title: Percutaneous transhepatic biliary drainage may serve as a successful rescue procedure in failed cases of endoscopic therapy for a post-living donor liver transplantation biliary stricture.
abstract: BACKGROUND
  Although a biliary stricture is one of the most important complications that develop after living donor liver transplantation (LDLT), a standard approach has not yet been established.
  
  
  OBJECTIVE
  The aim of this study was to evaluate the usefulness of nonoperative management in repairing a post-LDLT biliary stricture.
  
  
  METHODS
  A total of 60 patients were referred, from July 2004 to July 2007, for management of a post-LDLT biliary stricture. The patients had ERCP if the hepatic arterial flow was patent on a Doppler sonography. If endoscopic therapy failed, then percutaneous transhepatic drainage (PTBD) was performed to dilate the stricture. If the percutaneous approach also failed, then a repeated PTBD was performed after a 3-dimensional abdominal CT (3D-CT).
  
  
  METHODS
  Division of Gastroenterology, Department of Internal Medicine, Yongdong Severance Hospital.
  
  
  METHODS
  Sixty patients were referred from Catholic University Hospital of Korea for ERCP.
  
  
  RESULTS
  ERCP was performed on all 60 patients, and 38 (63%) were successfully treated. When the shape of the distal side of the bile-duct anastomosis was classified into 3 categories (pouched, triangular, and intermediate), the pouched shape showed the lowest success rate of endoscopic therapy (25% [4/16]). Fifteen of 22 patients in whom endoscopic therapy failed were treated by using PTBD. Nine of the 15 patients were successfully managed in the first PTBD attempt, and 4 of the 6 patients in whom the first attempt of PTBD failed had repeated PTBD after a 3D-CT. Four patients were successfully treated with repeated PTBD of the alternative branch approach after a 3D-CT.
  
  
  CONCLUSIONS
  ERCP is a feasible first modality in the treatment of a post-LDLT biliary stricture, but, in failed cases, especially in the pouched shape, PTBD can be attempted. When initial PTBD trial fails, a biliary-tract examination, such as a 3D-CT, can be useful for a repeated PTBD trial.
authors.affiliation: Department of Internal Medicine, Yonsei University College of Medicine, Yongdong Severance Hospital, Gangnam-Ku, Seoul, South Korea.
authors.forename: Eak Seong
authors.initials: ES
authors.lastname: Kim
authors.forename: Byung Jun
authors.initials: BJ
authors.lastname: Lee
authors.forename: Jong Yun
authors.initials: JY
authors.lastname: Won
authors.forename: Jong Yong
authors.initials: JY
authors.lastname: Choi
authors.forename: Dong Ki
authors.initials: DK
authors.lastname: Lee
mesh_terms: D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D002779:Cholestasis / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D015331:Cohort Studies; D004322:Drainage / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D011183:Postoperative Complications / Q000175:diagnosis / Q000628:therapy; D011336:Probability; D012008:Recurrence; D018570:Risk Assessment; D015607:Stents; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler