Efficacy of Endoscopic Stenting On Biliary Strictures After Orthotopic Liver Transplantation: A Prospective Study

Abstract

Background: Biliary tract complications represent the major drawback of orthotopic liver transplantation (OLT), ranging from 15 to 35%, and are associated with relevant morbidity and mortality. Several treatment options are available, but a standard approach has not yet been established. Aim: of this study was to prospectively compare the efficacy of a single stent vs multiple simultaneous stents for endoscopic treatment of biliary strictures after OLT. Material and methods. From January 2004 to January 2007, 198 patients underwent OLT at our centre. Out of them, 30% experienced biliary complications; thirty patients were referred for a therapeutic ERCP. We recorded 24 biliary strictures, 15 out of them associated with biliary stones, and 6 biliary leakages, 2 of these associated with stenosis. Biliary complications occurred from 10 days to 24 months after transplantation (median 2 months). Each patient underwent diagnostic MRCP to detect the type and site of lesions. Exclusion criteria were graft rejection (liver biopsy), pre-transplant liver illness recurrence, bile duct ischemia (Doppler US + CT). Twenty-six patients (20 males, 6 females, mean age 55.3 years, range 28-67) with anastomotic strictures entered the study protocol. After a basal ERCP with balloon dilatation and single plastic stent placement, all patients were randomly assigned to one of two groups and prospectively followed up. Fourteen patients (group A) underwent ERCP with balloon dilatation and double stent placement. Twelve patients (group B) were treated with a placement of a single biliary stent. After basal ERCP, each patient underwent single or double stent exchanges at 2-3 months interval over a period of 12 months. Mean follow up period was 24 months. Factors assessed pre and post ERCP included symptoms and biochemical tests of liver function. Results: We performed totally 130 therapeutic ERCP. In group A, all 14 patients had 2 stents placed simultaneously for a total of 4 exchanges. In Group B, a total of 60 single stent placement/exchanges (mean 5 per patient) were performed. At the end of treatment period, normalization of biochemical tests of liver function was observed for all patients in Group A (100%), whereas Group B patients showed lower success rates (40%) (p = 0.013). Conclusions: Multiple simultaneous stenting proved to be superior to single stent placement for the treatment of post-OLT anastomotic strictures and may obviate surgical procedures.