Plastic versus metal stenting in bile leaks management after liver transplantation

Aims Post-liver transplant (LT) bile leaks (BL) are successfully treated by endoscopic retrograde cholangiopancreatography (ERCP). Compared to plastic stents, the use of fully-covered self-expandable metal stents (fc-SEMSs) is burdened by studies reporting a higher rate of adverse events (AEs) and current European guidelines do not provide clear indication for their up-front use for BLs management. To date, no studies have compared plastic stents with fc-SEMSs for post-LT BLs treatment. We aimed to evaluate the safety and efficacy of plastic versus fc-SEMS in treating post-LT BLs in a tertiary endoscopy center.

Methods We conducted a retrospective review of all LT patients who underwent ERCP for BL management at our center from January 2018 to March 2024. Out of 7043 ERCPs, 30 were performed for post-LT BLs treatment. The decision to use fc-SEMS was made on a case-by-case basis, considering: cholangiographic evidence of significant anastomotic dehiscence (greater than 90°), the presence of a large gap between the leak edges, and an associated biliary stricture.

Results Thirty patients were included, all but one undergoing duct-to-duct anastomosis. The general characteristics of the study population are summarized in Table 1. Fourteen patients (46.7%) received plastic stents, while 16 (53.3%) received fc-SEMSs. Technical success was achieved in 100% of the plastic stent group and 93.8% in the fc-SEMS group, while clinical success rates were 100% for both groups. There was no significant difference in AEs rate between the two groups (42.9% in the plastic stent group vs. 37.5% in the fc-SEMS group, p=0.1), and none of the procedure-related complications were severe. Concerning biliary strictures, 3 out of 7 patients already had a coexistent stricture at the same site before BL treatment. Of the remaining 4 with a de novo stricture, 2 underwent up-front plastic stent placement, and 2 a fc-SEMS. None of the patients required rescue procedures as PTBD, surgery or re-transplant due to BL persistence. The average number of ERCP sessions needed to fully treat the BLs was 2 (SD±1) per patient in both groups. Median follow-up was 8 months (IQR 1-27.3).

Conclusions ERCP with either plastic stents or fc-SEMSs effectively treats post-LT BLs, with no significant differences in AEs between the two groups. Therefore fc-SEMS could be considered not only in cases where plastic stent treatment fails but also as a primary, effective, and safe therapeutic option.

Publication History

Article published online:
27 March 2025