Intraductal placement of non‐flared fully covered metallic stent for refractory anastomotic biliary strictures after living donor liver transplantation: Long‐term results of prospective multicenter trial

Abstract

Background and Aim Fully covered self‐expandable metallic stent (FCSEMS) may be an effective modality for managing anastomotic biliary stricture (ABS) after liver transplantation. However, stent migration and stent‐induced ductal injury are the main limitations. The objective of this study was to evaluate the usefulness of an unflared, intraductal FCSEMS that was designed to minimize migration and ductal injury for refractory ABS after living donor liver transplantation (LDLT). Methods A total of 32 consecutive patients with symptomatic ABS after LDLT unresolved by plastic stents with or without balloon dilation at four tertiary medical centers were prospectively enrolled. A short (3 or 5 cm) FCSEMS having long lasso (10 cm) used in this study had unflared convex ends to minimize tissue hyperplasia and smaller center portion to prevent migration. The FCSEMS was placed above the papilla and removed at 3–4 months after stenting. Results Technical and clinical success rates of intraductal placement with FCSEMS were 100% (32/32) and 81.2% (26/32), respectively. Early stent migration was observed in five (15.6%) patients. However, three patients with early stent migration had stricture resolution without needing additional intervention. Intended stent removal was successful in 27 (100%) patients (median, 101 days; range, 23–118 days). No stent‐induced ductal change was observed in all patients. Stricture recurrence was observed in 11.5% (3/26) of patients during 639 days of median duration of follow‐up (range, 366–2079 days). Conclusions Intraductal placement of an unflared short FCSEMS may be a promising option for refractory ABS after LDLT with minimal stent‐induced ductal injury and stent migration.

Evaluation of the Feasibility and Effectiveness of Placement of Fully Covered Self-Expandable Metallic Stents via Various Insertion Routes for Benign Biliary Strictures

“…The additional PS was placed in the contralateral hepatic duct to prevent segmental cholangitis, which was caused by obstruction of the biliary branch in cases of hilar stricture. Six months after initial stenting, the stent was removed through the working channel of a therapeutic scope by grasping the lasso using forceps [ 6 ]. If the stricture was not resolved, a new FCSEMS was placed for an additional 6 months.…”

Efficacy of a modified short fully covered self‐expandable metal stent for perihilar benign biliary strictures

“…Serial plain abdominal radiographs were obtained following successful stent placement, the next day, after 1 week, and then monthly to evaluate stent migration. Five to 6 months after initial stenting, the stent was removed through the working channel of a therapeutic duodenoscope by grasping the lasso using forceps 15 . After removal, a balloon‐occluded cholangiogram was obtained to evaluate stricture resolution and the presence of any de novo strictures.…”

“…Stent migration was defined as movement of the entire FCSEMS above or below the stricture site. Stricture recurrence was defined both clinically and as a cholangiogram‐documented relapse of a stricture after initial clinical success 15 . Stent malfunction was defined as any condition causing cholangitis or jaundice by stent occlusion or migration.…”

“…Five to 6 months after initial stenting, the stent was removed through the working channel of a therapeutic duodenoscope by grasping the lasso using forceps. 15 After removal, a balloon-occluded cholangiogram was obtained to evaluate stricture resolution and the presence of any de novo strictures. Biliary stones on the upper portion of the stricture level were removed after the resolution of the stricture (Fig.…”

“…Therefore, for the effective management of perihilar BBS within 2 cm of the hilar confluence or intrahepatic duct stricture, more adequately modified stents or methods are required. The clinical efficacy of modified short FCSEMS for the prevention of spontaneous migration and iatrogenic bile duct injury was reported in refractory biliary stricture and liver transplantation‐related biliary strictures 14,15 . We performed this study to evaluate the efficacy of a modified short FCSEMS for the treatment of perihilar BBS within 2 cm of the hilar confluence that failed initially with plastic stents.…”