Bile Duct Anastomosis Supplied With Biodegradable Stent in Liver Transplantation: The Initial Experience

Do We Need to Use a Stent in Biliary Reconstruction to Decrease the Incidence of Biliary Complications in Liver Transplantation? A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Biliary complications are a significant cause of morbidity post-transplantation, and the routine use of biliary stents in liver transplantation to reduce these complications remains controversial. This study aimed to compare the incidence of biliary complications with and without the use of trans anastomotic biliary stent in liver transplantation.

METHOD

PubMed, Scopes, Web of Science, and Cochrane library were searched for eligible studies from inception to February 2022, and a systematic review and meta-analysis were done to compare the incidence of biliary complications in the two groups.

RESULTS

Seventeen studies with a total of 2623 patients were included. The pooled results from the included studies showed an equal rate of biliary complications (i.e., strictures, leaks and cholangitis) in stented and non-stented patients after liver transplantation. However, the cost and biliary intervention rates are higher in stented patients. In addition to that, our sub-group analysis showed no significant decrease in the incidence of biliary complications after using trans anastomotic biliary stent in living donor liver transplant (LDLT), deceased donor liver transplant (DDLT), Roux-en-Y hepaticojejunostomy (RYHJ), and duct-to-duct anastomosis, pediatric, and adult liver transplantation.

CONCLUSION

No added benefit on the routine use of endobiliary stent in liver transplantation. However, stented patients are at higher risk of needing multiple ERCPs.

The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review

Biliary complications are one of the main concerns after liver transplantation, and to avoid these, the use of a T-tube has been advocated in biliary reconstruction. Most liver transplantation centres perform a biliary anastomosis without a T-tube to avoid the risk of complications and T-tube-related costs. Several meta-analyses have reached discordant conclusions regarding the benefits of using the T-tube. An umbrella review was performed to summarise quantitative measures about overall biliary complications, biliary leaks, biliary strictures and cholangitis associated with the T-tube use after liver transplantation. Published systematic reviews and meta-analyses related to the use of T-Tube in liver transplantation were searched and analysed. From the comprehensive literature search from PubMed, EMBASE and Cochrane Library databases on the 25th of October 2021, 104 records were retrieved. Seven meta-analyses and two systematic reviews were included in the final analysis. All the meta-analyses of RCT stated no differences in overall biliary complications and biliary leaks when using T-tube for a liver transplant (I2 ≥ 90% and I2 range 0-76%, respectively). The meta-analysis of the RCTs evaluating the risks of biliary strictures after liver transplantation showed that T-tube protects from the complication (I2 range 0-80%). Biliary anastomosis without a T-tube has equivalent overall biliary complications and bile leaks compared to the T-tube reconstruction. The incidence of biliary strictures is attenuated in patients with T-tubes, and most meta-analyses of RCTs have very low heterogeneity. Therefore, the present umbrella review suggests a selective T-tube use, particularly in small biliary ducts or transplants with marginal grafts at high risk of post-LT strictures.

USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience

Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.

Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model

Purpose

The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis.

Methods

Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion.

Results

In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05).

Conclusion

Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.

Archimedes Absorbable Internal Biliary Stent in Liver Transplants to Prevent Bile Leak

BACKGROUND

Biliary complications, especially bile leaks, are an important cause of early postoperative morbidity and, rarely, mortality after liver transplant. The risk is higher in living donor liver transplant (LDLT) compared to deceased donor liver transplant (DDLT). Attempts to reduce bile leaks have included refinements in the biliary anastomosis technique and use of various external and internal stents, with inconsistent benefits. Recent availability and successful use of the absorbable Archimedes stent has prompted its intrabiliary placement across the anastomosis.

METHODS

In this retrospective study, we analyzed the data of 20 adult patients who underwent a liver transplant with duct-to-duct biliary anastomosis using the Archimedes stent. Both DDLT and LDLT were performed using cava-preserving hepatectomy followed by standard implantation methods. Duct-to-duct biliary anastomosis was performed in all cases using interrupted sutures with extracorporeal knots over an absorbable intrabiliary stent. In addition to standard postoperative care, patients were monitored for bile leak.

RESULTS

Nine DDLTs had a single anastomosis over a 10-Fr stent. Out of 11 LDLT patients, 7 had a single anastomosis and 4 patients had 2 anastomoses, all over a 6-Fr stent. Two patients died, 1 as a result of graft primary nonfunction and another because of multidrug-resistant pneumonia. One patient had ascending cholangitis owing to stent migration in the duodenum. This episode was treated with endoscopic stent removal and appropriate antibiotics, with good recovery. None of the other patients had bile leaks, biloma, or stent-related complications.

CONCLUSIONS

Archimedes internal absorbable biliary stents can be safely used in both living and deceased donor liver transplants to prevent bile leaks.

Biliary complications after liver transplantation: current perspectives and future strategies

Importance

Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation.

Objective

The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT.

Evidence Review

a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment.

Findings

Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks.

Conclusions and Relevance

BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.

Case report: Trans-papillary free stenting of the cystic duct and of the common bile duct in a double biliary ducts anastomoses of a right lobe living donor transplantation

Background

One of the major issues related to the living donor liver transplantation recipient outcome is still the high rate of biliary complication, especially when multiple biliary ducts are present and multiple anastomoses have to be performed.

