Metallic vs plastic stents to treat biliary stricture after liver transplantation: a systematic review and meta-analysis based on randomized trials

Abstract

Background and study aims The first-line approach to anastomotic biliary stricture after orthotopic liver transplantation (OLTX) involves endoscopic retrograde cholangiopancreatography (ERCP). The most widely used technique is placement of multiple plastic stents, but discussions are ongoing on the benefits of fully-covered self-expandable metallic stents (FCEMS) in this situation. This study aimed to compare results from use of plastic and metal stents to treat biliary stricture after transplantation.

Patients and methods Searches were performed in the Medline, EMBASE, SciELO/LILACS, and Cochrane databases, and only randomized studies comparing the two techniques were included in the meta-analysis.

Results Our study included four randomized clinical trials totaling 205 patients. No difference was observed between the stricture resolution rate (RD: 0.01; 95 %CI [−0.08 – 0.10]), stricture recurrence (RD: 0.13; 95 %CI [−0.03 – 0.28]), and adverse events (RD: −0.10; 95 %CI [−0.65 – 0.44]) between the plastic and metallic stent groups. The metallic stent group demonstrated benefits in relation to the number of ERCPs performed (MD: −1.86; 95 %CI [−3.12 to −0.6]), duration of treatment (MD: −105.07; 95 %CI [−202.38 to −7.76 days]), number of stents used (MD: −10.633; 95 %CI [−20.82 to −0.44]), and cost (average $ 8,288.50 versus $ 18,580.00, P < 0.001).

Conclusions Rates of resolution and recurrence of stricture are similar, whereas the number of ERCPs performed, number of stents used, duration of treatment, and costs were lower in patients treated with FCEMS, which shows that this device is a valid option for initial treatment of post-OLTX biliary stricture.

• References

• 1 Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: A systematic review of the incidence, risk factors and outcome. Transpl Int 2011; 24: 379-392
• 2 Kochhar G, Parungao JM, Hanouneh IA. et al. Biliary complications following liver transplantation. World J Gastroenterol 2013; 19: 2841-2846
• 3 Nemes B, Gámán G, Doros A. Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol 2015; 9: 447-466
• 4 Albert JG, Filmann N, Elsner J. et al. Long-term follow-up of endoscopic therapy for stenosis of the biliobiliary anastomosis associated with orthotopic liver transplantation. Liver Transplant 2013; 19: 586-593
• 5 Suárez F, Otero A, Solla M. et al. Biliary complications after liver transplantation from maastricht category-2 non-heart-beating donors. transplantation 2008; 85: 9-14
• 6 Seehofer D, Eurich D, Veltzke-Schlieker W. et al. Biliary complications after liver transplantation: Old problems and new challenges. Am J Transplant 2013; 13: 253-265
• 7 Kao D, Zepeda-Gomez S, Tandon P. et al. Managing the post-liver transplantation anastomotic biliary stricture: Multiple plastic versus metal stents: A systematic review. Gastrointest Endosc 2013; 77: 679-691
• 8 Poley JW, Lekkerkerker MN, Metselaar HJ. et al. Clinical outcome of progressive stenting in patients with anastomotic strictures after orthotopic liver transplantation. Endoscopy 2013; 45: 567-570
• 9 Tringali A, Barbaro F, Pizzicannella M. et al. Endoscopic management with multiple plastic stents of anastomotic biliary stricture following liver transplantation: Long-term results. Endoscopy 2016; 48: 546-551
• 10 Coté GA, Slivka A, Tarnasky P. et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution. JAMA 2016; 315: 1250
• 11 Kahaleh M, Brijbassie A, Sethi A. et al. Multicenter trial evaluating the use of covered self-expanding metal stents in benign biliary strictures: time to revisit our therapeutic options?. J Clin Gastroenterol 2013; 47: 695-699
• 12 Devière J, Reddy DN, Püspök A. et al. Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 2014; 147: 385-395
• 13 Kaffes A, Griffin S, Vaughan R. et al. A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Therap Adv Gastroenterol 2014; 7: 64-71
• 14 Jiménez-Pérez M, Melgar Simón JM, Durán Campos A. et al. Endoscopic management of post-liver transplantation biliary strictures with the use of fully covered metallic stents. Transplant Proc 2016; 48: 2510-2514
• 15 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
• 16 Sauer P, Chahoud F, Gotthardt D. et al. Temporary placement of fully covered self-expandable metal stents in biliary complications after liver transplantation. Endoscopy 2012; 44: 536-538
• 17 Tarantino I, Traina M, Mocciaro F. et al. Fully covered metallic stents in biliary stenosis after orthotopic liver transplantation. Endoscopy 2012; 44: 246-250
• 18 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
• 19 Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. [updated March 2011] In: The Cochrane Collaboration 2011 Table 7.7.a: Formulae for combining groups
• 20 Clark HD, Wells GA, Huët C. et al. Assessing the quality of randomized trials: Reliability of the Jadad scale. Control Clin Trials 1999; 20: 448-452
• 21 Guyatt GH, Oxman AD, Vist GE. et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. Chinese J Evidence-Based Med 2009; 9: 8-11
• 22 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005; 5: 13
• 23 Tal AO, Finkelmeier F, Filmann N. et al. Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial. Gastrointest Endosc 2017; 86: 1038-1045
• 24 Martins FP, De Paulo GA, Contini MLC. et al. Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: A randomized controlled trial. Gastrointest Endosc 01/2018; 87: 131.e1-131.e13
• 25 Levels of Evidence. Univ Oxford: Oxford Centre for Evidence-based Medicine; 2009 (November 1998) 4-5 www.cebm.net