Endo‐therapies for biliary duct‐to‐duct anastomotic stricture after liver transplantation: Outcomes of a nationwide survey

Abstract

Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography; IQR, inter quartile range; LT, liver transplanted; PEP, post-ERCP pancreatitis; SEMS, self-expandable metal stent. AbstractBackground: The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. Aim:To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy.Methods: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group).Results: Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self-expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self-expandable metal stenting). After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered self-expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self-expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self-expandable metal stenting) respectively. Procedure-related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median followup of 25 months. Conclusion:Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered self-expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned. K E Y W O R D S biliary anastomotic stricture, ERCP, fully covered metal stenting, liver transplantation, plastic multistenting How to cite this article: Cantù P, Tarantino I, Baldan A, et al. Endo-therapies for biliary duct-to-duct anastomotic stricture after liver transplantation: Outcomes of a nationwide survey.

A unique type of fully covered metal stent for the management of post liver transplant biliary anastomotic strictures

“…A number of studies have compared different types of stent for the resolution of anastomotic strictures. Cantù et al performed a large prospective study comparing 3 groups: single plastic stenting (SPS), multiple plastic stenting (MPS) and the traditional longer-length FCSEMS [ 4 ]. SPS placement performed the least well with a stricture resolution rate of 61%.…”

“…Stenting has historically been with plastic stents, on a 3-monthly basis for up to a year. Although multiple plastic stent (MPS) placement has higher efficacy at resolving strictures compared to single plastic stents (SPS), plastic stents in general are at risk of stent occlusion, and often require multiple ERCPs before stricture resolution is achieved [ 4 ]. FCSEMS (fully covered self expanding metallic stents) have been shown to resolve benign strictures; however, stent migration can occur because the centre of the stent does not always overlie the stricture [ 5 – 7 ].…”

A unique type of fully covered metal stent for the management of post liver transplant biliary anastomotic strictures

“…Cantù et al performed a large prospective study comparing 3 groups: single plastic stenting (SPS), multiple plastic stenting (MPS) and the traditional longer-length FCSEMS. 4 SPS placement performed the least well with a stricture resolution rate of 61%. Both multiple plastic stenting and FCSEMS placement was associated with a high rate of stricture resolution (88%), although there was a 19% migration rate within the FCSEMS group.…”

“…Stenting has historically been with plastic stents, on a 3-monthly basis for up to a year. Although multiple plastic stent (MPS) placement has higher e cacy at resolving strictures compared to single plastic stents, plastic stents in general are at risk of stent occlusion, and often require multiple ERCP before stricture resolution is achieved [4]. FCSEMS (fully covered self expanding metallic stents) have been shown to resolve benign strictures; however, stent migration can occur because the centre of the stent does not always overlie the stricture [5][6][7].…”

One-step Percutaneous Transhepatic Cholangioscopy Combined With High-frequency Needle-knife Electrotomy in Biliary Strictures After Liver Transplantation

“…Stricture resolution was de ned as no or only a minimum waist discerned on cholangiography without clinical symptoms including jaundice after stent removal or migration requiring an endoscopic reintervention for the biliary stricture. Recurrent stricture was de ned as elevated liver enzymes or cholangitis requiring an endoscopic re-intervention for the biliary stricture [14][15]. All patients were placed under regular follow-up, with periodic monitoring of clinical conditions by biochemical testing and imaging examination (CT/MRCP/ cholangiogram).…”