Clinical value of MRC in the follow-up of liver transplant patients with a choledochojejunostomy

BACKGROUND: We investigated the clinical value of magnetic resonance cholangiography (MRC) in liver transplant patients receiving choledochojejunostomy (CDJ). METHODS: Twenty-five MRCs were performed in 23 initially asymptomatic patients 19 months (mean) after liver transplantation with biliary reconstruction via CDJ. The images were evaluated by consensus (two investigators) for bile duct strictures and dilatations. As a standard of reference, clinical follow-up (including laboratory analysis) was used in 20 cases and direct cholangiography or surgery in three cases. RESULTS: Fourteen pathologic findings were observed in 11 patients (anastomotic strictures in four, left or right bile duct strictures in three, and peripheral segmental dilatations with or without strictures in seven). Patients with pathologic MRC findings had significantly higher levels of alkaline phosphatase (p < 0.05) and more frequently had histories of cholangitis than did patients with normal MRC. Four of six patients with stenoses of the central bile ducts subsequently developed biliary complications requiring treatment (three confirmed by direct cholangiography). In patients with unremarkable bile ducts or only peripherally located changes on MRC, no bile duct complications or relevant changes in the cholestasis parameters occurred during follow-up (mean = 30 months). CONCLUSION: MRC can noninvasively detect pathologic biliary tract changes in liver transplant patients in the asymptomatic stage and provide information for planning invasive therapeutic procedures.     

肝移植术后胆道并发症的内镜诊治

目的：探讨肝移植术后胆道并发症的内镜诊疗价值。方法：2001年4月～2004年7月对12例肝移植术后胆道并发症患者，应用电子十二指肠镜进行胆道造影，乳头切开、取石、放置鼻胆管或塑料内支架引流等诊疗方法。结果：原位肝移植术后出现胆道并发症12例，共行ERCP15次：胆管吻合口狭窄、胆总管结石伴急性梗阻性化脓性胆管炎3例，急诊内镜取石、鼻胆管引流，再次内镜胆总管塑料内支架引流。胆管吻合口狭窄伴胆管泥沙样结石2例，内镜乳头切开、取石、引流。胆管吻合口狭窄5例，其中塑料内支架引流2例，未置引流1例，鼻胆管放置失败1例，胆管吻合口严重狭窄导丝无法通过1例。胆漏2例，因胆总管吻合口严重狭窄，导丝未能通过。结论：肝移植术后胆道并发症经内镜诊疗具有微创、安全、有效，有一定的诊疗价值。     

Biliary complications after liver transplantation: the role of endoscopy

Biliary complications are important causes of early and late postoperative morbidity and mortality after liver transplantation and are seen in 10-20 % of the patients. The common biliary complications include bile leaks, stones or debris, and anastomotic strictures. Less common complications are hilar strictures, intrahepatic strictures, and papillary stenosis/dysfunction. The complications are similar in living-donor and cadaveric liver transplantations, except for a higher incidence of bile leaks among living-donor transplant recipients. The clinical presentation of post-liver transplant bile duct complications is often subtle, and noninvasive imaging studies may sometimes fail to detect mild but clinically significant stenoses or small leaks. Early recognition and prompt treatment of biliary complications following liver transplantation reduces the morbidity and improves long-term graft and patient survival. In this report, we discuss the role of endoscopy in the diagnosis, treatment options, and the outcome for patients with biliary complications following liver transplantation.     

