PICTURES IN DIGESTIVE PATHOLOGY

1130-0108/2015/107/10/631-632Revista española de enfeRmedades digestivasCopyRight © 2015 aRán ediCiones, s. l.

Rev esp enfeRm dig (MadridVol. 107, N.º 10, pp. 631-632, 2015

Direct peroral cholangioscopy with a conventional videogastroscope in a transplanted patient with anastomotic stricture and choledocholithiasisEduardo Rodrigues-Pinto1, Pedro Pereira1, Susana Lopes1 and Guilherme Macedo1

1Gastroenterology Department. Centro Hospitalar São João. Porto, Portugal

Female patient, 74 years-old, liver transplanted in 1991 due to primary biliary cirrhosis, later submitted to endoscopic ret-rograde cholangiopancreatography (ERCP) in 2009 because of biliary anastomotic stricture and choledocholithiasis. Successful sphincterotomy and placement of two plastic stents 8.5 Fr 7 cm was achieved, which were left in place for 3 months. The sub-sequent ERCP in 2010 revealed a proximal bile duct dilatation, without lithiasis. The patient was maintained on surveillance. In 2014, the patient presented with cholangitis. Magnetic reso-nance imaging revealed bile duct dilatation (24 mm) above the anastomosis, with upstream lithiasis. ERCP revealed a deformed duodenal papilla by previous sphincterotomy. Cholangiogram showed a dilated proximal bile duct (25 mm) with stenosis of surgical anastomosis and multiple subtraction defects, consis-tent with biliary stones (Fig. 1). Balloon catheter passage failed to remove the largest stone, despite the use of multiple devices. Direct peroral cholangioscopy (POC) was performed with a vid-eogastroscope (Olympus® GIF-Q180), with identification of a membranous ring correspondent to anastomosis (Fig. 2), which was dilated (Boston Scientific® CRE™ Wireguided Balloon Di-lator) under direct and fluoroscopic control up to 10 mm, with no complications (Fig. 3). Subsequent fragmentation of biliary stone (Figs. 4 and 5) was achieved under mechanical lithotripsy

Fig. 1. Cholangiography. Dilated distal bile duct (25 mm) with stenosis of surgical anastomosis and a biliary stone with approximately 20 mm.

Fig. 2. Direct peroral cholangioscopy. Identification of a membranous ring correspondent to biliary anastomosis.

Fig. 3. Fluoroscopy. Dilation of biliary anastomosis with a balloon dilator.

(Olympus® BML-110 Mechanical Lithotriptor) with removal of multiple fragments with balloon catheter (Olympus® Single Use 3-Lumen Extraction Balloon V). Final cholangiogram re-

632 E. RODRIGUES-PINTO ET AL. Rev esp enfeRm Dig (maDRiD)

Rev esp enfeRm Dig 2015; 107 (10): 631-632

Fig. 4. Fluoroscopy. Lithiasis upstream the anastomosis. Fig. 5. Direct peroral cholangioscopy. Fragmentation of biliary stone.

vealed no subtraction defects, with proper drainage at the end of the procedure. The patient was placed on prophylactic anti-biotherapy (ciprofloxacin), remaining asymptomatic until now. Biliary strictures are one of the most common adverse events after liver transplantation, occurring in as many as 40% of pa-tients in the postoperative period (1). The optimal strategy for treating these strictures remains to be defined (2). Direct POC is a useful technique for the study and treatment of biliary dis-eases, providing high quality endoscopic imaging of the biliary tree and anastomotic strictures (3). Once it uses a conventional endoscope it has a large diameter-working channel for interven-tional procedures, including tissue sampling with larger biopsy forceps, to differentiate from malignant strictures. Therapeutic interventions with direct POC can be expanded, like intraductal lithotripsy and evaluation of residual stones after mechanical lithotripsy for retained common bile duct stones (4). Dilation was performed only at cholangioscopy once a better visualiza-

tion of the stenosis was possible, allowing dilating with a larger balloon and removing the stone under direct visualization.

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