Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial

Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures

BACKGROUND

Endoscopic management is the first-line therapy for post-liver-transplant anastomotic strictures. Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months, data on safety and duration for metal stents in this setting is scarce. Due to limited access to endoscopic retrograde cholangiopancreatography (ERCP) during the coronavirus disease 2019 pandemic in our centre, there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy. This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.

AIM

To compare the safety and efficacy profile of different stenting durations using Kaffes stents.

METHODS

Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query. Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records. The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months. Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for ≤ 120 d or > 120 d.

RESULTS

During the study period, a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course. In 33 ERCPs, the stent was removed or exchanged on a 3-month interval. No pancreatitis, perforations or deaths occurred. Minor post-ERCP complications were similar between the 3-month (abdominal pain and intraductal migration) and 6-month (abdominal pain, septic shower and embedded stent) groups - 6.1% vs 9.1% respectively, P = 0.40. All strictures resolved at the end of the stenting course, but the stenting course was variable from 3 to 22 months. The recurrence rate for stenting courses lasting for up to 120 d was 71.4% and 21.4% for stenting courses of 121 d or over (P = 0.03). There were 28 patients that were treated with a single ERCP with Kaffes, 21 with removal after 120 d and 7 within 120 d. There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course (71.0% vs 10.0%, P = 0.01).

CONCLUSION

Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

Management of biliary complications in liver transplant recipients using a fully covered self-expandable metal stent with antimigration features

BACKGROUND

Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple side-by-side plastic stents are typically used for management of anastomotic strictures, fully covered self-expandable metal stents (FCSEMS) can be used to decrease the number of ERCPs with longer periods of stent patency. The risk of migration can limit their use. FCSEMS with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events (AEs).

METHODS

Single center retrospective study of LT patients who required FCSEMS from 1/2014 to 4/2022. Primary outcomes included stricture resolution and recurrence. Secondary outcomes were stent migration, occlusion, removability, and number of ERCPs.

RESULTS

Forty-three patients (mean age 55.5 years) with anastomotic strictures (N.=37), bile leaks (N.=4) or both (N.=2) were included. The median time from LT to FCSEMS placement was 125 days. Within one year of LT, 31 patients required intervention; early intervention at less than 30 and 90 days was needed in 7 and 19 patients, respectively. The median length of follow-up was 816.5 days. Stricture resolution was seen in 35 patients (81%) after a median stent dwell time of 130.5 days; recurrence occurred in 8 patients. There were three instances of partial stent migration that did not require reintervention or interfere with removability. The mean number of ERCPs required was 2.5.

CONCLUSIONS

The use of a FCSEMS with antimigration features yields effective stricture resolution with longer stent dwell times and fewer ERCPs.

Long-term outcomes of fully covered self-expandable metal stents for refractory biliary strictures after living donor liver transplantation: a retrospective study at a tertiary center

BACKGROUND AND AIMS

Endoscopic multiple plastic stents are an established first-line treatment for anastomotic biliary stricture (ABS) management after liver transplantation (LT). Fully covered self-expandable metallic stents (FCSEMSs) have recently been used with favorable outcomes, but long-term treatment outcomes remain an issue for ABS. We evaluated the long-term outcomes of FCSEMS for the management of refractory ABS after LT.

METHODS

We reviewed the prospectively collected and maintained endoscopic retrograde cholangiography database at Asan Medical Center to retrieve consecutive post-LT ABS cases that underwent an endoscopic FCSEMS placement between August 2009 and August 2019 after MPS placement failure.

RESULTS

A total of 34 patients were enrolled in this study. Technical success had been achieved in all subjects (100%). The median stent placement duration was 3.1 months (IQR 2.7-6.1). Stricture resolution was achieved in 26 patients (clinical success 76.5%, 95% confidence interval 62-91). Early adverse events developed in 3 patients (8.8%), including distal stent migration. Late adverse events occurred in 9 patients (26.5%), including cholangitis (n = 7, 20.6%) and asymptomatic distal stent migration (n = 2, 5.9%). The median follow-up period was 57.9 months (IQR 51.9-64.3). Stricture recurrence occurred in 3 of 26 patients who achieved clinical success (11.5%).

