Prospective evaluation of single operator peroral cholangioscopy in liver
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The study evaluated the use of single-operator peroral cholangioscopy (SOC) using the SpyGlass system in 16 liver transplant recipients with biliary complications. Two distinct cholangioscopic patterns of anastomotic strictures were identified - pattern A with mild findings and pattern B with severe findings. Patients with pattern A responded better to endoscopic therapy, requiring shorter stenting durations than pattern B. SOC allowed direct visualization of lesions, acquisition of biopsies, and identification of additional stones. The findings suggest SOC may help predict and guide management of biliary complications after liver transplant.
![Introduction
ā¢ Biliary complications occur in upto 20% patients after deceased donor LT
ā¢ ERCP
ļ first-line therapeutic approach
- confirms diagnosis
- allows therapy
- success rate - 80% to 100% [1, 4, 6]
ļ limitations
- cannot directly visualize the bile duct
- cannot specify characteristics of stricture or filling defect
ā¢ Single-operator cholangioscopy (SOC) system using the SpyGlass direct
visualization system (Boston Scientific Corp., Natick, MA)
ļ Main indication:
o evaluation of indeterminate pancreatico- biliary strictures
o treatment of large, difficult to remove common bile duct stones
ļ high procedure success rate
ļ high accuracy in distinguishing benign and malignant lesions [12-17]](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-2-320.jpg)
![Clinical evolution according to cholangioscopic
findings in patients with A.S.
Characteristic Pattern A (n=9) Pattern B (n=3) P Value
Duration of stenting (days) 167Ā±87 457Ā±257 0.01
ERCP procedures with stenting 2.7Ā±1.2 5.3Ā±2.5 0.03
Success of endoscopic therapy [n(%)] 8(88.9) 1(33.4) 0.13](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-11-320.jpg)
![Characteristics of patients with A.S.
Variable Pattern A (n=9) Pattern B(n=3) P value
Baseline data
Age (years 55.6Ā±8.4 53.9Ā±11.4 0.81
Male sex [n(%)] 8(88.9) 2(66.7) 0.45
HCV etiology [n(%)] 8(88.9) 3(100) >0.99
Post liver transplant data
Bile leak[n(%)] 2(22.2) 0(0) >0.99
T ā tube use[n(%)] 3(33.3) 0(0) 0.51
Acute cellular rejection[n(%)] 1(11.1) 0(0) >0.99
CMV infection[n(%)] 2(22.2) 0(0) >0.99
Hepatic artery thrombosis[n(%)] 1(11.1) 0(0) >0.99
Immunosuppression at ERCP[n(%)]
Tacrolimus 3(33.3) 2(66.7) 0.53
Cyclosporine 3(33.3) 0(0) 0.51
Mammalian target of rapamycin inhibitor 2(22.2) 1(33.3) >0.99
Prednisolone 4(44.4) 0(0) 0.49
Mycophenolate mofetil 2(22.2) 0(0) >0.99
ERCP data](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-12-320.jpg)
![ā¢ All patients with A.S. - followed up until the A.S. was resolved or
surgery or percutaneous transhepatic cholangiography was needed
ā¢ Stenting period: pattern B (457 days) > pattern A (167 days) [P = 0.01]
ā¢ Maximum number of stents placed in any patient = 4
ā¢ Response to endoscopic therapy: pattern A(88.9%) > pattern
B(33.4%) [P = 0.13]
ā¢ Complications: 1 patient (6.2%) - cholangitis
ā¢ 3 patients with A.S. underwent hepaticojejunostomy because:
I. inability to traverse the stricture with a guide wire
II. development of a liver abscess (unrelated to procedure)
III. lack of a response despite multiple sessions
ā¢ No restenosis during follow-up
ā¢ No significant differences in age, sex, post liver transplant evolution,
or time from transplant to ERCP between pattern A and pattern B](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-13-320.jpg)
![Discussion
ā¢ Outcomes of patients who develop A.S. or other
complications after liver transplant has improved with
advances in surgical, endoscopic and radiological
management [2-5, 29]
ā¢ The main findings of this study indicate that
(1) ERCP-guided SOC with the SpyGlass system is feasible
and can successfully be performed in LT recipients with
biliary complications
(2) 2 different cholangioscopic AS patterns can be easily
identified and may help to predict responses to therapy
(3) histological findings in ASs show nonspecific
inflammatory changes](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-16-320.jpg)
![REFERENCESā¢ 1Thuluvath PJ, Pfau PR, Kimmey MB, Ginsberg GG. Biliary complications after liver transplantation: the role of
endoscopy.Endoscopy 2005;37:857ā863.
