The Role of Multiple Parallel Stents in the Management of Post-Orthotopic Liver Transplantation (OLT) Biliary Anastomotic Strictures (AS)

Abstract

Background: Efficacy of multiple parallel biliary stents for post-OLT AS has not been reported. Methods: We conducted a retrospective study of ERCP post-OLT to characterize biliary strictures and outcome of endoscopic therapy. Initial management of strictures was single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed, generally after balloon dilation. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to be safely accommodated by the duct was reached. Biliary reconstruction (BR) was undertaken for endoscopic failures or progressive liver dysfunction. Results: From 3/01 to 11/06, OLT was performed in 301 patients of whom 75 (25%) underwent 194 ERCPs (mean 2.6 ERCP per patient). Bile duct cannulation at initial ERCP was successful in 72 (96%). There were no cases of post-ERCP pancreatitis or major complications. Biliary strictures were seen in 48 of 72 patients (67%), of which 21 (44%) were early (<90 days) and 27 (55%) were late. 45 patients had AS. Associated findings were intra-hepatic strictures (IHS) in 5, filling defects in 18 and bile leak in 2. 3 had only IHS. 6 AS were diagnosed after an initial normal ERCP with a mean interval from initial to diagnostic ERCP of 581 days. Initial management of AS was single stent in 41 (91%), conservative management in 1 (2%) which resolved, and direct surgery in 3 (7%): 1 re-OLT, 2 BR for high-grade eccentric strictures precluding guide wire passage. Outcome of single stent was resolution in 23 (56%), parallel stenting in 12 (29%) and surgery in 6 (15%, 4 re-OLT, 2 BR for large stones proximal to high-grade strictures). 68% of early strictures resolved with single stent versus 39% of late strictures. Parallel stents were generally 10 Fr and the mean maximum number of stents was 3.25 (range 3-5). Outcome of parallel stents was resolution in 6 (50%), currently ongoing stenting in 3 (25%) and surgery in 3 (25%; 2 re-OLT, 1 BR for persistent AS and IHS). Overall, 12/45 (27%) patients had surgery: 7 (16%) re-OLT and 5 (11%) BR. In no case was failure of multiple parallel stents the indication for surgery. All 8 patients with IHS (5 with and 3 without AS) required re-OLT. Conclusions: 1. ERCP is a safe and effective approach to diagnosis and management of post-OLT biliary AS; 2. An initial normal ERCP does not exclude a subsequent stricture development; 3. Early AS may be primarily related to edema and frequently resolve with single stent; 4. Parallel stent placement is an effective therapeutic option in patients with persistent AS; 5. Patients with IHS likely representing ischemic bile duct injury frequently require re-OLT.