MRI在肝移植术后缺血性胆管病变中的应用

目的 探讨MRI、磁共振胰胆管造影(MRCP)在肝移植术后缺血性胆管病变(ITBL)中的应用价值。方法 经PTC或ERCP及病理结果确诊的肝移植术后ITBL患者23例,对其平扫、增强MR和MRCP图像进行观察。结果 根据胆管病变累及的部位和范围,将ITBL分为肝门型(Ⅰ型)、弥漫型(Ⅱ型)和肝内型(Ⅲ型)。Ⅰ型13例,MRI示12例胆管壁增厚,11例供体肝总管及胆总管不扩张,且伴有供肝肝总管、汇合部及左和(或)右肝管管腔内胆泥形成;MRCP主要表现为胆总管、肝总管、汇合部、左右肝管及其二级分支胆管显影不良或不显影。Ⅱ型8例,MRI示7例管壁增厚,6例供体肝总管及胆总管不扩张,且伴有供肝肝总管、汇合部及左和(或)右肝管管腔内胆泥形成;MRCP主要表现为肝内、外胆管广泛的不规则狭窄或扩张,胆管间断显影。Ⅲ型2例,MRI示供体肝总管及胆总管管腔均不扩张,管壁未见增厚;MRCP主要表现为肝内胆管不规则、节段性扩张,扩张不成比例、粗细不均呈"串珠"样。结论 肝移植术后ITBL以Ⅰ型和Ⅱ型常见。MRI在观察肝门部胆管管壁,管腔扩张程度及腔内容物有一定优势,而MRCP可全面观察胆管病变的部位和范围,提供整体信息;二者结合有助于ITBL的诊断及分型。     

肝移植缺血性胆道病变的超声造影研究

目的 探讨实时超声造影技术诊断肝移植术后缺血性胆道病变(ITBL)的临床应用价值.方法 25例经内镜下逆行性胰胆管造影或经皮肝穿刺胆道造影确诊,超声疑为胆道并发症的移植肝接受超声造影检查.以增厚最明显的肝门部胆管壁为观察目标,分析胆管壁增强特点.结果 胆管壁造影表现可分3类:①胆管壁无增强者6例,即胆管壁在动脉期、门脉期及延迟期均无增强;②胆管壁低增强水平者4例,即胆管壁在动脉期呈低增强,门脉期及延迟期持续低增强或消退为无增强;③胆管壁高增强水平者15例,即胆管壁在动脉期呈高或等增强,门脉期及延迟期消退为等或低增强.25例确诊病例中包括13例ITBL和12例非ITBL.ITBL组胆管壁无或低增强水平者10例(76.9%),高增强水平者3例(23.1%);非ITBL组均为高增强水平者,两组间差异有统计学意义(P=0.00).结论 超声造影检测胆管壁微循环灌注具有可行性,有可能为临床提供一种全新的从微血管层面诊断ITBL的影像学手段.     

Secondary sclerosing cholangitis from percutaneous transhepatic biliary drainage in a patient with gallbladder cancer after surgery: A case report

Secondary sclerosing cholangitis (SSC) is a chronic cholestatic liver disease characterized by fibrosis and stricture of the bile ducts. SSC in association with multiple factors such as spontaneous choledochoduodenal fistula and metastatic gallbladder cancer has rarely been reported. However, to the best of our knowledge, reports of SSC after percutaneous transhepatic biliary drainage (PTBD), especially in cases with diffuse calcification of the bile duct walls, have not been reported. We report a case of SSC from PTBD in a patient with gallbladder cancer after surgery. The patient underwent external percutaneous biliary drainage for malignant bile duct obstruction after cholecystectomy. Repeated exchanges were performed at the first and the sixth month after PTBD using an internal and external drainage catheter. Two months after the third catheter exchange, findings of laboratory and imaging examinations were suggestive of SSC. The liver function tests of the patient were suggestive of cholestasis. Multidetector computed tomography showed diffuse calcification of the bile duct walls. Cholangiography showed intrahepatic biliary stenosis or dilatation.     

