Clinical outcome of progressive stenting in patients with anastomotic strictures after orthotopic liver transplantation

Background and study aims: Anastomotic strictures are an important cause of morbidity after orthotopic liver transplantation (OLT). Endoscopic treatment is the primary treatment modality for biliary complications after OLT. The outcome and complications of a progressive stenting protocol are largely unknown.

Patients and methods: A longitudinal cohort study of OLTs was conducted. Only patients with late strictures were included. Treatment success was defined as cholangiographic stricture resolution and liver enzymes returning to normal with follow-up of at least 12 months.

Results: Between May 2000 and June 2009, 375 OLTs were performed. A duct-to-duct anastomosis was created in 304 cases (81 %). In 63 patients (21 %; 95 % confidence interval [CI] 16.5 % – 25.6 %) an anastomotic stricture developed and progressive stenting was started in 35. During treatment two patients died of a non-treatment-related cause and two patients underwent a second OLT during stent therapy. Therefore 31 patients were available for analysis (male : female 21:10; median age 61 years, range 28 – 75 years). Progressive stenting required a median number of 5 endoscopic retrograde cholangiopancreatography (ERCP) procedures (range 4 – 11). A median maximum of 4 stents (range 2 – 8) were inserted. A total of 21 patients (67.7 %; 95 %CI 50.1 % – 81.4 %) developed a treatment-related complication. In 33 out of a total of 155 ERCPs (21.3 %) a complication occurred: cholangitis (n = 12), transient cholestasis (n = 11), post-ERCP pancreatitis (n = 7), and treatment-related pain (n = 3). The median follow-up time after stent removal was 28 months (range 12 – 92). Treatment was successful in 25 patients (80.6 %; 95 %CI 63.7 % – 90.8 %).

Conclusion: Progressive stenting for anastomotic strictures after OLT is demanding and burdensome, necessitating a median of 5 ERCP procedures with complications occurring in one out of five procedures. Its success rate however is high (81 %), avoiding surgery in the large majority of patients.

• References

• 1 Rerknimitr R, Sherman S, Fogel EL et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 2002; 55: 224-231
• 2 Pfau PR, Kochman ML, Lewis JD et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000; 52: 55-63
• 3 Thuluvath PJ, Pfau PR, Kimmey MB et al. Biliary complications after liver transplantation: the role of endoscopy. Endoscopy 2005; 37: 857-863
• 4 Pascher A, Neuhaus P. Bile duct complications after liver transplantation. Transpl Int 2005; 18: 627-642
• 5 Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies. Liver Transpl 2008; 14: 759-769
• 6 Speer AG, Cotton PB, Russell RC et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987; 2: 57-62
• 7 Zajko AB, Campbell WL, Bron KM et al. Diagnostic and interventional radiology in liver transplantation. Gastroenterol Clin North Am 1988; 17: 105-143
• 8 Tzakis AG, Gordon RD, Shaw BW Jr et al. Clinical presentation of hepatic artery thrombosis after liver transplantation in the cyclosporine era. Transplantation 1985; 40: 667-671
• 9 Dubbeld J, Hoekstra H, Farid W et al. Similar liver transplantation survival with selected cardiac death donors and brain death donors. Br J Surg 2010; 97: 744-753
• 10 Sanchez-Urdazpal L, Gores GJ, Ward EM et al. Diagnostic features and clinical outcome of ischemic-type biliary complications after liver transplantation. Hepatology 1993; 17: 605-609
• 11 Tabibian JH, Asham EH, Goldstein L et al. Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures. Gastrointest Endosc 2009; 69: 1236-1243
• 12 Zoepf T, Maldonado-Lopez EJ, Hilgard P et al. Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantation. Liver Transplantation 2006; 12: 88-94
• 13 Rossi AF, Grosso C, Zanasi G et al. Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation. Endoscopy 1998; 30: 360-366
• 14 Schwartz DA, Petersen BT, Poterucha JJ et al. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation. Gastrointest Endosc 2000; 51: 169-174
• 15 Bourgeois N, Deviére J, Yeaton P et al. Diagnostic and therapeutic endoscopic retrograde cholangiography after liver transplantation. Gastrointest Endosc 1995; 42: 527-534
• 16 Tabibian JH, Asham EH, Han S et al. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc 2010; 71: 505-512
• 17 Pasha SF, Harrison ME, Das A et al. Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc 2007; 66: 44-51
• 18 Costamagna G, Pandolfi M, Mutignani M et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001; 54: 162-168
• 19 Kahaleh M, Behm B, Clarke BW et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video). Gastrointest Endosc 2008; 67: 446-454
• 20 Mahajan A, Ho H, Sauer B et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009; 70: 303-309
• 21 Kasher JA, Corasanti JG, Tarnasky PR et al. A multicenter analysis of safety and outcome of removal of a fully covered self-expandable metal stent during ERCP. Gastrointest Endosc 2011; 73: 1292-1297
• 22 Traina M, Tarantino I, Barresi L et al. Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: a preliminary study. Liver Transplantation 2009; 15: 1493-1498
• 23 Hu B, Gao DJ, Yu FH et al. Endoscopic stenting for post-transplant biliary stricture: usefulness of a novel removable covered metal stent. J Hepatobiliary Pancreat Sci 2011; 18: 640-645
• 24 Poley JW, Cahen DL, Metselaar HJ et al. A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video). Gastrointest Endosc 2012; 75: 783-789
• 25 Morelli JM, Mulcahy HE, Willner IR et al. Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement. Gastrointest Endosc 2003; 58: 374-379