Endoscopic stenting for post‐transplant biliary stricture: usefulness of a novel removable covered metal stent

Abstract

Background Endoscopic management of biliary anastomotic stricture (AS) following liver transplantation (LT) remains challenging. There are no dedicated self-expandable metal stents (SEMS) for this setting. Methods A short fully covered SEMS (FCSEMS) with a retrieval suture was designed. Between July 2008 and June 2010, 13 patients with post-LT AS had this FCSEMS placed endoscopically, keeping the whole stent inside the bile duct across the AS with the retriever out of the papilla. The stents were removed by forceps under endoscopy according to a schedule. Technical success, complications, AS resolution and the outcome for the patients were observed. Results Placement of the FCSEMS was successful on the first attempt in all patients. One patient with complicated infection did not respond to the stenting therapy and underwent stent retrieval ahead of schedule. Others kept well during stenting for a mean (SD) duration of 5.4 (1.7) months (range 2-8) without stent migration. All stents were removed successfully without great difficulty. AS resolution was obtained in all 12 patients, who were closely followed up for a mean (SD) time of 12.1 (8.0) months (range 1-26.5) after stent removal. Stricture recurrence occurred in one, who underwent a successful reintervention with a second FCSEMS. Others remain free from symptoms and have normal liver function up to now. Conclusions Endoscopic treatment of post-LT AS using a removable FCSEMS is technically feasible, safe, and effective. This dedicated method may play an increasing role in the future management of benign biliary strictures.Keywords Biliary stricture Á Complications Á Liver transplantation Á Self expanding metal stent (SEMS) Á Endoscopic therapy Abbreviations SEMSSelf-expandable metal stent FCSEMS Fully covered self-expandable metal stent PCSEMS Partially covered self-expandable metal stent LT Liver transplantation AS Anastomotic stricture

A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation

“…Early studies in partially covered stents and fully covered self-expanding metal stents (FCSEMSs) for benign biliary strictures including ASs have been positive [Kahaleh et al 2008;Traina et al 2009]. To date there are multiple publications of FCSEMSs in benign biliary strictures (BBSs) and ASs indicating good stricture resolution rates; however, problems such as stent migration have been reported [Hu et al 2011;Park Do et al 2011;Poley et al 2012;Tarantino et al 2012]. Other than stent migration, the key drawback of available FCSEMS is the length of the normal distal bile duct that needs traversing for the stent to cross the stricture.…”

Definitive outcomes of self-expandable metal stents in patients with refractory post-transplant biliary anastomotic stenosis

“…There have been several studies of FCSEMS in benign biliary strictures indicating good stricture resolution rates [7][8][9][10]. The FCSEMS offers the advantages of longer stent patency compared with a single plastic stent.…”

“…Compared with a multiple plastic stents, the potential benefits of a single FCSEMS are in its relative simplicity and the need for only two ERCP procedures, one for insertion and the other for removal. Multiple case series have been published using such stents after liver transplantation, with generally good outcomes [6,8,[11][12][13].…”

“…However, problems such as stent migration have been reported (6-7-8-9). In 2012, we published a case series of patients with biliary complications after liver transplantation and treated FCSEMS [8]. A total of 54 consecutive patients with biliary stricture and/or leak were treated with FCSEMS placement (Niti-S ComVi fully covered biliary stent, Taewoong Medical, Korea).…”

An Update to Hepatobiliary Stents

“…20 In another study, Kahaleh et al looked at 101 patients with malignant biliary strictures who received partially-covered Wallstents; only 3 cases of stent occlusion were reported at 12 months, and none were due to tumor ingrowth. 21,22 SEMS can have straight ends, flanges, or anchoring flaps. Flanges were introduced to control migration, especially in covered stents.…”