Clin Endosc.  2025 Mar;58(2):303-310. 10.5946/ce.2024.099.

Ex vivo cholangioscopy in liver grafts: a novel technique to assess the biliary tree during organ preservation and machine perfusion: a experimental non-clinical study

• Ly M
• Lau NS
• Huang J
• Ly H
• Ewenson K
• Mestrovic N
• Yousif P
• Liu K
• Majumdar A
• McCaughan G
• Crawford M
• Pulitano C

• KMID: 2566151
• DOI: http://doi.org/10.5946/ce.2024.099

Abstract

Background/Aims
Biliary complications are a leading cause of morbidity after liver transplantation, but can be reduced using real-time assessment of the biliary tree. This study described a novel technique for performing ex vivo cholangioscopy during cold static storage and normothermic machine perfusion (NMP) to assess the biliary tree before liver transplantation.
Methods
Human donor livers, which were considered unsuitable for transplantation, were perfused at 36ºC using a modified commercial ex vivo perfusion system. Ex vivo cholangioscopy was performed using a SpyGlass Discover system. Cholangioscopy was performed during cold static storage and after 12 hours in NMP. Bile duct biopsies and confocal microscopy were performed.
Results
Ex vivo cholangioscopy was performed on eight grafts. During cold static storage, luminal debris was visualized throughout the biliary tree. After 12 hours of reperfusion, the bile ducts appeared hyperemic, heterogeneous, and mottled. Confocal microscopy confirmed perfusion of biliary microvasculature.
Conclusions
We describe the first use of ex vivo cholangioscopy to assess the biliary tree before liver transplantation. This real-time technique can be used to assess biliary trees during cold static storage and NMP. In addition, cholangioscopy-based interventions can be used to better assess intrahepatic bile ducts.

Keyword

Biliary complication; Cholangioscopy; Liver transplantation

Figure

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  Fig. 1. (A) A female-to-female luer adaptor is secured to the distal common bile duct to act as a cholangioscope sheath. The sheath allows passage of the cholangioscope and for excess irrigation fluid to freely exit the biliary tree. (B) Cholangioscopy during cold static storage. The assistant is stabilizing the bile duct during cholangioscopy and providing intermittent irrigation. (C) Cholangioscopy is performed during liver splitting to identify a suitable location for transection. The line of biliary transection is indicated by the yellow dotted line.

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  Fig. 2. Cholangioscopy during cold static storage demonstrating significant debris and mucosal sloughing (red arrows) at the hepatic duct bifurcation (A) and subsegmental ducts (C). Repeat cholangioscopy during ex-vivo normothermic machine perfusion demonstrating hyperaemia and mucosal mottling at the hepatic bifurcation (B) and subsegmental ducts (D). Cross sectional biopsies collected during cold static storage (E) and after reperfusion (F) (×10 magnification, hematoxylin and eosin stain). Mucosal sloughing and ischemic injury (red arrows) can be seen during cold static storage. Reperfusion injury with severe mural stromal necrosis (asterisk) can be seen after reperfusion.

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  Fig. 3. Ex vivo cholangioscopy of grafts 1 to 4 during cold static storage and post-reperfusion. DCD, donation after circulatory death; DBD, donation after brain death.

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  Fig. 4. Ex vivo cholangioscopy of grafts 5 to 8 during cold static storage and post-reperfusion. DCD, donation after circulatory death; DBD, donation after brain death.

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