CONCLUSIONS

FCSEMS placement appears to be an effective and advisable intervention for refractory ABS as it can provide persistent stricture improvement over the long-term.

A practical approach to the endoscopic management of biliary strictures after liver transplantation

Biliary tract complications are an important cause of morbidity and mortality after liver transplantation (LT) occurring in 5% to 25% of patients. The most common biliary complication in LT recipients are strictures representing approximately half of these biliary adverse events. Bile duct strictures can be divided into anastomotic biliary strictures (ABS) and non-anastomotic biliary strictures (NABS) depending on their location in the biliary tree, being ABS the most encountered type. Several risk factors identified in previous studies can predispose to the development of ABS and NABS, especially those related to surgical techniques and donor characteristics. Magnetic resonance cholangiopancreatography (MRCP) is the recommended noninvasive imaging test for detecting post-LT biliary strictures, given its high sensitivity and specificity. Once the diagnosis of a biliary stricture after LT has been made, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy with good short and long-term results. Biliary sphincterotomy plus balloon dilation (BD) with placement of multiple plastic stents (MPS) has been the classic endoscopic approach for treating ABS, although fully-covered metallic stents (FCSEMS) have emerged as an alternative thanks to shorter total duration of stenting and fewer endoscopic procedures compared to MPS. In this review, we provide a practical update on the management of biliary strictures after LT, focusing our attention on the available evidence in the endoscopic therapy.

Study protocol for a prospective, multicentre, phase II trial on endoscopic treatment using two fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy

INTRODUCTION

The current endoscopic treatment for postoperative benign hepaticojejunostomy anastomotic stricture (HJAS) has a high technical success rate and is highly effective in the short term. However, long-term results have shown a high rate of stenosis recurrence, which indicates an insufficient response to treatment. Three prospective studies on fully covered self-expandable metallic stent (FC-SEMS) treatment for benign HJAS used the stenosis resolution rate as the primary endpoint, and no study has yet used the long-term non-stenosis rate (at 12 months) as the primary endpoint.

METHODS AND ANALYSIS

We launched the 'saddle-cross study', which will be conducted as a multicentre, prospective intervention of endoscopic treatment using two modified FC-SEMSs (BONASTENT️ M-Intraductal) that have been improved for benign stenosis in patients with benign HJAS, with the long-term non-restenosis rate (at 12 months) as the primary endpoint. This study aims to evaluate the long-term non-restenosis rate (at 12 months) and safety of the saddle-cross technique for benign HJAS. We plan to enrol 50 participants.

ETHICS AND DISSEMINATION

This study has been approved by the Certified Review Board of the National Cancer Center, Japan (CRB3180009). The results will be reported at various conferences and published in international peer-reviewed journals.

Endoscopic management of benign biliary strictures: Looking for the best stent to place

Benign biliary strictures (BBS) might occur due to different pancreaticobiliary conditions. The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations. The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS, considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable. The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment

The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of post-transplant strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent for extrahepatic strictures. In patients with unclear diagnoses or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be ensured.

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.

Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation

BACKGROUND AND AIMS

Fully covered metal stents (FCSEMSs) are increasingly used for treatment of biliary anastomotic strictures (ASs) after liver transplantation (LT), requiring fewer endoscopic interventions than does treatment with multiple plastic stents (MPSs). Previous studies, however, have reported adverse events such as stent migration and pancreatitis. The intraductal FCSEMS (ID-FCSEMS) potentially avoids these disadvantages. This study aimed to assess the efficacy and safety of ID-FCSEMSs compared with MPSs for AS.

