171 The Incidence and Endoscopic Management of Recurrent Post-Orthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management

Abstract

The Incidence and Endoscopic Management of Recurrent PostOrthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management Mehul M. Patel, Aaron B. Trimble, Isaac Galandauer, Jason Broker, Shireen A. Pais, Patricia Sheiner, Edward Lebovics Division of Gastroenterology and Hepatobiliary Diseases, Westchester Medical Center, Valhalla, NY; Division of Liver Transplant and Hepatobiliary Surgery, Westchester Medical Center, Valhalla, NY Background: Successful endoscopic management of post-OLT strictures with multiple parallel stents has been reported. Few data on the incidence and management of recurrent strictures. Methods: We conducted a retrospective study of post-OLT pts who had prior successful endoscopic therapy of a biliary stricture and developed recurrent stricture. Primary management of strictures was initially by single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to safely accommodate the duct was reached. Endoscopic success was defined by radiologic improvement, improved liver enzymes, and ability to pass a balloon 12mm across the stricture with minimal resistance. Biliary reconstruction was undertaken for endoscopic failures or progressive liver dysfunction. Pts in which recurrent strictures developed after initial successful endoscopic management were considered for retreatment. Pts currently undergoing primary endoscopic therapy who have not yet reached an endpoint were excluded. Outcomes of stent therapy were examined based on stricture location. Results: From 3/01 to 6/10, OLT was performed in 495 pts of whom 128 (26%) underwent 397 ERCPs (mean 3.1 ERCP per pt). Biliary strictures were seen in 86 (17.4%) pts of whom 69 (80%) had only anastomotic strictures (AS), 13 (15%) had both AS and non-anastomotic strictures (NAS) and 4 (5%) had only NAS. Of 62 pts with AS who reached an endpoint, 50 (80.6%) were treated successfully, 12 (19.3%) failed treatment and required surgical intervention. Of the 50 pts with successful AS treatment, 10 (20%) had recurrent strictures; 8 (80%) successfully retreated, 2 (20%) failed re-treatment. AS pts with or without recurrence did not significantly differ in the number of ERCPs until initial success, maximum number of parallel stents, or duration of initial stent therapy. Of 13 pts with both AS and NAS, 10 pts reached an end point; 6 (60%) were treated successfully, 4 (40%) failed treatment. 1 of 6 pts that were treated successfully developed a recurrent stricture, failed a second treatment, and ultimately required re-transplant. The 4 pts with NAS all failed endoscopic treatment and required surgical intervention. The mean time from primary stricture resolution to recurrence was 107 57 days. Overall 23 of 86 (26.7%) pts required biliary reconstruction. All 9 pts with intra-hepatic strictures required repeat OLT. Conclusions: 1. Successful endoscopic therapy of post-OLT AS carries a high recurrence rate of 20% requiring vigilant monitoring; 2. Repeat endoscopic therapy of recurrent AS has a similar success rate (80%) as primary therapy resulting in 20% of prior responders proceeding to surgical biliary reconstruction; 3. NAS do not respond well to endoscopic therapy.