Management of post-liver transplantation biliary stricture inaccessible by endoscopic retrograde cholangiopancreatography: A case report.

Background: One challenging scenario in the treatment of biliary stricture is that post-liver transplantation (LT) biliary strictures cannot be accessed using endoscopic retrograde cholangiopancreatography (ERCP). Here, we report such a case that was successfully treated using a novel endoscopic technique.

Case Summary: A 60-year-old man presented with obstructive jaundice caused by a post-LT biliary stricture. He underwent LT for compensated alcoholic liver cirrhosis and hepatocellular carcinoma. Laboratory investigations unveiled a cholestatic pattern of abnormalities in liver function and a total bilirubin level of 16 mg/dL. Magnetic resonance cholangiopancreatography revealed a stricture extending from the right intrahepatic bile duct into the common hepatic duct. Severe postoperative deformities made accessing the ampulla of Vater with a side-viewing duodenoscope impossible. Percutaneous transhepatic biliary drainage (PTBD) was performed to treat biliary obstruction. Moreover, to resolve the stricture completely, a fully covered self-expandable metal stent (FC-SEMS) with a novel proximal retrievable string was deployed into the post-LT biliary stricture through the PTBD tract. Before inserting the stent through the PTBD tract, the stent with the distal string was manually inverted to ensure that the distal part with the string became the proximal part for later endoscopic removal. After 6 mo, the FC-SEMS was successfully removed without complications, as the string was pulled out using a forward-viewing gastroscope.

Conclusion: Deployment and endoscopic removal of an FC-SEMS with a novel proximal string through the PTBD tract may be a viable option for treating post-LT biliary strictures that are inaccessible by ERCP.