METHODS

The cohorts of LT patients treated for AS with endoscopic stenting between 2010 and 2019 from 2 Dutch liver transplantation centers were retrospectively analyzed. Patients treated with ID-FCSEMSs or MPSs were included.

RESULTS

80 patients (44 with ID-FCSEMSs vs 36 with MPSs) were included, with a median follow-up time of 52 versus 64 months (P = .183). Stricture resolution was 93% in the ID-FCSEMS versus 97% in the MPS group (P = 1.000) after a median of 19 and 26 weeks, respectively (P = .031). The median number of ERCPs was 2 in the ID-FCSEMS group versus 4 in the MPS group (P < .001). Stricture recurrence occurred in 33% of ID-FCSEMS versus 29% of MPS patients (P = .653) after a median of 24 and 55 weeks (P = .403). Stent migration occurred in 16% of ID-FCSEMS versus 39% of MPS patients (P = .020). Post-ERCP fever was observed in 34% of ID-FCSEMS patients compared with 14% of MPS patients (P = .038). No significant differences were found in pancreatitis rate between the groups, being 6.8% for ID-FCSEMSs and 5.6% for MPSs (P = .816).

CONCLUSION

ID-FCSEMSs for the treatment of AS after LT provides similar stricture resolution and recurrence rates as MPSs, though with a significant reduction of procedures needed.

Fully covered metallic stents for anastomotic biliary strictures after living donor liver transplantation

Objectives

Anastomotic biliary strictures (ABSs) are common complications following living donor liver transplantation (LDLT). We evaluated the feasibility of a novel removable, intraductal, fully covered, self‐expandable metallic stent (FCSEMS) for the treatment of ABSs following LDLT.

Methods

Nine patients with duct‐to‐duct ABSs that developed following LDLT were prospectively enrolled in this study. We placed a short FCSEMS with a long lasso and middle waist formation in each patient's ABS above the papilla and removed it 16 weeks later.

Results

The FCSEMS placements were successful in all nine cases. Four patients experienced mild cholangitis, which was resolved with conservative treatment. Additionally, there was one case of distal migration. The FCSEMSs were successfully removed from all the patients, and the clinical success rate was 100%. Stricture recurrence occurred in one (11.1%) patient during the follow‐up period.

Limitations

The small number and lack of comparison with other types of FCSEMSs and plastic stents.

Conclusions

Intraductal placement of FCSEMSs is useful for treating refractory ABSs after LDLT, although further studies are required with larger sample sizes.

Safety and feasibility of a novel recanalization technique using guidewire puncture under cholangioscopy for complete biliary stricture after liver transplantation

Cholangioscopy is reportedly useful for selective guidewire placement across difficult biliary strictures, but few methods are available for complete stricture of biliary anastomosis. This study aimed to propose a guidewire puncture technique to recanalize totally obstructed anastomosis and discuss its safety and feasibility. From January 2015 to December 2021, a total of 11 patients with complete biliary anastomotic stricture after liver transplantation were enrolled. These patients underwent peroral single operator cholangioscopy (SpyGlass), whereas two failed cases on SpyGlass finally underwent percutaneous transhepatic cholangioscopy (PTCS). The steps of the recanalization technique were as follows: the stricture was viewed carefully to detect the closure point (CP) of the scar endoscopically, then the CP was targeted by the hard tip of the guidewire and broke through under guidance of the cholangioscope and fluoroscope. Complete occlusions were confirmed by SpyGlass in all cases. A total of 13 hard-tip guidewire punctures were performed under cholangioscopy, and ten punctures were successful (technical success rate, 76.9% [10/13]). After recanalization of the occluded anastomosis, plastic stent or metallic stent was deployed in three and seven patients, respectively. No procedure-related complications occurred during or after the cholangioscopy-assisted guidewire puncture. After a mean follow-up of 12 months, stents had been removed in five patients. The other six patients were still receiving stent treatment. This study demonstrated that the guidewire puncture technique under cholangioscopy is safe and feasible for complete stricture of biliary anastomosis, and the success rate is satisfactory.

ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

Long-Term Results of Endoscopic Metal Stenting for Biliary Anastomotic Stricture after Liver Transplantation

(1) Background: Anastomotic biliary stricture (ABS) is a well-known complication of liver transplantation which can lead to secondary biliary cirrhosis and graft dysfunction. The goal of this study was to evaluate the long-term outcomes of endoscopic metal stenting of ABS in the setting of deceased donor liver transplantation (DDLT). (2) Methods: Consecutive DDLT patients with endoscopic metal stenting for ABS between 2010 and 2015 were screened. Data on diagnosis, treatment and follow-up (until June 2022) were collected. The primary outcome was endoscopic treatment failure defined as the need for surgical refection. (3) Results: Among the 465 patients who underwent LT, 41 developed ABS. It was diagnosed after a mean period of 7.4 months (+/-10.6) following LT. Endoscopic treatment was technically successful in 95.1% of cases. The mean duration of endoscopic treatment was 12.8 months (+/-9.1) and 53.7% of patients completed a 1-year treatment. After a mean follow-up of 6.9 years (+/-2.3), endoscopic treatment failed in nine patients (22%) who required surgical refection. Conclusions: Endoscopic management with metal stenting of ABS after DDLT was technically successful in most cases, and half of the patients had at least one year of indwelling stent. Endoscopic treatment long-term failure rate occurred in one fifth of the patients.

Post-ERCP pancreatitis occurs more frequently in self-expandable metallic stents than multiple plastic stents on benign biliary strictures: a meta-analysis

BACKGROUND

The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes.

CONCLUSIONS

Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement.

METHODS

A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity.

RESULTS

Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, p = .64; and OR = 2.3, 95%CI: 0.68-7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, p = .07).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.

A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video)

BACKGROUND

In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents.

METHODS

This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021.

RESULTS

The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25-122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%).

CONCLUSIONS

The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.

Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy

BACKGROUND

The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis.

METHODS

A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up.

RESULTS

Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents.

CONCLUSIONS

Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.

Feasibility and safety of a novel 3D-printed biodegradable biliary stent in an in vivo porcine model: a preliminary study

To assess the feasibility and safety of a novel 3D-printed biodegradable biliary stent using polycaprolactone (PCL) in an in vivo porcine model. In this animal study using domestic pigs, biodegradable radiopaque biliary stents made of polycaprolactone (PCL) and barium sulfate were produced using 3D printing and surgically inserted into the common bile duct (CBD) of pigs (stent group, n = 12). Another five pigs were allocated to the control group that only underwent resection and anastomosis of the CBD without stent insertion. To check the position and status of the stents and stent-related complications, follow-up computed tomography (CT) was performed every month. The pigs were sacrificed 1 or 3 months after surgery, and their excised CBD specimens were examined at both the macroscopic and microscopic levels. Three pigs (one in the stent group and two in the control group) died within one day after surgery and were excluded from further analysis; the remaining 11 in the stent group and 3 in the control group survived the scheduled follow-up period (1 month, 5 and 1; and 3 months, 6 and 2 in stent and control groups, respectively). In all pigs, no clinical symptoms or radiologic evidence of biliary complications was observed. In the stent group (n = 11), stent migration (n = 1 at 3 months; n = 2 at 1 month) and stent fracture (n = 3 at 2 months) were detected on CT scans. Macroscopic evaluation of the stent indicated no significant change at 1 month (n = 3) or fragmentation with discoloration at 3 months (n = 5). On microscopic examination of CBD specimens, the tissue inflammation score was significantly higher in the stent group than in the control group (mean ± standard deviation (SD), 5.63 ± 2.07 vs. 2.00 ± 1.73; P = 0.039) and thickness of fibrosis of the CBD wall was significantly higher than that of the control group (0.46 ± 0.12 mm vs. 0.21 ± 0.05 mm; P = 0.012). Despite mild bile duct inflammation and fibrosis, 3D-printed biodegradable biliary stents showed good feasibility and safety in porcine bile ducts, suggesting their potential for use in the prevention of postoperative biliary strictures.

Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture

BACKGROUND

Endoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.

AIM

To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.

METHODS

This study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (Hanarostent^TM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.

RESULTS

Three patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.

CONCLUSION

In this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.

Current endoscopic approaches to biliary strictures

PURPOSE OF REVIEW

To summarize the current status and future perspectives of the endoscopic management of biliary strictures.

RECENT FINDINGS

In addition to conventional diagnostic modalities, such as cross-sectional imaging and endoscopic ultrasonography (EUS), per-oral cholangioscopy is helpful for indeterminate biliary strictures. It allows direct visualization of the biliary tract and targeted biopsy. For distal malignant biliary obstruction (MBO), a self-expandable metal stent (SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) is a standard of care. EUS-guided biliary drainage (EUS-BD) is an emerging alternative to percutaneous transhepatic biliary drainage in cases with failed ERCP. EUS-BD is also an effective salvage option for perihilar MBO, which can not be managed via ERCP or percutaneous transhepatic biliary drainage. Preoperative drainage is necessary for most jaundiced patients as neoadjuvant chemotherapy is widely administered for resectable and borderline resectable pancreatic cancer, and a SEMS is preferred in this setting, too. For benign biliary strictures, a covered SEMS can improve stricture resolution and reduce the number of endoscopic sessions as compared to plastic stents.

SUMMARY

ERCP and EUS play a central role in the diagnosis and drainage for both malignant and benign biliary strictures.

Feasibility and Safety of ERCP in the Treatment of Biliary Strictures after Liver Transplantation: With a Report of 37 Cases

Background. Liver transplantation (LT) is an effective treatment option for patients with end-stage liver disease; biliary complications are important cause of death in posttransplant patients. Endoscopic retrograde cholangiopancreatography (ERCP) has an irreplaceable role in the diagnosis and treatment of patients with biliary tract disease. Methods. The clinical data of patients with biliary strictures (BS) after LT treated with ERCP admitted to the Third Xiangya Hospital of Central South University from September 2016 to October 2021 were reviewed; the changes in temperature, bilirubin, and albumin before and after treatment and postoperative complications were analyzed. Results. A total of 41 patients were included in the study, and biliary stents were successfully placed in 37 cases (90.2%), while 4 cases (9.8%) were unsuccessful due to complete BS. Patients with ERCP guided biliary stenting had a significant improvement in bilirubin index compared to the preoperative period ( $P<0.05$ ). 27 patients (73.0%) had complete relief of symptoms after 1 ERCP-guided treatment, and 10 patients (27.0%) developed BS again at different times after the first ERCP treatment, among which 8 patients developed BS again within 1 year after the first treatment and 2 patients developed BS again after 1 year after the first treatment. The incidence of endoscopy-related adverse events was 35.14%, with no serious adverse events. Conclusion. ERCP-guided biliary stenting was an effective and safety treatment for BS after LT.

Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie

Biliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten Verfahren.

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.

Impact of a shorter replacement interval of plastic stents on premature stent exchange rate in benign and malignant biliary strictures

BACKGROUND AND AIM

The main disadvantage of plastic stents is the high rate of stent occlusion. The usual replacement interval of biliary plastic stents is 3 months. This study aimed to investigate if a shorter interval of 6-8 weeks impacts the median premature exchange rate (mPER) in benign and malignant biliary strictures.

METHODS

All cases with endoscopic retrograde cholangiopancreatography (ERCP) and plastic stent placement were retrospectively analyzed since establishing an elective replacement interval of every 6-8 weeks at our institution and mPER was determined.