磁共振胰胆管成像对肝移植术后胆系的评价

背景:由于肝移植术后患者出现胆道并发症时,没有特征性体征,此种并发症很难发现。MRI特别是磁共振胰胆管成像是一种具有安全、准确、非侵袭性特点,可用于综合评估移植后肝脏功能和并发症的有效手段。目的:评估磁共振胰胆管成像对肝移植术后胆系的显示以及诊断胆管并发症的价值。设计:对比观察。单位:南方医科大学南方医院影像中心。对象:于2003-01/2005-01在南方医科大学南方医院影像中心接受影像学检查肝移植患者13例,均为男性,年龄40-58岁。术前临床诊断为原发性肝癌2例,重症肝硬化11例。10例行原位经典式肝移植,3例行背驮式原位肝移植术,所有胆管吻合方式为胆总管端-端吻合。移植后至首次MR检查时间15d-1年。所有患者对检测项目均知情同意。方法:13例原位肝移植患者术后均用磁共振快速自选回波序列及快速小角度激发梯度回波序列常规扫描、磁共振胰胆管成像、钆喷替酸葡甲胺动态增强检查,分析各序图像特点。主要观察指标:磁共振胰胆管成像对重建胆道和胆道并发症的显示。结果:3例患者胆管管径正常,吻合口无狭窄。1例厚层磁共振胰胆管成像胆管未显影。胆管扩张8例;胆管狭窄5例;胆总管结石2例;胆囊管残端黏液囊肿2例;T管拔管后胆漏1例;排斥反应2例。结论:磁共振胰胆管成像不仅可显示肝移植术后外科重建胆道的影像,而且可准确、快速诊断肝移植术后胆道并发症。     

Stent retriever for dilation of pancreatic and bile duct strictures. brand@uke.uni-hamburg.de

BACKGROUND AND STUDY AIMS: Dilation of high grade strictures of pancreatic or biliary ducts using dilating or balloon catheters may fail. We evaluated the efficacy of the 7-Fr Soehendra Stent Retriever used as a dilator. PATIENTS AND METHODS: Following sphincterotomy, the stricture was first negotiated with a 260 cm long 0.032-inch J-type Terumo wire. Dilation was then attempted using a 7-Fr dilating catheter. If the stricture could not be traversed, the 7-Fr Stent Retriever was inserted over the Terumo wire to dilate the stricture. Between May 1996 and January 1997, the Stent Retriever was used for dilation in 32 patients with biliary or pancreatic duct strictures. RESULTS: The indication for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was symptomatic chronic pancreatitis in 21 patients (twelve men, nine women; mean age 45.7, range 26-70). The mean length (+/-SD) of the pancreatic duct strictures was 20mm+/-10 (range 3-55) with a prestenotic ductal diameter of 9mm+/-2 (range 2-15). Out of 21 patients, nine suffered from pancreaticolithiasis and were treated with extracorporeal shock wave lithotripsy. All but three patients underwent successful stenting in the same session. Another 11 patients (four men, seven women; mean age 67.4, range 47-85) had cholestasis because of benign or malignant bile duct strictures. The mean length of the strictures was 20mm+/-5 (range 3-40), and the mean prestenotic diameter was 10mm+/-5 (range 4-21). Stenting was easily done in all of these patients in the same session. Symptom relief was observed within the first week after stenting in all patients with a biliary or pancreatic stricture. In seven cases, material for cytological examination was obtained from the bile duct, which revealed malignancy in two cases. There was no complication associated with the use of the Stent Retriever. One subcapsular liver perforation was caused by the guide wire and occurred prior to the use of the Retriever. CONCLUSIONS: Tight pancreatic and bile duct strictures can be dilated successfully with the Stent Retriever. The procedure is of low risk. In addition, tissue sampling is possible in some cases.     

Biliary complications after orthotopic liver transplantation: MRCP findings

Orthotopic liver transplantation is a widely accepted treatment for end-stage liver disease and selected cases of hepatocellular carcinoma. Despite surgical progresses, biliary complications after transplantation remain a serious cause of morbidity, mortality, and graft dysfunction or failure in recipients. Early complications occur within a few weeks after transplantation and are mainly represented by bile leakage. Late complications, which become evident from 3 months to years, include strictures, stones, intraductal debris or sludge formation, kinking and ampullary dysfunction. Donor-to-recipient common bile duct disproportion has been reported as a borderline condition. Diagnosis is challenging because of the low specificity of clinical and biologic findings. Sonography does not provide projectional images of the biliary tract or direct evaluation of the anastomoses. Moreover, direct cholangiographic procedures have an unacceptable rate of complications to be used in patients with low clinical suspicion. Magnetic resonance cholangiography is a safe and accurate tool, playing an increasing role in the diagnosis and management of biliary complications. Heavily T2-weighted images provide panoramic, detailed evaluation of the biliary tract, showing biliary complications as a variable combination of bile duct dilatation, strictures, filling defects, fluid collections and peculiar morphologic changes, as described in this paper.     

