Management of Anastomotic Biliary Strictures After Liver Transplant: Role of Covered Metal Stents
Watson A, Haq K, Khorfan K, Singla S, Yoshida A, and Moonka D. Management of Anastomotic Biliary Strictures After Liver Transplant: Role of Covered Metal Stents. Am J Transplant 2019; 19:504.
Am J Transplant
Purpose: Biliary complications, including anastomotic biliary strictures (ABS), remain the most common cause of morbidity in liver transplant (LT) patients. Endoscopic therapy has become the first line treatment for these patients. The use of multiple plastic stents (MPS) in parallel is the current standard of care, but fully-covered self-expandable metal stents (cSEMS) are increasingly being utilized. Here we present one of the largest retrospective reviews regarding the management of ABSs after LT. Methods: We reviewed all endoscopic retrograde cholangio-pancreatographs (ERCP) performed between January 2011 and August 2017 in post-LT patients at a single tertiary care center. No patients who underwent initial ERCP after this date were reviewed to allow for adequate follow-up. A total of 151 patients underwent ERCP. ABSs were found in 115 patients. ERCP with initial stent placement was successfully performed in 112/115 (97.4%) patients. Four additional patients were excluded from analysis because of death prior to undergoing repeat ERCP. The remaining 108 patients were eligible for analysis. Results: Plastic stents were the index stent in all 108 patients. Serial ERCPs were performed until ABS resolution or treatment failure. A mean of 2.74 ERCPs were performed with a mean indwelling stent duration of 102.9 days. Stricture resolution was achieved with plastic stents in 95/108 (88.0%) patients. Mean follow-up was 1226.4 days. Of the 13 patients with initial treatment failure, 10 patients received cSEMS placement for salvage therapy and 9 of these patients ultimately achieved ABS resolution (90%). The other three patients required surgery. Twelve of 95 (12.6%) patients with initial stricture resolution had ABS recurrence during the follow-up period. Five of these patients ultimately received cSEMS placement and all 5 showed resolution of ABS. Of the seven other patients, five received repeat MPS placement with resolution and two required surgical revision. Migration of cSEMS occurred in 4/15 (26.7%) patients. All four patients received repeat cSEMS placement with resolution of ABS. There were no deaths or cases of severe pancreatitis as a result of treatment for ABS. Conclusions: Our retrospective review supports the ongoing use of endoscopic biliary stent placement for the management of ABS in LT patients. Resolution can be attained with either MPS or cSEMS placement. cSEMS are an excellent option for refractory or recurrent ABS with success rates of 90 and 100% respectively. We did experience a high stent migration risk and vigilance to this complication is warranted.