ā¢ 2Safdar K, Atiq M, Stewart C, Freeman ML. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol
Hepatol2009;3:183ā195.
ā¢ 3Ayoub WS, Esquivel CO, Martin P. Biliary complications following liver transplantation. Dig Dis Sci 2010;55:1540ā1546.
ā¢ 4Krok KL, CĆ”rdenas A, Thuluvath PJ. Endoscopic management of biliary complications after liver transplantation. Clin Liver Dis2010;14:359ā
371.
ā¢ 5Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies. Liver
Transpl 2008;14:759ā769. 6Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary
complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2011;24:379ā
392.
ā¢ 7Kawai K, Nakajima M, Akasaka Y, Shimamotu K, Murakami K. A new endoscopic method: the peroral choledocho-pancreatoscopy (author's
transl) [in German]. Leber Magen Darm 1976;6:121ā124.
ā¢ 8Nakajima M, Akasaka Y, Fukumoto K, Mitsuyoshi Y, Kawai K. Peroral cholangiopancreatoscopy (PCPS) under duodenoscopic guidance. Am J
Gastroenterol 1976;66:241ā247.
ā¢ 9Rƶsch W, Koch H, Demling L. Peroral cholangioscopy. Endoscopy 1976;8:172ā175.
ā¢ 10Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first
report.Endoscopy 1977;9:27ā30.
ā¢ 11Chathadi KV, Chen YK. New kid on the block: development of a partially disposable system for cholangioscopy. Gastrointest Endosc Clin N
Am 2009;19:545ā555.
ā¢ 12Draganov PV, Lin T, Chauhan S, Wagh MS, Hou W, Forsmark CE. Prospective evaluation of the clinical utility of ERCP-guided
cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011;73:971ā979.
ā¢ 13Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Darisetty S, et al. Role of single-operator peroral cholangioscopy in the
diagnosis of indeterminate biliary lesions: a single-center, prospective study. Gastrointest Endosc 2011;74:511ā519.
ā¢ 14Chen YK, Parsi MA, Binmoeller KF, Hawes RH, Pleskow DK, Slivka A, et al. Single-operator cholangioscopy in patients requiring evaluation
of bile duct disease or therapy of biliary stones (with videos). Gastrointest Endosc 2011;74:805ā814.
ā¢ 15Maydeo A, Kwek BE, Bhandari S, Bapat M, Dhir V. Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary
and pancreatic ductal stones (with videos). Gastrointest Endosc 2011;74:1308ā1314.