Cholangioscopy using a new type of cholangioscope for the diagnosis of biliary tract disease: a case series

We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.     

Benign diseases of the biliary tract: evaluation with MR cholangiography.

MR cholangiography (MRC) is a noninvasive, rapid means of evaluating the biliary tract that, in many instances, may replace invasive procedures such as diagnostic endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography. This article describes and illustrates the MRC features of benign diseases of the biliary tract such as choledocholithiasis; intrahepatic bile duct calculi; congenital anomalies, including aberrant bile ducts and choledochal cysts; postsurgical strictures; and strictures related to chronic pancreatitis.     

肝移植术后胆管狭窄的超声表现

目的 了解肝移植术后胆管狭窄的超声表现.方法 采用超声观察41例肝移植术后胆管狭窄患者肝内外胆管有无扩张及其内径、胆管壁厚度及其回声,并与46例肝移植术后无胆管并发症者比较.结果 胆管狭窄组的肝内胆管内径、胆管壁厚度、肝内胆管扩张和胆管壁回声增强的发生率均大于无胆管并发症组,差异具有统计学意义(P＜0.05).结论 肝移植术后出现肝内胆管扩张、胆管壁增厚及回声增强、胆管腔变细等征象,对于胆管狭窄的诊断有重要价值.     

原位肝移植后胆管狭窄与胆道内镜下球囊扩张及支撑管治疗

背景：肝移植术后胆管狭窄主要是胆管吻合口的狭窄，介入球囊扩张只能暂时通畅胆道，没有根本解决问题。 目的：观察应用胆道内镜技术诊断和治疗原位肝移植后胆管狭窄的效果。 设计、时间及地点：病例分析，于2001—07／2005—10在大连市肝胆外科研究所，大连市友谊医院肝胆外科住院患者10例，天津第一中心医院器官移植科住院患者4例均在行原位肝移植术后发生胆管狭窄。 对象：纳入14例中男10例，女4例，平均年龄46岁，肝移植术均采用供、受者胆管端一端吻合。 方法：对14例原位肝移植术后发生胆管狭窄的病例进行胆道内镜的诊断和分析，同时采用胆道镜下球囊扩张后支撑管方法治疗肝移植后胆道狭窄。 主要观察指标：T管造影、内镜下肝内外胆管黏膜直观：结石的分布、吻合口胆管黏膜的；供-受体胆管吻合口的愈合情况：炎症水肿的情况、狭窄；经内镜取石、狭窄扩张治疗后上述指标的复查。结果：①胆管狭窄的诊断：经胆道造影和内镜诊断胆管吻合口狭窄13例，其中1例是结石导致的狭窄假象；非吻合口狭窄1例。②胆管狭窄的治疗：通过胆道造影明确的吻合口狭窄中，1例采取球囊扩张1次治愈，2例行经内镜十二指肠乳头括约肌切开术＋网篮取石芊鼻胆引流术后仍然发生胆系感染和黄疸而行手术以及纤维胆道镜治疗。通过T型管造影，1例发现条状负影，无狭窄，纤维胆道镜观察胆管吻合口愈合佳，黏膜移行良好；2例肝内显影差或不显影而呈胆管消失改变，纤维胆道镜取净结石后，扩张吻合口的狭窄后支撑三四个月后狭窄消失，黏膜移行良好。8例肝内外胆管显影模糊，肝外和肝内Ⅰ、Ⅱ级胆管有条索状、柱状、树枝状负影和非吻合性狭窄征象，纤维胆道镜观察取净结石后观察吻合口处均有不同程度的狭窄、充血水肿，扩张支撑平均2．5个月后，狭窄消失，黏膜移行佳。1例造影提示吻合口狭窄，狭窄扩张后，内镜观察未发现结石，支撑2个月后拔管治愈。结论：胆道内镜可直观原位肝移植术后胆管狭窄的情况，进行可靠的诊断，并有效完成支撑管扩张治疗胆管狭窄。     

Stone or stricture as a cause of extrahepatic cholestasis--do liver function tests predict the diagnosis?

