Failed ERCP after liver transplant, PTCD in place: what would you do?

Post-transplant. Failed ERCP. A PTCD is already in.

A 2-minute case from my bile duct strictures lecture. Watch the case, pick your move, then see what we did.

This is a very tough stricture. The patient has already been through multiple ERCPs. A PTCD is in place. The endoscopic attempt still failed on the left side.

1. The case

A 61-year-old man after liver transplant (OLT 2012). He had multiple ERCPs with stenting because of common bile duct strictures due to ischemic cholangiopathy.

A PTCD was placed two days earlier, with insertion of two wire catheters. ERCP the day after failed to cannulate the left system.

2. Why this one is hard

A complex ischemic bile duct stricture after transplant, several strictures, and a left system the duodenoscope could not reach. In my words in the lecture: what would you do? Try some more ERCP, give antibiotics, do more PTC?

3. What would you do?

Pick one before you read on:

A. Consult surgery for a hepaticojejunostomy.
B. Repeat percutaneous drainage.
C. Abort the case and treat with antibiotics.
D. Keep going with other ERCP techniques.

Why are ischemic bile duct strictures after liver transplant so hard to treat?

They are often complex. This patient had needed multiple ERCPs with stenting for common bile duct strictures caused by ischemic cholangiopathy. Even with a PTCD placed two days earlier, the next ERCP could not cannulate the left system.

What are the options after a failed ERCP when a PTCD is already in place?

The lecture slide lists four: consult surgery for a hepaticojejunostomy, more percutaneous drainage, abort the case and treat with antibiotics, or keep going with ERCP using other techniques and tools.