Gun-Sight Technique With Dual Hepatic Vascular Embolization for Sigmoidal Refractory Biliary Stricture After Living-Donor Liver Transplantation: A Case Report.

Background: Biliary stricture is a common complication after living-donor liver transplantation (LDLT), but its management is challenging. We herein report a case of successful internal drainage achieved through combination of the gun-sight technique and dual hepatic vascular embolization (DHVE).

Case Presentation: A 54-year-old woman with primary biliary cholangitis underwent ABO-incompatible LDLT with the right lobe. Duct-to-duct biliary anastomosis was performed, and V5 and V8 of the graft were reconstructed using a vein graft. However, 5 months after surgery, magnetic resonance cholangiopancreatography revealed stricture of the bile duct anastomosis. Endoscopic stenting could not be attempted because of the sigmoidal bending of the bile duct. Instead, percutaneous transhepatic cholangiographic drainage (PTCD) of the anterior and posterior branches was performed. We attempted to remove the PTCD tube by an endofistulization technique. We performed the gun-sight technique, originally employed for transjugular intrahepatic portosystemic shunt procedures, to create a pathway for internal drainage of the posterior segment. The anterior lobe was abandoned by applying DHVE, resulting in no external drainage tubes.

Conclusion: Application of the gun-sight technique with DHVE for sigmoidal refractory biliary stricture after LDLT appears to be a feasible treatment.