Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: A preliminary study

Abstract

After liver transplantation, the most common biliary complication is the anastomotic stricture, which is followed by biliary leakage. Studies have focused on the endoscopic treatment of biliary complications in transplanted patients with duct-to-duct reconstruction, showing a success rate of 70% to 80% after orthotopic liver transplantation and of 60% after living-related liver transplantation. Once the endoscopic approach fails, surgical treatment with a Roux-en-Y choledochojejunostomy is the sole alternative treatment. The aim of this prospective observational study was to analyze the efficacy and safety of fully covered self-expandable metallic stents for the treatment of posttransplant biliary stenosis and leaks in patients in whom conventional endoscopic retrograde cholangiopancreatography (ERCP) failed. From January 2008 to January 2009, 16 patients met the criteria of endoscopic treatment failure, and instead of surgery, a fully covered stent was placed. All patients had at least 6 months of follow-up (mean follow-up of 10 months). After removal, 14 patients showed immediate resolution of both the biliary stenosis and leak. After a mean of 10 months of follow-up, only 1 patient showed biliary stenosis recurrence. No major complications occurred in any of the patients, except for stent migration in 6 patients, although these presented with no clinical consequences. In conclusion, in patients not responding to standard endoscopic treatment, the placement of fully covered metal stents is a valid alternative to surgery. A cost analysis should be performed in order to evaluate whether to treat transplanted patients suffering from biliary complications with covered self-expandable metallic stent placement as first-line therapy. Liver Transpl 15: [1493][1494][1495][1496][1497][1498] 2009 Biliary complications are the most frequent complications after liver transplantation. Available data show a rate of biliary complications in transplant recipients ranging from 8% to 35%. This complication rate is higher for living-related liver transplantation (LRLTx) versus orthotopic liver transplantation (OLTx).1,2 Biliary complications include strictures, biliary leaks, stones or debris, and Oddi dysfunction. The most common biliary complication is the anastomotic stricture, which is followed by biliary leakage, although patients often develop more than 1 complication. 3Depending on the type of surgical biliary reconstruction (ie, choledochojejunostomy or duct-to-duct anastomosis), biliary complications can be treated by percutaneous transhepatic cholangiography or by endoscopic retrograde cholangiopancreatography (ERCP). ERCP is currently considered the diagnostic gold standard for patients with duct-to-duct anastomosis because it allows a direct approach for interventional procedures.2 Several studies have evaluated the endoscopic treatment of biliary complications in patients with duct-to-duct reconstruction and have shown a success rate of approxAbbreviations: ALT, alanine aminotransferase; ERCP, endoscopic retrograde c...

Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers

“…Aside from these two approaches (sphincterotomy alone and sphincterotomy with plastic stent placement), some authors also advocate the use of FCSEMS for patients with bile leaks (mainly post-cholecystectomy leaks) given the high resolution rates (93%-95%) in early studies. 26,27,38,39 In our clinical experience FCSEMS are useful in some LT recipients with large or refractory bile leaks, though FCSEMS were not placed during the present study. While FCSEMS may be effective for bile leaks, some stents carry a risk of new stricture formation in LT recipients, thus more information is needed in these patients.…”

Percutaneously placed covered retrievable stents for the treatment of biliary anastomotic strictures following living donor liver transplantation

“…Gore & Associates, Flagstaff, AZ) in 5 patients (including 3 liver transplant recipients) at a mean of 38 days after percutaneous transhepatic stent placement and without complications, although the clinical outcomes were not available. Traina et al 12 also reported an 87.5% immediate resolution rate of the biliary strictures following 2 months of endoscopic covered metal stent placement in 16 liver transplant recipients. However, clinical success rate in LDLT recipients was 60% (3 of 5 patients).…”

“…Gwon et al 19 proposed that covered stents longer than 40 mm might reduce stent migration although they removed these stents at a mean of 6.7 weeks after stent placement. On the contrary, Traina et al 12 reported 38% of stent migration rate following endoscopic placement of 16 covered retrievable stents (60-80 mm in length) during 2 months. Therefore, we assume that a longer duration of stent placement may bring about a higher risk of stent migration and, therefore, stent modification may be necessary in order to prevent stent migration.…”

Indications for ERCP

“…The types of stent used in these situations continue to evolve as stent technology changes. Two studies performed by Traina et al and Kahaleh et al reported resolution of the majority of bile leaks after the use of self-expandable metal biliary stents [16,17]. However, there were instances of stent migration and stricture formation with the use of these metal stents and cost-effectiveness is questionable.…”