RESULTS

A total of 3979 ERCPs (1199 patients) were analyzed, including 1262 (31.7%) malignant and 2717 (68.3%) benign cases, respectively. The median stent patency (mSP) was 41 days (range 14-120) for scheduled stent exchanges, whereas it was 17 days (1-75) for prematurely exchanged stents. The mPER was significantly higher for malignant (28.1%, 35-50%) compared with benign strictures (15.2%, 10-28%), P < 0.0001, respectively. mSP was significantly shorter in cases with only one stent (34 days [1-87] vs 41 days [1-120]) and in cases with only a 7-Fr stent (28 days [2-79]) compared with a larger stent (34 days [1-87], P = 0.001). Correspondingly, mPER was significantly higher in cases with only one stent (23% vs 16.2%, P < 0.0001) and only a 7-Fr stent (31.3% vs 22.4%, P = 0.03).

CONCLUSION

A shorter replacement interval does not seem to lead to a clinically meaningful reduction of mPER in benign and malignant strictures. Large stents and multiple stenting should be favored as possible.

Endoscopic Management of Biliary Strictures after Orthotopic Liver Transplantation: A Single Center Experience Study

Background and Aim. Endoscopic therapy is the method of choice in the management of biliary strictures after orthotopic liver transplantation (OLT). Even though the mainstay approach for OLT stricture complications is represented by consecutive procedures of multiple plastic stents (MPS) insertion, a valuable alternative is the use of fully covered self-expandable metal stents (FCSEMS). The aim of the study was to compare MPS with FCSEMS used in the management of OLT biliary strictures, in terms of clinical outcomes and complications. Material and Methods. This is a retrospective, single-center study conducted between February 2014 and November 2019 in the Clinical Emergency Hospital of Bucharest, Romania. We enrolled all consecutive patients who developed biliary strictures after OLT and were treated by endoscopic retrograde cholangiopancreatography (ERCP) either with MPS or FCSEMS. Results. Thirty-six patients were included in the study, 27 patients had MPS and nine patients had FCSEMS. 106 ERCP procedures were performed and 159 stents were inserted. The mean number of ERCP procedures required per patient was significantly higher for MPS than for FCSEMS (3.34 ± 1.46 vs. 2.11 ± 0.33, p < 0.001). In the FCSEMS group only one patient had three procedures, due to stent migration. Difficult cannulation was encountered in 22 patients, 18 patients from MPS group and four patients from FCSEMS group. Dilation was performed in 20 (77%) MPS patients and in four FCSEMS patients (44%). Overall, we used 159 stents for stricture resolution, 149 plastic stents and 10 FCSEMS. Mean number of stents inserted was significantly lower in the FCSEMS group compared to MPS group (1.16 ± 0.40 vs. 5.73 ± 2.64, p < 0.001). Conclusions. Stricture resolution using FCSEMS is comparable to MPS and even has some advantages. In line with prior studies, FCSEMS are effective, with fewer complications and similar outcome compared to plastic stents. Other particular aspects should be further assessed, especially long-term follow up of FCSEMS and their cost efficiency.

Biliary stones or ulcers at the choledochojejunal anastomotic site involving the jejunal mucosa at stent removal may be recurrent factors in patients with benign choledochojejunal anastomotic stenosis undergoing endoscopic biliary stenting using fully-covered self-expandable metal stents

BACKGROUND

Temporary fully-covered self-expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS.

METHODS

Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated.

RESULTS

The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in 4 patients. FCSEMS removal was successfully performed on 14 patients, excluding 1 with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, 4 had anastomotic ulcers. The median follow-up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (p=0.003) or anastomotic ulcers at FCSEMS removal (p=0.018) were associated with recurrence.

CONCLUSIONS

Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy.