ā¢ 16Siddiqui AA, Mehendiratta V, Jackson W, Loren DE, Kowalski TE, Eloubeidi MA. Identification of cholangiocarcinoma by using the Spyglass
SpyScope system for peroral cholangioscopy and biopsy collection. Clin Gastroenterol Hepatol 2012;10:466ā471.](https://image.slidesharecdn.com/prospectiveevaluationofsingle-operatorperoralcholangioscopyinliver-140714111326-phpapp01/85/Prospective-evaluation-of-single-operator-peroral-cholangioscopy-in-liver-22-320.jpg)
Prospective evaluation of single operator peroral cholangioscopy in liver
- 1. Prospective Evaluation of Single- Operator Peroral Cholangioscopy in Liver Transplant Recipients Requiring an Evaluation of the Biliary Tract Domingo Balderramo et al Liver Transplantation: Volume 19, Issue 2, pages 199ā206, February 2013 Presented by: Dr. Amitesh Kumar Moderator: Dr. Neeraj Saraf
- 2. Introduction ā¢ Biliary complications occur in upto 20% patients after deceased donor LT ā¢ ERCP ļ first-line therapeutic approach - confirms diagnosis - allows therapy - success rate - 80% to 100% [1, 4, 6] ļ limitations - cannot directly visualize the bile duct - cannot specify characteristics of stricture or filling defect ā¢ Single-operator cholangioscopy (SOC) system using the SpyGlass direct visualization system (Boston Scientific Corp., Natick, MA) ļ Main indication: o evaluation of indeterminate pancreatico- biliary strictures o treatment of large, difficult to remove common bile duct stones ļ high procedure success rate ļ high accuracy in distinguishing benign and malignant lesions [12-17]
- 3. Aim of the study To describe both cholangioscopic and histological findings of biliary lesions in liver transplant recipients using the SOC-SpyGlass direct visualization system
- 4. Study Design ā¢ Prospective ā¢ Descriptive ā¢ Single center - Hospital Clinic in Barcelona, a tertiary care hospital
- 5. Study Population ā¢ Inclusion criteria: Adult recipients of deceased donor liver transplant with biliary complications referred for ERCP between June 2009 and July 2011 ā¢ Exclusion criteria: ļrefusal to participate in the study ļinability to provide informed consent ļpregnancy ļliving donor liver transplant ļprevious Roux-en-Y hepaticojejunostomy ļconfirmed malignancy of the biliary tree ļadvanced liver failure ļcoagulopathy ļhemodynamic instability ļsepsis
- 6. Procedures ā¢ ERCP and cholangioscopy - all patients ā¢ Biliary sphincterotomy - if not done previously ā¢ If anastomotic stricture present ļ following were evaluated -Borders -Ulcers -concentricity versus eccentricity ļ 2 patterns a) scarring and minimal inflammatory changes b) edema, ulceration and severe inflammatory changes ļ 2 - 4 biopsies taken ļ stents placed as required ā¢ If anastomotic stricture absent ļ descriptive findings of anastomosis and bile duct recorded ļ 2 to 4 biopsies of anastomosis taken ļ endoscopic therapy of any biliary complication (eg: stone removal)
- 7. Outcomes and Definitions ā¢ Main outcome measure: -feasibility of procedure -adequate visualization -ability to obtain biopsy ā¢ Secondary outcomes -impact on endoscopic therapy -incidence of adverse events -total cholangioscopy time ā¢ Plastic stents removed every 3 months ļ stricture evaluated ļ If A.S. still present ļ further therapy with balloon dilation and stent placement ā¢ Stricture considered to be relieved- if no evidence of stenosis on cholangiography and free passage of extraction balloon ā¢ ERCP therapy defined as failing - when there was indication for percutaneous transhepatic cholangiography or surgery during follow-up
- 8. RESULTS ā¢ 23 patients met the inclusion criteria ā¢ 7 patients were excluded ļ hemodynamic instability (n = 2) ļ bacterial infection (n = 2), cytomegalovirus infection (n = 1) ļ recent T-tube extraction (n = 1) ļ previous postsphincterotomy bleeding (n = 1) ā¢ Finally, 16 patients were included ļ anastomotic stricture -12 ļ CBD stones - 2 ļ bile leak - 1 ļ SOD ā 1 ā¢ Complete SOC successful in 15 of 16 (93.8%) In 1 patient, cholangioscope could not be advanced across the stricture ā¢ 5patients - T-tube placed previously ā¢ Total cholangioscopy time was 26.8 Ā± 10.1 minutes.
