A Systematic Review on Efficacy and Safety of Partially and Fully Covered Self-Expandable Metal Stent (SEMS) Compared to Multiple Plastic Stents (MPS) in the Endoscopic Management of Anastomotic Biliary Stricture Post Orthotopic Liver Transplantation (OLT)

Abstract

Purpose: Anastomotic biliary strictures (AS) account for up to 80% of biliary strictures post OLT. Several case series have reported stricture resolution rates in the range of 60-90% with balloon dilatation and multiple plastic stents (MPS). This strategy requires multiple ERCPs with associated risks, cost and patient burden. More recently, partially and fully covered SEMSs have been increasingly utilized in this setting, given their larger diameter and easy removability. It is not clear whether there are clear advantages of using SEMS over MPS in all cases. Methods: A systematic review on SEMS and MPS placement for AS was performed after searching Medline and Embase databases using the search terms anastomotic/biliary/bile duct stricture, endoscopy and ERCP. Inclusion criteria were 1) anastomotic stricture post OLT, 2) MPS or partially or fully covered SEMS. Exclusion criteria were 1) non anastomotic stricture, 2) living donor liver transplant, 3) single plastic stent, 4) uncovered SEMS, 5) studies including <5 patients. Data on clinical success and complications were extracted and summarized. Results: From a total of 791 studies, 8 studies (N=441) utilizing MPS and 9 studies (N=199) utilizing SEMS fulfilled the inclusion and exclusion criteria (table 1 and table 2) and were included in this review. For the 8 MPS studies, the stricture resolution rates were higher when MPS duration was >6 months (88-100%) compared to those with <6 months (65-87%). The mean or median number of ERCPs per patient in MPS ranged between 3-4.2 and 2.5-3.5 when stenting duration was >6 months and <6 months, respectively. Five of the 8 SEMS studies involved previous plastic stenting plus balloon dilation. The stricture resolution rates were higher when SEMS duration was >3 months (80-95%) compared to those with <3 months (53-88%), but did not seem to differ whether there was previous plastic stenting plus balloon dilation or not (53-92% vs 67-95%). The mean or median number of ERCP per patient in SEMS ranged between 2.1-7.4 (3.4-7.4 in those with previous plastic stenting plus balloon dilation vs 2.1-3 in those without). Although the overall complication rates were low, SEMS migration rates were significant at 4-47%.Table: [160] Table 1. Results of studies utilizing multiple plastic stents + dilation in endoscopic management of AS post OLTTable: [160] Table 2. Results of studies utilizing partially or fully covered SEMS in endoscopic management of ASConclusion: Although SEMS appeared to be a promising option in the endoscopic management of AS post OLT, current evidence does not support its routine use.