Metal versus plastic stents in the management of benign biliary strictures: systematic review and meta-analysis of randomized controlled trials

Benign biliary strictures (BBS) are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with the placement of multiple plastic stents (MPS) or a covered self-expandable metal stent (CSEMS). In this meta-analysis, we compared the efficacy and safety of MPS and CSEMS in the management of BBS. We reviewed several databases from inception to 28 April 2021 to identify RCTs that compared MPS with CSEMS in the management of BBS. Our outcomes of interest were stricture resolution, stricture recurrence, adverse events, stent migration and mean number of ERCPs to achieve stricture resolution. Data were analyzed using a random-effects model. We included eight RCTs with 524 patients. We found no significant difference in the rate of stricture resolution (risk ratio, 1.02; 95% CI, 0.96-1.10), stricture recurrence (risk ratio, 1.68; 95% CI, 0.72-3.88) or adverse events (risk ratio, 1.17; 95% CI, 0.73-1.87) between groups. Mean number of ERCPs was significantly lower in the CSEMS group (SMD, -1.99; 95% CI, -3.35 to -0.64). The rate of stent migration was significantly higher in the CSEMS group. CSEMS are comparable in efficacy and safety to MPS in the management of BBS but require fewer ERCPs to achieve stricture resolution.

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.

Cost analysis of a long-term randomized controlled study in biliary duct-to-duct anastomotic stricture after liver transplantation

Multiple plastic stent (MPS) for biliary anastomotic stricture (AS) after liver transplantation requires multiple procedures with consequent costs. To compare the success, adverse events and treatment-related costs of fully covered self-expandable metal stents (FCSEMS) versus MPS. Thirty liver transplant (LT) patients with clinically relevant naïve AS were prospectively randomized to FCSEMS or MPS, with stent numbers increased at 3-month intervals. Treatment costs per patient were calculated for endoscopic retrograde cholangiopancreatography (including all devices and stents) and overall hospital stay. Radiological success was achieved in 73% of FCSEMS (median indwelling period of 6 mos) and 93% of MPS patients (P = NS) (median period of 11 mos). AS recurrence occurred in 36% of FCSEMS and 7% of MPS patients (P = NS), and AS re-treatment was needed in 53% and 13% (P < 0.01), respectively, during follow-up of 60 (34-80) months. Stents migrated after 29% and 2.6% of FCSEMS and MPS procedures, respectively (P < 0.01). Including re-treatments, long-term clinical success was achieved in 28/30 (93%) patients. Overall treatment-related costs were similar between groups. In the subgroup of LT patients in clinical remission after first-line treatment, treatment costs were 41% lower per FCSEMS patient compared with MPS patients. FCSEMS did not perform better than MPS. FCSEMS migration increased the rate of re-treatment and costs.

Efficacy of a modified short fully covered self-expandable metal stent for perihilar benign biliary strictures

BACKGROUND AND AIM

Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self-expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent-induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS.

METHODS

Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5-6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow-up period were measured.

RESULTS

Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138-196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow-up period (median 635 days) after stent removal, only one recurrence developed.

CONCLUSIONS

Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution.

IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

BACKGROUND

Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment.

OBJECTIVE

On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS).

METHODS

Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal.

RESULTS

At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence.

CONCLUSION

Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation

BACKGROUND

Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.

AIM

To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.

METHODS

This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.

RESULTS

Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).

CONCLUSION

In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.

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.).

Variation in Tacrolimus Trough Concentrations in Liver Transplant Patients Undergoing Endoscopic Retrograde Cholangiopancreatography: A Retrospective, Observational Study

Objective

High variabilities in tacrolimus (TAC) exposure are still problems that confuse physicians. TAC trough levels (TAC C_min) fluctuated considerably after endoscopic retrograde cholangiopancreatography (ERCP) treatment in several liver transplant (LT) patients. We aimed to investigate the variation regularity of TAC C_min post-ERCP and related factors.

Methods

This study was a retrospective, observational study conducted at the First Affiliated Hospital of Zhejiang University in China. From October 2017 to January 2019, 26 LT patients that received ERCP were included (73 TAC C_min measures). The absolute difference and the variation extent in TAC C_min pre- and post-ERCP were analyzed. Patients were divided into mild and obvious variation groups, and the differences were compared.

