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Biliary strictures and biliary leaks are the most common forms of post-transplant biliary complication [1–3]. These are thought to be due to multiple factors including ischemia, ischemia–reperfusion injuries, cytomegalovirus infection, and surgical techniques [2]. Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography, and surgery are the primary approaches used in addressing strictures, with ERCP being the gold standard as a diagnostic and therapeutic tool with the use of balloon dilations and placement of multiple parallel plastic stents [1–3]. However, some strictures have proven to be technically challenging or untreatable, mandating the use of percutaneous transhepatic cholangiographic drainage or even surgical hepaticojejunostomy. Herein we report a new method to deliver twowires above an impassable and severe anastomotic stricture by utilizing the pusher catheter as a “mini-overtube.” A 55-year-old man had undergone orthotopic liver transplantation (OLT) because of hepatitis C virus-related cirrhosis and hepatocellular carcinoma. After the OLT he had elevated results in liver function tests but biopsy had shown a viable liver transplant. Therefore the patient had undergone ERCP, which had shown an anastomotic biliary stricture. This had been managed by sphincterotomy and placement of a single 10-Fr 12-cm plastic stent because of the severity of the stricture. At follow-up ERCP, the previous stent was removed using a snare. Biliary sphincterotomy and balloon dilation of the stenosis was performed (6-mm Titan balloon; Cook Medical, Winston Salem, North Carolina, USA) with removal of debris and sludge and extraction of the balloon without complications. However, on further evaluation only a single 0.035-inch guidewire (Metro; Cook Medical) could be advanced through the anastomosis (●" Fig.1). Several techniques and accessories were used without success in the attempt to pass a second wire: a tapered tip catheter, various sphincterotomes, balloons, and straight and J-tipped wires. Because the path was so narrow and tortuous, an alternative approach was pursued as follows. A stent delivery device (Cook Medical), namely the inner guiding catheter and pusher without the stent, was passed over the existing Fig.1 a Cholangiography showing a severe and complex anastomotic stricture following a liver transplant. b Only one guidewire could be passed through the stricture: the second wire has flipped back (yellow arrow).

Utility of a stent pusher catheter as a “mini-overtube” in the endoscopic management of post-liver transplant biliary strictures