- 9. Summary of demographic and clinical characteristics and cholangioscopic findings SL NO SEX/ AGE ETIOL OGY COMPLI CATION A.S. TYPE BORDER A.S. PATTERN ADDITIONAL FINDINGS NEED FOR SURGERY TIME FROM LT to ERCP (MNTH) STENTING PERIOD (DAYS) ERCP WITH STENTING 1 M/54 HCV AS CONC IRR A STONES NO 13.8 238 4 2 M/65 HCV AS CONC IRR A NO NO 28.3 309 5 3 M/47 ALD AS CONC REG A NO NO 5.8 113 2 4 M/48 HCV AS ECC IRR A STONES NO 12.2 131 2 5 M/64 HCV AS CONC IRR A NO NO 4.2 175 3 6 M/65 HCV AS CONC IRR A NO YES 12.6 * * 7 F/49 HCV AS CONC IRR A NO NO 27.1 124 2 8 M/60 HCV, HBV AS CONC IRR A NO NO 64.5 195 3 9 M/45 HCV AS ECC IRR A NO NO 2.1 178 2 10 F/66 HCV AS CONC IRR B STONES YES 30.4 720 8 11 M/43 HCV AS ECC IRR B STONES NO 36.2 443 5 12 M/51 HCV AS ECC IRR B NO YES 7.6 207 3 13 F/73 HCV STONE REG CONT NO 153.8 - - 14 F/41` ALF STONE REG CONT NO 230.1 - - 15 F/45 ALF BILE LEAK REG CONT NO 1.9 101 1 16 M/48 HCV SOD REG CONT STONES 13.8 - -
- 10. Cholangioscopy Findings ā¢ Two patterns in A.S. (A) mild erythema and scarring (n = 9) (B) severe edema, erythema, ulceration with sloughing (n = 3) ā¢ Patients without A.S. - pale mucosa, mild edema, no stenosis (C) ā¢ Biliary epithelium of native or graft bile duct outside the anastomosis - no significant abnormalities ā¢ Additional CBD stones noted which were not seen in initial cholangiograms for 5 patients (31%) (D)
- 11. Clinical evolution according to cholangioscopic findings in patients with A.S. Characteristic Pattern A (n=9) Pattern B (n=3) P Value Duration of stenting (days) 167Ā±87 457Ā±257 0.01 ERCP procedures with stenting 2.7Ā±1.2 5.3Ā±2.5 0.03 Success of endoscopic therapy [n(%)] 8(88.9) 1(33.4) 0.13
- 12. Characteristics of patients with A.S. Variable Pattern A (n=9) Pattern B(n=3) P value Baseline data Age (years 55.6Ā±8.4 53.9Ā±11.4 0.81 Male sex [n(%)] 8(88.9) 2(66.7) 0.45 HCV etiology [n(%)] 8(88.9) 3(100) >0.99 Post liver transplant data Bile leak[n(%)] 2(22.2) 0(0) >0.99 T ā tube use[n(%)] 3(33.3) 0(0) 0.51 Acute cellular rejection[n(%)] 1(11.1) 0(0) >0.99 CMV infection[n(%)] 2(22.2) 0(0) >0.99 Hepatic artery thrombosis[n(%)] 1(11.1) 0(0) >0.99 Immunosuppression at ERCP[n(%)] Tacrolimus 3(33.3) 2(66.7) 0.53 Cyclosporine 3(33.3) 0(0) 0.51 Mammalian target of rapamycin inhibitor 2(22.2) 1(33.3) >0.99 Prednisolone 4(44.4) 0(0) 0.49 Mycophenolate mofetil 2(22.2) 0(0) >0.99 ERCP data
- 13. ā¢ All patients with A.S. - followed up until the A.S. was resolved or surgery or percutaneous transhepatic cholangiography was needed ā¢ Stenting period: pattern B (457 days) > pattern A (167 days) [P = 0.01] ā¢ Maximum number of stents placed in any patient = 4 ā¢ Response to endoscopic therapy: pattern A(88.9%) > pattern B(33.4%) [P = 0.13] ā¢ Complications: 1 patient (6.2%) - cholangitis ā¢ 3 patients with A.S. underwent hepaticojejunostomy because: I. inability to traverse the stricture with a guide wire II. development of a liver abscess (unrelated to procedure) III. lack of a response despite multiple sessions ā¢ No restenosis during follow-up ā¢ No significant differences in age, sex, post liver transplant evolution, or time from transplant to ERCP between pattern A and pattern B
- 14. Histopathological Findings ā¢ Adequate tissue ā 81% patients ā¢ Pattern A: (1) Nuclear pseudostratification, prominent nucleoli, focal mucinous metaplasia, and focal intraepithelial inflammatory cells (mostly neutrophils) (2) Subepithelial mucinous biliary glands associated with a chronic inflammatory infiltrate