Case presentation and conclusion

We report a case of adult-to-adult right lobe living donor liver transplantation performed for a recipient affected by alcohol-related cirrhosis with MELD score of 17. End-stage liver disease was complicated by refractory ascites, portal hypertension, small esophageal varices and portal gastropathy, hypersplenism, and abundant right pleural effusion. Here in the attached video we described the adult-to-adult LDLT procedures, where a right lobe with two biliary ducts draining respectively the right anterior and the right posterior segments has been transplanted. LDLT required a biliary reconstruction using the native cystic and common bile ducts stented trans-papillary with two 5- French 6 cm long soft silastic catheter. None major complications were detected during post-operative clinical courses. Actually, the donor and the recipient are alive and well. The technique we describe in the video, allow to keep the biliary anastomoses protected and patent without having the risk of creating cholestasis and the need of invasive additional procedure. No living donor right lobe transplantation should be refused because of the presence of multiple biliary ducts.

Duodenum sparing technique for preventive stenting of biliary tract anastomosis in pigs

The main aim of this study was to find a standardized method for preventive stenting of biliary tract anastomosis with biodegradable self-expandable stent from polydioxanone and to evaluate the functionality of the stent. The experimental study was conducted using four pigs with a follow-up of eight weeks. The procedure was done under general anaesthesia. The function of the stent was verified by clinical stage, blood test, magnetic resonance cholangiopancreatography and necropsy. Our duodenum sparing technique was described in detail and photographically documented. All pigs finished the follow-up period without clinical, laboratory or radiologic signs of biliary obstruction. Necropsy did not reveal complication of the procedure or anastomotic stricture. In conclusion, this study demonstrated a simple new duodenum sparing method of transanastomotic insertion of a biodegradable self-expandable stent from polydioxanone. We did not find any complications during the follow-up. This method will be used in our follow-up study with an extended experimental control group of animals and a longer follow-up period to verify the preventive functionality of this stent.

Novel Application of Internal-External Drainage Catheter as Biliary Stent for Percutaneous Transhepatic Treatment of Biliary Strictures in Living Donor Liver Transplantation Recipient Patients

OBJECTIVES

Although endoscopic management is considered as the first-line treatment for biliary strictures, it may be challenging in living donor liver transplant recipients due to the complex nature of duct-to-duct reconstruction. In this study we present the use of a pigtail drainage catheter as a biliary stent to treat biliary strictures after a living donor liver transplant.

METHODS

Twenty-seven patients with biliary strictures were treated with our novel technique. In this technique, a pigtail catheter was trimmed into 3 parts (proximal, middle, and distal portions). A suture string was passed through the distal hole of the middle portion, which was then reversed and used as a stent while the proximal portion was used as a pusher. Following balloon dilation of the stenotic segment, the distal, reversed middle, and proximal portions were loaded over the guidewire. After proper placement of the stent, the retractor suture string, pusher, and guidewire were removed. The stent was removed during the third or fourth month of placement through endoscopic retrograde cholangiopancreatography (ERCP) in all patients.

RESULTS

No significant complications developed during the procedure or follow-up period. Ten patients required re-stenting by ERCP during the same session. The mean follow-up period was 2 years. Cholestase enzymes and bilirubin levels were within normal limits in all patients during follow-up.

CONCLUSION

Stents derived from drainage catheter facilitate treatment of biliary strictures in patients not eligible for the retrograde approach. This stent is cheap, easy to implement, can be easily removed by ERCP, and re-stenting can be applicable in retrograde if needed.

The Status of SEMS Versus Plastic Stents for Benign Biliary Strictures

PURPOSE OF REVIEW

Benign biliary strictures can be treated with plastic stents and self-expandable metal stents (SEMS). This review article delineates the latest scientific evidence for their usage.

RECENT FINDINGS

Despite evolving literature on both type of stents as treatment modalities of benign biliary strictures, which encompass mainly anastomotic strictures and strictures related to chronic pancreatitis, no final conclusions can be drawn regarding the superiority of a particular stent. SEMS tend to have higher stricture resolution rates and fewer procedural requirements which are partly offset by higher stent migration and stricture recurrence rates compared with plastic stents. Additional studies focusing on new SEMS types with anti-migration features as well as cost-effectiveness calculations are necessary for clinical decision-making when treating patients with benign biliary strictures.

Anastomotic Biliary Stricture Development after Liver Transplantation in the Setting of Retained Prophylactic Intraductal Pediatric Feeding Tube: Case and Review

The biliary anastomosis remains a common site of postoperative complications in liver transplantation (LT). Biliary complications have indeed been termed the "Achilles' heel" of LT, and while their prevention, diagnosis, and treatment have continued to evolve over the last two decades, various challenges and uncertainties persist. Here we present the case of a 33-year-old man who, 10 years after undergoing LT for idiopathic recurrent intrahepatic cholestasis, was noted to have developed pruritus and abnormalities in serum liver biochemistries during routine post-liver transplant follow-up. Abdominal ultrasound revealed a linear, 1.5 mm hyperechoic filling defect in the common bile duct; magnetic resonance cholangiopancreatography demonstrated a curvilinear filling defect at the level of the choledochocholedochostomy, corresponding to the ultrasound finding, as well as an anastomotic biliary stricture (ABS). On endoscopic retrograde cholangiography (ERC), a black tubular stricture with overlying sludge was encountered and extracted from the common bile duct, consistent with a retained 5 Fr pediatric feeding tube originally placed at the time of LT. The patient experienced symptomatic and biochemical relief and successfully underwent serial ERCs with balloon dilatation and maximal biliary stenting for ABS management. With this case, we emphasize the importance of ensuring spontaneous passage or removal of intraductal prostheses placed prophylactically at the time of LT in order to minimize the risk of chronic biliary inflammation and associated sequelae, including cholangitis and ABS formation. We also provide herein a brief review of the use of prophylactic internal transanastomotic prostheses, including biliary tubes and stents, during LT.