Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation

Endohepatology: Applications in Liver Transplant

The term "endohepatology" was coined over the last 15 years to describe the integration of interventional endoscopy and hepatology for the management of patients with chronic liver disease. In this article, we will review the diagnostic and therapeutic applications of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among liver transplantation candidates and recipients.

Endoscopic Management of Recurrent Anastomotic Biliary Stricture Following Deceased Orthotopic Liver Transplantation

Background/Objectives: Data on the natural history and endoscopic treatment outcomes of recurrent anastomotic biliary stricture (RABS) after orthotopic liver transplantation (OLT) are limited. This study aimed to evaluate the incidence and outcomes of RABS after OLT. Methods: A retrospective single-center study on OLT patients who underwent successful endoscopic treatment of ABS was conducted. The incidence of RABS, risk factors for recurrence, and outcomes of repeat endoscopic therapy were recorded. Results: A total of 131 OLT patients with ABS underwent endoscopic treatment, of which 119 successfully completed an endoscopic treatment course. After a median follow-up of 51.5 months (IQR 18.5-86.25) from ABS resolution, 26/119 patients (22.7%) developed RABS. All patients with RABS underwent a second endoscopic treatment course; 24 patients received self-expandable metal stents and 2 received plastic stents. Re-treatment was successful in 21 patients (80.8%) after a median of 8.5 months (IQR 5.25-14.50) and a total of 62 ERCPs. Adverse events occurred in two patients (7.4%)-one bacteremia and one suprastenotic biliary stricture. After a median follow-up of 65.5 months (IQR 20.75-125.5) from stent removal, only one patient had a second recurrence, which was treated with a Roux-en-Y hepaticojejunostomy. Multivariate analysis showed that older age at ABS diagnosis (OR 1.1; 95% CI: 1.1-1.2 p = 0.04) was the only independent risk factor for recurrence. Conclusions: RABS affects more than 20% of patients after successful endoscopic treatment. A second endoscopic therapy with covered self-expandable metal stents is a safe and effective option and should be considered before more invasive options.

Biliary Endoscopic Retrograde Cholangiopancreatography

Since inception in 1968, biliary endoscopic retrograde cholangiopancreatography (ERCP) has transformed into a highly effective, minimally invasive modality for the identification and treatment of a variety of biliary pathologies including benign, malignant, and iatrogenic diseases. The diagnostic role of ERCP has been largely replaced by high-quality imaging modalities including endoscopic ultrasound and magnetic resonance cholangiopancreatography. However, there continues to be significant demand for therapeutic procedures. This article reviews the general principles of ERCP, as well as common indications, contraindications, and potential adverse events with which endoscopists and referring physicians should be familiar.

Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures

BACKGROUND

Endoscopic management is the first-line therapy for post-liver-transplant anastomotic strictures. Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months, data on safety and duration for metal stents in this setting is scarce. Due to limited access to endoscopic retrograde cholangiopancreatography (ERCP) during the coronavirus disease 2019 pandemic in our centre, there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy. This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.

AIM

To compare the safety and efficacy profile of different stenting durations using Kaffes stents.

METHODS

Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query. Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records. The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months. Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for ≤ 120 d or > 120 d.

RESULTS

During the study period, a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course. In 33 ERCPs, the stent was removed or exchanged on a 3-month interval. No pancreatitis, perforations or deaths occurred. Minor post-ERCP complications were similar between the 3-month (abdominal pain and intraductal migration) and 6-month (abdominal pain, septic shower and embedded stent) groups - 6.1% vs 9.1% respectively, P = 0.40. All strictures resolved at the end of the stenting course, but the stenting course was variable from 3 to 22 months. The recurrence rate for stenting courses lasting for up to 120 d was 71.4% and 21.4% for stenting courses of 121 d or over (P = 0.03). There were 28 patients that were treated with a single ERCP with Kaffes, 21 with removal after 120 d and 7 within 120 d. There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course (71.0% vs 10.0%, P = 0.01).

CONCLUSION

Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

A practical approach to the endoscopic management of biliary strictures after liver transplantation

Biliary tract complications are an important cause of morbidity and mortality after liver transplantation (LT) occurring in 5% to 25% of patients. The most common biliary complication in LT recipients are strictures representing approximately half of these biliary adverse events. Bile duct strictures can be divided into anastomotic biliary strictures (ABS) and non-anastomotic biliary strictures (NABS) depending on their location in the biliary tree, being ABS the most encountered type. Several risk factors identified in previous studies can predispose to the development of ABS and NABS, especially those related to surgical techniques and donor characteristics. Magnetic resonance cholangiopancreatography (MRCP) is the recommended noninvasive imaging test for detecting post-LT biliary strictures, given its high sensitivity and specificity. Once the diagnosis of a biliary stricture after LT has been made, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy with good short and long-term results. Biliary sphincterotomy plus balloon dilation (BD) with placement of multiple plastic stents (MPS) has been the classic endoscopic approach for treating ABS, although fully-covered metallic stents (FCSEMS) have emerged as an alternative thanks to shorter total duration of stenting and fewer endoscopic procedures compared to MPS. In this review, we provide a practical update on the management of biliary strictures after LT, focusing our attention on the available evidence in the endoscopic therapy.

A Short Fully Covered Self-Expandable Metal Stent for Management of Benign Biliary Stricture Not Caused by Living-Donor Liver Transplantation

Background: This study evaluated the effectiveness of short fully covered self-expanding metal stents (FCSEMS) with an anti-migration design in treating benign biliary strictures (BBS) not related to living donor liver transplantation (LDLT). Methods: A retrospective analysis was conducted on 75 patients who underwent FCSEMS insertion for BBS management. Stents were initially kept for 3 months and exchanged every 3 months until stricture resolution. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. Results: The study outcomes were technical success, stenosis resolution, and treatment failure. Technical success was 100%, with stricture resolution in 99% of patients. The mean onset time of BBS post-surgery was 4.4 years, with an average stent indwelling period of 5.5 months. Stricture recurrence occurred in 20% of patients, mostly approximately 18.8 months after stent removal. Early cholangitis and stent migration were noted in 3% and 4% of patients, respectively. Conclusions: This study concludes that short FCSEMS demonstrate high efficacy in the treatment of non-LDLT-related BBS, with a low incidence of interventions and complications. Although this is a single-center, retrospective study with a limited sample size, the findings provide preliminary evidence supporting the use of short FCSEMS as a primary treatment modality for BBS. To substantiate these findings, further research involving multicenter studies is recommended to provide additional validation and a broader perspective.