About the diagnosis and treatment of suspected bile duct pathology in Roux-en-Y liver transplant patients

T. MOREELS (1), L. MONINO (1), G. DAHLQVIST (1), B. DELIRE (1), L. COUBEAU (2), O. CICCARELLI (2), E. BONACCORSI RIANI (2), P. GOFFETTE (3), E. SOKAL (4), H. PIESSEVAUX (1) / [1] Cliniques universitaires Saint-Luc, Brussels, Belgium, Hépato-Gastroentérologie, [2] Cliniques universitaires Saint-Luc, Brussels, Belgium, Transplantation abdominale, [3] Cliniques universitaires Saint-Luc, Brussels, Belgium, Radiologie, [4] Cliniques universitaires Saint-Luc, Brussels, Belgium, Gastroentérologie & Hépatologie Pédiatrique Introduction Biliary complications after liver transplantation are frequently dealt with by means of endoscopic retrograde cholangiopancreatograpy (ERCP) using a duodenoscope. However, when the bile duct is anastomosed on a Roux-en-Y jejunal limb, the biliary system is out of reach for conventional ERCP, and it is accessed usually via percutaneous transhepatic cholangiography (PTC) or surgery. Aim We retrospectively studied the feasibility of single-balloon enteroscopy-assisted ERCP (SBE-ERCP) to evaluate and treat biliary complications in liver transplant patients with Roux-en-Y reconstruction. Methods Between 2016 and 2020 all SBE-ERCP procedures in liver transplant patients were analysed for indications, technical and clinical success and adverse events. Results A total of 40 patients (26 males) with a mean age of 43±3 years (range 13-81) underwent 69 SBE-ERCP procedures. Indications were suspicion of anastomotic stricture (40%), cholangitis (32.5%), bile duct stones (20%), biliary leak (2.5%), haemobilia (2.5%) and sepsis of unknown origin (2.5%). Technical success rate per patient was 85% (34/40). Failure was due to inability to reach the hepaticojejunal anastomosis. SBE-ERCP was normal in 12/34 (35%), confirmed the anastomotic stricture in 12/34 (35%), bile duct stones in 6/34 (18%), indwelling metallic stent in 2/34 (6%) and biliary leak and bile duct torsion both in 1/34 (3%). Biliary endoscopic interventions: balloon dilatation (6-9 mm), plastic stent insertion (4-7 Fr), stone extraction, bile duct biopsy and direct cholangioscopy in 1 to 6 ERCP procedures per patient. Only minor adverse events (self-limiting cholangitis) were encountered in 5/34 patients (15%). Of all 69 SBE-ERCP procedures, 54% were considered easy, 27% were difficult or very difficult (9%) and 10% were impossible. Clinical success of therapeutic SBE-ERCP was measured by the evolution of biliary liver function tests before, 1 day after and 30 days after the last SBE-ERCP procedure. There was a significant decrease in gamma-GT serum levels (345±90 U/L before, 257±73 U/L after and 146±27 U/L after 30 days, p=0.023) and alkaline phosphatase levels (337±70 U/L before, 343±89 U/L after and 198±53 U/L after 30 days, p=0.044), whereas the decrease in bilirubine serum levels was not significant. Conclusions Endoscopic evaluation of the bile duct system is feasible and safe using single-balloon enteroscopy-assisted ERCP in liver transplant patients with Roux-en-Y reconstruction. It allows close examination of the hepaticojejunostomy and the intrahepatic bile ducts, and endoscopic therapy leads to clinical improvement of liver function tests