- 15. ā¢ Pattern B: (1) Moderate fibrinous material with scattered neutrophilic aggregates (2) Mild nuclear pseudostratification and abundant intraepithelial neutrophils ā¢ Patients without A.S. - normal columnar epithelial biliary cells with basal nuclei ā¢ There were no findings compatible with graft rejection, fungal infection, cytomegalovirus infection, or post transplant lymphoproliferative disorder
- 16. Discussion ā¢ Outcomes of patients who develop A.S. or other complications after liver transplant has improved with advances in surgical, endoscopic and radiological management [2-5, 29] ā¢ The main findings of this study indicate that (1) ERCP-guided SOC with the SpyGlass system is feasible and can successfully be performed in LT recipients with biliary complications (2) 2 different cholangioscopic AS patterns can be easily identified and may help to predict responses to therapy (3) histological findings in ASs show nonspecific inflammatory changes
- 17. ā¢ Responses to endoscopic treatment in LT recipients with A.S. may differ according to the cholangioscopy pattern ā¢ Patients with pattern A: ļ responded better than patients ļ required fewer days of stenting to achieve a final response to endoscopic therapy ā¢ Patients with Pattern B ļ needed more ERCP sessions with stenting ļ require prolonged therapy ļ should be considered for early surgery if there is no good response after 1 or 2 sessions to prevent a prolonged course of ERCP and itās complications
- 18. Suggested treatment algorithm based on findings of SOC
- 19. Limitations of the study ā¢ Small sample size ā¢ Single-center study ā¢ Presence of a learning curve with this procedure ā¢ Patients who underwent living donor LT or recipients of transplants from donors after cardiac death, who have a higher incidence of A.S. versus recipients of cadaveric donors were not included
- 20. Conclusion ā¢ ERCP-guided SOC with the SpyGlass system is feasible and can be successfully performed in liver tranplant recipients with biliary complications ā¢ Cholangioscopic findings of A.S. may predict the response to ERCP therapy
- 21. Suggested future studies ā¢ Further prospective studies comparing ERCP alone to ERCP plus SOC ā¢ Large prospective, multicenter study that could evaluate predetermined criteria based on patient characteristics, surgical characteristics of transplants, radiographic and cholangiographic criteria, and visual characteristics under SOC as well as correlations of specific endpoints with the outcomes of endoscopic therapy, the need for surgical reinterventions, and clinical outcomes
- 22. REFERENCESā¢ 1Thuluvath PJ, Pfau PR, Kimmey MB, Ginsberg GG. Biliary complications after liver transplantation: the role of endoscopy.Endoscopy 2005;37:857ā863. ā¢ 2Safdar K, Atiq M, Stewart C, Freeman ML. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol2009;3:183ā195. ā¢ 3Ayoub WS, Esquivel CO, Martin P. Biliary complications following liver transplantation. Dig Dis Sci 2010;55:1540ā1546. ā¢ 4Krok KL, CĆ”rdenas A, Thuluvath PJ. Endoscopic management of biliary complications after liver transplantation. Clin Liver Dis2010;14:359ā 371. ā¢ 5Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies. Liver Transpl 2008;14:759ā769. 6Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2011;24:379ā 392. ā¢ 7Kawai K, Nakajima M, Akasaka Y, Shimamotu K, Murakami K. A new endoscopic method: the peroral choledocho-pancreatoscopy (author's transl) [in German]. Leber Magen Darm 1976;6:121ā124. ā¢ 8Nakajima M, Akasaka Y, Fukumoto K, Mitsuyoshi Y, Kawai K. Peroral cholangiopancreatoscopy (PCPS) under duodenoscopic guidance. Am J Gastroenterol 1976;66:241ā247. ā¢ 9Rƶsch W, Koch H, Demling L. Peroral cholangioscopy. Endoscopy 1976;8:172ā175. ā¢ 10Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first report.Endoscopy 1977;9:27ā30. ā¢ 11Chathadi KV, Chen YK. New kid on the block: development of a partially disposable system for cholangioscopy. Gastrointest Endosc Clin N Am 2009;19:545ā555. ā¢ 12Draganov PV, Lin T, Chauhan S, Wagh MS, Hou W, Forsmark CE. Prospective evaluation of the clinical utility of ERCP-guided cholangiopancreatoscopy with a new direct visualization system. Gastrointest Endosc 2011;73:971ā979. ā¢ 13Ramchandani M, Reddy DN, Gupta R, Lakhtakia S, Tandan M, Darisetty S, et al. Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study. Gastrointest Endosc 2011;74:511ā519. ā¢ 14Chen YK, Parsi MA, Binmoeller KF, Hawes RH, Pleskow DK, Slivka A, et al. Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos). Gastrointest Endosc 2011;74:805ā814. ā¢ 15Maydeo A, Kwek BE, Bhandari S, Bapat M, Dhir V. Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos). Gastrointest Endosc 2011;74:1308ā1314. ā¢ 16Siddiqui AA, Mehendiratta V, Jackson W, Loren DE, Kowalski TE, Eloubeidi MA. Identification of cholangiocarcinoma by using the Spyglass SpyScope system for peroral cholangioscopy and biopsy collection. Clin Gastroenterol Hepatol 2012;10:466ā471.
- 23. REFERENCES contdā¦ ā¢ 17Draganov PV, Chauhan S, Wagh MS, Gupte AR, Lin T, Hou W, Forsmark CE. Diagnostic accuracy of conventional and cholangioscopy-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term follow-up study.Gastrointest Endosc 2012;75:347ā353. ā¢ 18Wright H, Sharma S, Gurakar A, Sebastian A, Kohli V, Jabbour N. Management of biliary stricture guided by the SpyGlass direct visualization system in a liver transplant recipient: an innovative approach. Gastrointest Endosc 2008;67:1201ā1203 ā¢ 19Parsi MA, Guardino J, Vargo JJ. Peroral cholangioscopy-guided stricture therapy in living donor liver transplantation. Liver Transpl2009;15:263ā 265.Direct Link: ā¢ 20Hoffman A, Kiesslich R, Moench C, Bittinger F, Otto G, Galle PR, Neurath MF. Methylene blue-aided cholangioscopy unravels the endoscopic features of ischemic-type biliary lesions after liver transplantation. Gastrointest Endosc 2007;66:1052ā1058. ā¢ 21Siddique I, Galati J, Ankoma-Sey V, Wood RP, Ozaki C, Monsour H, Raijman I. The role of choledochoscopy in the diagnosis and management of biliary tract diseases. Gastrointest Endosc 1999;50:67ā73 ā¢ 22GĆ¼rakar A, Wright H, Camci C, Jaboour N. The application of SpyScopeĀ® technology in evaluation of pre and post liver transplant biliary problems. Turk J Gastroenterol 2010;21:428ā432. ā¢ 23Rerknimitr R, Sherman S, Fogel EL, Kalayci C, Lumeng L, Chalasani N, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc2002;55:224ā231. ā¢ 24Pfau PR, Kochman ML, Lewis JD, Long WB, Lucey MR, Olthoff K, et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000;52:55ā63 ā¢ 25Thuluvath PJ, Atassi T, Lee J. An endoscopic approach to biliary complications following orthotopic liver transplantation. Liver Int2003;23:156ā 162.Direct Link: ā¢ 26Costamagna G, Tringali A, Mutignani M, Perri V, Spada C, Pandolfi M, Galasso D. Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc 2010;72:551ā557. ā¢ 27Dumonceau JM, Tringali A, Blero D, DeviĆØre J, Laugiers R, Heresbach D, Costamagna G; for European Society of Gastrointestinal Endoscopy. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012;44:277ā 298. ā¢ 28Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446ā454. ā¢ 29LondoƱo MC, Balderramo D, CĆ”rdenas A. Management of biliary complications after orthotopic liver transplantation: the role of endoscopy. World J Gastroenterol 2008;14:493ā497.