Fully Covered Self-expanding Metal Stents In Biliary Complications After Orthotopic Liver Transplantation: A Single Center Experience

Abstract

Introduction: Anastomotic biliary stricture and bile leak are common morbidities after orthotopic liver transplantation (OLT). Anastomotic strictures can occur in up to 15% of patients, which can lead to liver failure, retransplantation, and even death. Fully covered self-expandable metal stents (FCSEMS) have become an alternative to serial plastic stenting. However, current evidence has not shown an advantage over plastic stents, and they are associated with morbidities, such as stent migration. We present our experience with FCSEMS for biliary complications after OLT. Methods: We retrospectively reviewed ERCP reports from August 2015 to May 2017. Orthotopic liver transplant patients were identified by ERCP indication. Date of first stent placement, type of stent, resolution, and follow-ups were noted. Only patients with full follow-up with no further need of stenting were included in the current analysis. Results: Forty-seven OLT patients were identified; 21 patients had a first stent placed since August 2015 and 14 had full follow-up. Ten patients had stent placement for anastomotic stricture, and 4 patients for bile leak. All 14 patients initially had a plastic stent placed. Eight had resolution at first follow-up (57%), including all 4 with bile leak. Of the remaining 6 patients with persistent anastomotic stricture at first follow-up, 4 had FCSEMS placed and 2 had plastic stents placed. With FCSEMS placement, 2 had complete resolution, 1 had improvement, and 1 required FCSEMS with resolution at second follow-up. For repeat plastic stenting, 1 had 2 plastic stents placed and had persistent but patent stricture at second follow-up. The other patient received FCSEMS with complete resolution at second follow-up. Thus, of 10 patients with anastomotic stricture requiring stenting, 50% received FCSEMS, and 83% of patients who had repeat stenting ultimately received FCSEMS. No patients with FCSEMS had stent migration at follow-up. Conclusion: Our retrospective analysis reveals that both plastic and metal stenting can be used successfully for anastomotic stricture. Plastic stent placement required repeat stenting on first follow-up 43% of the time. In these cases, use of FCSEMS achieved 80% stricture resolution rate at next follow up. Furthermore, stent migration did not occur in our cohort. These findings provide more evidence that FCSEMS can be safely and effectively used for anastomotic stricture, which may reduce the need for serial plastic stenting.Table: Table. Patients with either anastomotic stricture or bile leak after orthotopic liver transplantation requiring stenting since August 2015 who had full follow-up.