regarding the use of choledochoscopy in the diagnosis or management of these complications after OLT. We report on our initial experience with 4 patients who underwent choledochoscopy (Olympus and Pentax) after OLT for anastomotic stricture in 2, filling defects in 1, and inability to drain the left hepatic system in 1. In all patients, standard cholangiogram was performed by ERCP (3) or PTC (1). Choledochoscopy was performed 9 months to 8 years after OLT. There were 2 male, 2 female, ages range 3- 51 yrs old. In the 2 patients with stricture, previously unidentified anastomotic ulcers and severe inflammatory changes were noted. Brushings revealed fungal elements in 1 and were negative in the other. In the patient with adherent filling defects at the level of the anastomosis, choledochoscopy revealed 2 yellowish stones attached to suture material. After stone-suture removal, the cholangiogram and choledochoscopy were normal. In these 3 patients, the epithelium of the donor bile duct was pink and shiny compared to a grayish and duller epithelium of the recipient bile duct. Biopsies in 1 were non-revealing. In the patient with left hepatic drainage problem, a Roux-en-Y biliojejunal anastomosis had been performed. Three attempts at percutaneous drainage had failed. Percutaneous choledochoscopy showed severe inflammation and a stricture proximal to the bilioenteral anastomosis. A wire was advanced under direct visualization into the left system for subsequent drainage. In conclusion, while this experience is limited and in progress, and the clinical significance of some of the findings is unknown, choledochoscopy may provide additional information to routine cholangiography both in the diagnosis and management of biliary complications after OLT.