BACKGROUND: Cholestasis, roughly divided into intrahepatic and extrahepatic forms, is a clinical challenge. Extrahepatic cholestasis, characterized by dilated bile ducts, is caused by either a bile duct stone or stricture, with stricture most often related to a malignancy. The aim of the present study was to analyze the value of common liver function tests in separating patients with malignant bile duct strictures from those with stones. METHODS: All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) were included in the study population if a bile duct stricture related to a malignancy was found by ERCP (n=103) or if a bile duct stone was successfully extracted during ERCP, thus confirming the diagnosis of a stone (n=109). Plasma alkaline phosphatase, gamma-glutamyltransferase, alanine aminotransferase and bilirubin values were determined in the morning before ERCP. RESULTS: Plasma bilirubin (p<0.001), alkaline phosphatase (p<0.001) and alanine aminotransferase (p=0.040) levels were significantly higher in patients with malignant bile duct strictures than in those with bile duct stones. In addition, gamma-glutamyltransferase levels seemed to be higher in patients with malignant strictures than in those with stones, although the difference did not reach statistical significance (p=0.053). In receiver operating characteristic analyses, bilirubin proved to be the best laboratory test in differentiating patients (p=0.001 vs. alkaline phosphatase, p<0.001 vs. alanine aminotransferase and p<0.001 vs. gamma-glutamyltransferase). With a plasma bilirubin cutoff value of 145 micromol/L, four out of five patients were categorized correctly. CONCLUSIONS: Plasma bilirubin seems to be the best liver function test in distinguishing patients with malignant bile duct strictures from those with bile duct stones. This routine test should receive more attention in clinical decision-making than has previously been given.     

肝移植术后胆道并发症的内镜下诊治

目的初步探讨内镜在肝移植术后胆道并发症诊治中的临床应用价值。方法35例肝移植术后出现胆道并发症患者,共行ERCP124次,其中行ERCP次数最少为1次,最多为17次,平均为3.54次。根据患者的情况进行扩张、EST、取石、鼻胆管引流、内支架置入等治疗。结果13例为单纯的胆道吻合口狭窄,经胆道扩张后胆道梗阻症状解除,其中1例术后4个月因肝癌远处转移死亡;3例为单纯吻合口胆瘘,经EST及支撑管,胆瘘愈合;7例胆道狭窄合并胆瘘,经EST及胆道扩张后放入支撑管,胆瘘愈合;12例胆道狭窄合并狭窄上端胆总管及肝内胆管结石,经胆道扩张后取出部分结石。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度下降,临床症状明显改善,无严重并发症发生。结论内镜对于肝移植术后胆道并发症的诊断与治疗安全而有效,避免了患者再次外科手术。     

原位肝移植后经皮胆道内治疗胆管狭窄

背景：肝移植后胆道并发症其常见问题，采用经皮经肝胆管引流球囊扩张或单纯经皮经肝胆管引流已成为改善肝移植后胆道并发症的有效方式。 目的：通过病例随访评价经皮胆道内球囊扩张及肝胆管引流对原位肝移植后胆管狭窄治疗的有效性。 设计、时间及地点：回顾性病例分析，为1999—07／2007—03首都医科大学附属北京朝阳医院放射科接受经皮胆道内治疗的肝移植后胆道并发症患者53例。男46例，女7例，年龄17～64岁。所有患者都因肝移植后血清胆红素水平异常升高，经CT或MRI证实为胆道梗阻。 方法：53例中50例患者接受了经皮经肝胆管引流，36例常规通过右侧肝内胆管进行，14例患者接受了双侧（左侧和右侧肝内胆管）肝胆管引流，其中6例是在第2次治疗中对左侧肝内肝管引流：13例同时进行了胆道球囊扩张：3例患者进行了单纯球囊扩张治疗。 主要观察指标：对53例患者进行平均9．6个月的随访，观察经皮胆道内干预后血清胆红素水平异常升高致黄疸的控制情况。 结果：1例患者带T管治疗随访至1个月时由于急性排斥反应而死亡，1例患者经皮经肝胆管引流随访至1个月时肝功能衰竭自动出院，51例患者到随访结束时黄疸情况均缓解甚至治愈，血清胆红素水平下降甚至正常。一次有效率达79％（42／53），11例患者（21％，11／53）需要多次治疗，其中5例为第～次治疗失败，6例因黄疸复发。治疗与随访过程中未出现与操作相关的严重并发症。 结论：原位肝移植后胆道并发症采用经皮经肝胆管引流和球囊扩张治疗安全性较高，未见特殊并发症。     

