S3374 Plastic vs Metal Stents for Anastomotic Biliary Strictures After Orthotopic Liver Transplant (OLT)

Abstract

Introduction: Biliary anastomotic stricture is the most common complication of orthotopic liver transplantation (OLT) occurring in about 20% of cases. Endoscopic stent placement across the stricture with plastic or metal stents is the first-line treatment strategy. The aim of this study is to investigate the difference between plastic and metal stents in terms of anastomotic biliary stricture resolution and adverse events. Methods: This is a retrospective study of post OLT patients who underwent ERCP over a 3-year period between 2018-2020. Out of 178 post OLT patients who underwent ERCP, 108 were excluded because of only one ERCP performed and repeat ERCP was not indicated or because ERCP was performed for indications other than anastomotic biliary strictures. Data was collected up to 3 consecutive ERCP procedures during the studied period. Results: A total of 70 patients with anastomotic biliary strictures were included in the study. ERCP was performed on a native papilla in 32 (45.7%), advanced cannulation techniques were performed in 5 (7.1%), and prophylactic pancreatic stents were placed in 6 (8.6%) cases. Plastic stents (PS) were used in 53 (75.7%) of which multiple plastic stents were used in 27 cases, whereas 17 (24.3%) cases were treated with fully covered self-expanding metal stents (FCSEMS). Average follow up duration was 2.2 (1-3) months for PS and 3.7 (2-5) months for FCSEMS (P < 0.01). Biliary strictures resolved in 21 (30.0%) patients on repeat ERCP most of which from the FCSEMS group (58.8% vs 20.8%) (P = 0.009). Plastic stents were exchanged to FCSEMS in 11 (20.8%) patients during the second ERCP follow-up. On the third ERCP during the studied period, biliary strictures resolved in 71.4% of the FCSEMS group vs 33.3% of the PS group (P = 0.03). Using multiple plastic stents instead of a single plastic stent didn’t seem to improve biliary stricture resolution rate. Two patients (2.4%) developed post-ERCP pancreatitis, both patients had a native papilla and underwent FCSEMS placement with sphincterotomy and without pancreatic duct manipulation (P = 0.06). There was no difference between the stents used in terms of post-procedural cholangitis or stent migration rates. Conclusion: FCSEMS outperformed PS with respect to the anastomotic biliary stricture resolution rate over 3 endo-therapy sessions. Post-ERCP pancreatitis, although uncommon, occurred exclusively in the FCSEMS group.