Sequential multistenting protocol in biliary stenosis after liver transplantation: a prospective analysis

Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group

BACKGROUND AND STUDY AIM

The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success.

PATIENTS AND METHODS

Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment.

RESULTS

All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004).

CONCLUSIONS

cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.

Role of ERCP in Benign Biliary Strictures

Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.

Endoscopic and Percutaneous Biliary Interventions after Liver Transplantation: Nationwide Data in Korea

Background/Aims

Biliary complications including biliary strictures and bile leaks are the most common complications that occur after liver transplantation (LT). Endoscopic treatment with endoscopic retrograde cholangiography (ERC) is considered the first-line treatment, and percutaneous transhepatic cholangiography (PTC) can serve as an alternative or rescue therapy. However, nationwide clinical data on the frequency of ERC and PTC following LT have not yet been investigated.

Methods

Using the nationwide claims database, we investigated patients who underwent LT between 2012 and 2014 in Korea and followed them until 2015. We analyzed the prevalence and characteristics of patients and biliary procedures, including ERC and PTC implemented after LT.

Results

A total of 3,481 patients underwent LT during the 3-year study period. Among them, 3.0% of patients underwent biliary intervention postoperatively during the same hospitalization period, and 21.4% of patients received biliary intervention later on after initially being discharged from the hospital following LT. A total of 16.9% and 12.1% of patients underwent ERC and PTC after LT, respectively. The median period from LT to the first biliary intervention was 7.8 months (interquartile range, 3.5 to 14.6 months), and these patients underwent an average of 3.2±2.8 biliary procedures during the follow-up period. Patients undergoing living donor LT were more than twice as likely to undergo biliary procedures as those undergoing deceased donor LT (25.5% vs 12.1%).

Conclusions

Approximately one-fourth of patients in Korea who underwent LT subsequently underwent ERC or PTC. Compared with deceased donor LT patients, those undergoing living donor LT underwent more biliary interventions and were more difficult to treat.

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.

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

BACKGROUND

Endoscopic management is the mainstay for biliary strictures after liver transplantation. However, this method is often failed in cases associated with hepatolithiasis or refractory strictures. The aim of this study is to investigate whether 1-step percutaneous transhepatic biliary cholangiography (PTC) combined with high-frequency needle-knife electrotomy can be an alternative method in biliary strictures after liver transplantation that could not be treated by endoscopic management.

METHODS

Clinical data of 14 patients suffering from biliary strictures after liver transplantation from June 2014 to January 2018 were retrospectively analyzed. One-step PTC combined with high-frequency needle-knife electrotomy was used to resolve the strictures.

RESULTS

One-step PTC was successfully performed in all 14 patients. In 10 of 12 (83.3%) patients with hepatolithiasis, the stones were removed completely. Stricture resolution was detected in 13 of 14 (92.9%) patients at first postoperative choledochoscopy. Three mild adverse events occurred (cholangitis, 2 patients; delayed hemobilia, 1 patient), but were resolved with conservative treatment. The follow-up after supporting catheter removal was 15.7±4.5 months. Only 1 patient (8.3%) had stone recurrence and no stenosis occurred during supporting-catheter-free follow-up.

CONCLUSIONS

One-step PTC combined with high-frequency needle-knife electrotomy seems to be a useful for treating biliary strictures after liver transplantation.

Post-operative biliary strictures

Post-operative biliary stricture is a cumbersome condition, secondary to biliary or vascular damage. Its risk factors include biliary or vascular anatomical variants, local inflammation, and poor surgical expertise. Intra-operative diagnosis is difficult, and in most cases, patients present with obstructive symptoms within a few weeks. Magnetic resonance cholangiography is a pivotal test to confirm the clinical picture, to study the level of the damage, and to guide treatment. Nowadays, endoscopic stenting is the first-line treatment in most centers. Multi-stenting treatment achieves long-term clinical success for more than 90% of patients, however multiple procedures are needed. In order to optimize healthcare provider costs, shorter duration endotherapies with covered metal stents are under evaluation. Radiological and surgical approaches are considered in the event of endoscopy failure.

Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes

BACKGROUND AND AIMS

Minimally invasive treatments of anastomotic benign biliary stricture (BBS) after orthotopic liver transplantation (OLT) include endoscopic placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMSs). No multiyear efficacy data are available on FCSEMS treatment after OLT.

METHODS

We prospectively studied long-term efficacy and safety of FCSEMS treatment in adults aged ≥18 years with past OLT, cholangiographically confirmed BBS, and an indication for ERCP with stent placement. Stent removal was planned after 4 to 6 months, with subsequent follow-up until 5 years or stricture recurrence. Long-term outcomes were freedom from stricture recurrence, freedom from recurrent stent placement, and stent-related serious adverse events (SAEs).

RESULTS

In 41 patients, long-term follow-up began after FCSEMS removal (n = 33) or observation of complete distal migration (CDM) (n = 8). On an intention-to-treat basis, the 5-year probability of remaining stent-free after FCSEMS removal or observation of CDM was 48.9% (95% confidence interval [CI], 33.2%-64.7%) among all patients and 60.9% (95% CI, 43.6%-78.2%) among 31 patients with over 4 months of FCSEMS indwell time. In 28 patients with stricture resolution at FCSEMS removal or observed CDM (median, 5.0 months indwell time), the 5-year probability of no stricture recurrence was 72.6% (95% CI, 55.3%-90%). Sixteen patients (39%) had at least 1 related SAE, most commonly cholangitis (n = 10).

CONCLUSIONS

By 5 years after temporary FCSEMS treatment of post-OLT BBS, approximately half of all patients remained stent-free on an intention-to-treat basis. Stent-related SAEs (especially cholangitis) were common. FCSEMS placement is a viable long-term treatment option for patients with post-OLT BBS. (Clinical trial registration number: NCT01014390.).