Treatment of Biliary Stricture After Live Donor Liver Transplantation With Combined Metal and Plastic Stent Insertion: A Feasibility and Safety Study

Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation

OBJECTIVES

Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs.

METHODS

Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up.

RESULTS

A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%).

CONCLUSIONS

The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.

Long-term Outcome of the Rendezvous Technique in Patients With Severe Biliary Anastomotic Stricture That Cannot Cannulate After Liver Transplant

BACKGROUND

Nearly all publications related to endoscopic treatment of biliary anastomotic stricture after liver transplant have reported cases that can be cannulated. However, very few publications discuss endoscopic treatment of biliary anastomotic stricture (BAS) in which the guide wire does not pass through the stricture site. The purpose of this article is to analyze the long-term outcome of the Rendezvous technique in severe strictures through which guide wires cannot cannulate.

METHODS

Between 2010 and 2017, a total of 29 patients who underwent Rendezvous technique because of severe BAS after liver transplant were included in the study.

RESULTS

Twenty-nine patients who underwent the Rendezvous technique showed a 100% technical success rate. Ten patients (34.4%) required stent removal; the mean stenting period was 14.9 (SD, 5.6) months (range, 6.65-24.14 months). A total of 19 patients were maintained without stent removal; the stent-maintaining period was 13.1 (SD, 8.4) months (range, 3.48-38.61 months). Two patients receiving left lobe grafts maintained the stents for 27.1 (SD, 16.2) months. In left lobe graft, the duct anastomosis position moves to the right posteroinferior side of the patient.

CONCLUSIONS

Our results suggest that the stenting period of the Rendezvous technique was longer in severe BAS than in cannulated endoscopic retrograde cholangiopancreatography cases. Especially in the left liver, the position of the duct anastomosis changed to the right posteroinferior of the patient. Thus, the donor duct and the recipient duct are angulated, kinking worsens, and the stenting period becomes longer.

Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options

Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures.

Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation

Background

Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist.

Methods

We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent.

Results

A total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically.

Conclusions

The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.

The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures

PURPOSE OF REVIEW

Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage.

RECENT FINDINGS

Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.