Results

The TAC C_min in LT patients significantly increased in the first three days post-ERCP (p<0.05) and increased by more than 20% in 18 out of 26 (69.2%) patients. The mean extent of variation in TAC C_min was 45.1% (95% confidence interval [CI]: 28.3–81.3%) and 31.4% (95% CI: 9.7–53.1%) on days 1 and 3 post-ERCP, respectively. The increasing TAC C_min gradually returned to baseline within a week (p>0.05). The daily TAC dose and total bile acid (TBA) level were significantly higher (p<0.05) in patients with obvious variation in TAC C_min. The differences in other demographics, clinical characteristics, variation in laboratory data, and serum amylase levels between the two groups were not significant.

Conclusion

The TAC C_min significantly increased in LT patients during the first three days after ERCP, and the level returned to baseline within a week. The daily TAC dose and TBA levels may be related to this increase. Frequent drug concentration monitoring should be executed in the early phase post-ERCP, especially in patients with related factors.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture

A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.

Management of Post-Transplant Anastomotic Stricture Using Self-Expandable Metal Stent

Anastomotic stricture (AS) is one of the complications of liver transplantation (LT) and can occur in up to 40% of living-donor LTs. Endoscopic management has become the first-line treatment of AS, and multiple plastic stents insertion has been mainly used in the past. Recently, many treatments utilizing fully covered self-expandable metal stents (cSEMSs) have been attempted, and results showing adequate treatment outcome have been reported. In this review, we look into the treatment performance and cautionary steps needed when using cSEMS as a treatment for AS.

Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture

Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.

Recent innovations in therapeutic endoscopy for pancreatobiliary diseases

The development of endoscopic treatment for pancreatobiliary diseases in recent years is remarkable. In addition to conventional transpapillary treatments under endoscopic retrograde cholangiopancreatography (ERCP), new endoscopic ultrasound-guided therapy is being developed and implemented. On the other hand, due to the development/improvement of various devices such as new metal stents, a new therapeutic strategy under ERCP is also advocated. The present review focuses on recent advances in the endoscopic treatment of pancreatic pseudocysts, walled-off necrosis, malignant biliary strictures, and benign biliary/pancreatic duct strictures.

Intraductal placement of non-flared fully covered metallic stent for refractory anastomotic biliary strictures after living donor liver transplantation: Long-term results of prospective multicenter trial

BACKGROUND AND AIM

Fully covered self-expandable metallic stent (FCSEMS) may be an effective modality for managing anastomotic biliary stricture (ABS) after liver transplantation. However, stent migration and stent-induced ductal injury are the main limitations. The objective of this study was to evaluate the usefulness of an unflared, intraductal FCSEMS that was designed to minimize migration and ductal injury for refractory ABS after living donor liver transplantation (LDLT).

METHODS

A total of 32 consecutive patients with symptomatic ABS after LDLT unresolved by plastic stents with or without balloon dilation at four tertiary medical centers were prospectively enrolled. A short (3 or 5 cm) FCSEMS having long lasso (10 cm) used in this study had unflared convex ends to minimize tissue hyperplasia and smaller center portion to prevent migration. The FCSEMS was placed above the papilla and removed at 3-4 months after stenting.

RESULTS

Technical and clinical success rates of intraductal placement with FCSEMS were 100% (32/32) and 81.2% (26/32), respectively. Early stent migration was observed in five (15.6%) patients. However, three patients with early stent migration had stricture resolution without needing additional intervention. Intended stent removal was successful in 27 (100%) patients (median, 101 days; range, 23-118 days). No stent-induced ductal change was observed in all patients. Stricture recurrence was observed in 11.5% (3/26) of patients during 639 days of median duration of follow-up (range, 366-2079 days).

CONCLUSIONS

Intraductal placement of an unflared short FCSEMS may be a promising option for refractory ABS after LDLT with minimal stent-induced ductal injury and stent migration.