212例胆道良性狭窄的临床分析

目的 分析胆道良性狭窄的原因及诊治情况,提高其防治效果.方法 回顾性分析天津市南开医院2004年1月至2006年12月胆道良性狭窄患者212例,其中3例有2处狭窄,并对其病因、诊断及治疗进行分析.结果 胆道良性狭窄主要以炎性狭窄为主,占65.12%(140/215).与手术相关的狭窄(瘢痕性狭窄及胆道损伤)占20.46%(44/215),成为第二位致狭窄原因.狭窄部位又以胆总管下段狭窄为主,占总数的52.09%(112/215).本组中采用狭窄部支撑法31.37%(64/204),胆道内引流法18.13%(37/204),狭窄部成型43.63%(89/204),狭窄段切除法1.96%(4/204).结论 炎性狭窄占良性胆道狭窄的首位,狭窄部位又以胆总管下段狭窄为主.对于胆道良性狭窄术前诊断可决定手术方式及预后,因此术前诊断方法尤为重要.胆道良性狭窄的治疗施行手术内窥镜联合治疗,其中狭窄部支撑法、胆道内引流法及狭窄部成型是主要方法.     

Endoscopic gallstone extraction following hydrostatic balloon dilatation of stricture in the common bile duct

A patient with long-standing biliary complaints and a previous cholecystojejunostomy, reputed to be suffering from primary biliary cirrhosis was, on endoscopic retrograde cholangiography (ERC), found to have several large gallstones proximal to a stenosis in the common bile duct. After endoscopic papillotomy (EPT), and endoscopic hydrostatic dilatation of the stricture, the gallstones were successfully removed by means of an endoscopic stone extractor. After 15 months the patient remains well, with no complaints, and with completely normal liver function tests.     

原位肝移植后胆管损伤的病理学改变(英文)

背景:肝移植术后胆道损伤引起的并发症是临床上诊治的难点,是抑制肝移植发展的瓶颈。目的:在成功应用胆道内镜治疗肝移植术后胆道并发症的同时,对胆管的损伤进行观察记录并取活检病理,分析不同胆管损伤、组织病理学类型与肝移植术后胆管并发症的关系。设计、时间及地点:病例分析,于2001-07/2005-10在大连市肝胆外科研究所,友谊医院肝胆外科完成。对象:将19例肝移植术后患者根据胆管并发症发生情况分为3组:正常组4例,胆管损伤组12例,肝动脉损伤组3例。方法:利用内镜技术,分别对3组患者进行胆管观察、记录,内镜下取活检进行病理分析。对于无T管者,应用子母胆道镜观察、取活检。主要观察指标:应用胆道内镜观察T管造影、肝内外胆管黏膜外观及病理学检查结果、供-受体胆管吻合口的愈合情况。胆管损伤组经内镜取石、狭窄扩张治疗后行上述指标的复查。结果:①正常组患者肝内外胆管解剖正常,无狭窄、瘢痕,胆管黏膜颜色正常,供-受体胆管吻合口愈合佳。病理学检查均可见修复性的黏膜组织,被覆上皮完整。②胆管损伤组患者胆管内有各种类型的单发、多发及铸型结石,胆管均有不同程度损伤,经内镜取净结石、解除梗阻后,胆管黏膜均有不同程度的修复,造影检查胆树恢...     

Obstructive jaundice as a long-term complication in a patient with liver transplantation

Obstructive jaundice related to stricture and stone in cystic duct was found in a patient 6 years after liver transplantation and cholecystojejunostomy. Complications with biliary drainage following liver transplantation are discussed. In the presence of dilated ducts seen by ultrasound, percutaneous transhepatic cholangiography performed immediately can lead to surgical correction, thus preventing failure of the liver transplant.The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the views of the Department of the Army or of the Department of Defense