Multiple Plastic Stents Research Articles

Clinical efficacy of anti-migration features in fully covered metallic stents for anastomotic biliary strictures after liver transplantation: comparison of conventional and anti-migration stents

Anastomotic biliary strictures (ABSs) are one of the most frequent adverse events that occur after orthotopic liver transplantation (OLT). Multiple plastic stents (MPS) have been validated for this indication. More recently, fully covered self-expandable metallic stents (FCSEMSs) have been used with positive outcomes, but also have a higher rate of migration, which may limit success. Our primary objective was to compare stent migration rates observed with standard FCSEMSs (Std-FCSEMSs) and so-called anti-migration FCSEMSs (Am-FCSEMSs), which are newly designed with reversed proximal side flaps. Secondary objectives were to compare rates of stricture resolution and procedure-related morbidity. We conducted a retrospective analysis of a subset of patients (FCSEMSs for post-OLT ABS) from 2 prospectively maintained databases of (1) OLT patients, and (2) ERCP and stent placement. Between January 2009 and January 2016, consecutive patients presenting with ABS after OLT referred to Cochin Hospital (Paris, France) for ERCP and receiving a FCSEMS were included. Exclusion criteria were any other cause of biliary stricture (ie, malignant stricture, ischemic origin), and biliary fistulae. One hundred twenty-five FCSEMSs (57 Am-FCSEMSs, 52 type 1 Std-FCSEMSs, and 16 type 2 Std-FCSEMSs) were used in 75 patients for ABS after OLT, with a planned stent placement period of 6 months in all patients. Patient characteristics and rates of previous endoscopic treatment or timing of ABS occurrence after OLT were not different between the groups. The rate of FCSEMS complete migration was 16% (20/125), consisting of 1.7% (1/57) for Am-FCSEMSs and 28% (19/68) for type 1 and 2 Std-FCSEMSs (P< .0001). All attempted stent removals (100% of patients) were successful. First follow-up ERCP after each FCSEMS highlighted a stricture resolution rate of 78.4% (98/125), including 93% (53/57) for Am-FCSEMSs and 66.2% (45/68) for type 1 and 2 Std-FCSEMSs (P< .001). After a median follow-up of 28 months after stent removal (range, 12-66 months), stricture recurrence was observed in 12.3% (range, 11%-17%) of patients treated with Am-FCSEMSs against 55.9% (range, 54%-56%) of those receiving Std-FCSEMSs (P< .0001). In patients with ABS after OLT, the use of Am-FCSEMSs significantly decreased the risk of stent migration, improved stricture resolution at the time of stent removal, and reduced the rate of stricture recurrence during follow-up. Endoscopic removal success and procedure-related morbidity were similar for both standard and anti-migration stents.

Single brand, fully-covered, self-expandable metal stent for the treatment of benign biliary disease: when should stents be removed?

The two most relevant endoscopic treatable benign biliary diseases (BBD) are benign biliary strictures (BBSs) and biliary leaks (BLs), often associated with high morbidity. The most common endoscopic treatment for biliary strictures involves placement of multiple plastic stents (PSs), with or without balloon dilation, followed by planned exchange of the stents. Thus, there continues to be high interest in pursuing alternative endoscopic approaches that may achieve better results with fewer interventions. In this setting, the use of a fully-covered, self-expandable metal stent (FCSEMS) is an attractive alternative to single or multiple PSs for the treatment of BBDs. A single metal stent can remain in place for a longer period of time before removal; however, the maximum time the stent can be remain in place is still not well defined. The aim of this review is to determine the removal time of the TaeWoong® FCSEMS, placed for BBD. According to our data analysis, considering the absence of loss of the covering of the FCSEMS and of any adverse events during and after stent removal, leaving the TaeWoong medical FCSEMS in situ for an 8 months' period seems to be acceptable for benign biliary diseases. Further studies need to evaluate their removability at 1 year.

Sa1294 PLASTIC BILIARY STENT PLACEMENT IS NON-INFERIOR TO METAL STENTS IN LONG-TERM MANAGEMENT OF REFRACTORY POST-LIVER TRANSPLANT ANASTOMOTIC STRICTURES

Anastomotic strictures occur in 5%-15% of deceased donor liver transplants and in up to 32% of live donor transplants. Endoscopic therapy includes balloon dilation and stenting, either via multiple plastic stents or use of self-expanding metal stents (SEMS). Recurrence rates after an initially-successful endoscopic treatment has been reported between 18-34% at one year follow-up. Very little literature is available on the long-term prognosis. Our aim was to describe the long-term success rate of plastic and SEMS in the management of post-transplant refractory anastomotic strictures. A retrospective analysis of consecutive patients undergoing endoscopic stent placement for refractory anastomotic strictures in a post-liver transplant population from 2010 to 2017 was conducted. Their age at first intervention, sex (percent male), reason for liver transplantion and number of ERCPs were collected. Patients were then separated by first SEMS indwelling time of <6 months or ≥6 months and by type of initial stent placed (SEMS vs. plastic). The mean number of ERCPs after the 1st SEMS was placed were compared in the 6 month indwelling time, and type of initial stent (SEMS vs. plastic) groups using student’s t-test. 31 patients were identified. Their mean age at intervention (first SEMS) is 53 years (range 36-74), and 74% (23) were males. The most common reasons for liver transplantation were combinations including non-alcoholic steatohepatitis n=6 (19%), alcoholic cirrhosis n=6 (19%), hepatocellular carcinoma n=6 (19%), primary biliary cholangitis n=4 (13%), primary sclerosing cholangitis n=3 (10%) and others. The mean number of total ERCPs was 6.7 ± 5.2, with a mean number of 4.3 ±3.5 ERCPs after 1st SEMS. Overall, 13 (42%) patients went straight to SEMS placement, and 18 (58.1%) had previously-placed plastic stents. Average follow up was 1283 days (range: 118-2641 days). Statistical analysis showed a trend toward no difference in the mean number of ERCPs required between patients who received SEMS versus plastic stents at their first procedure (4.1 ± 4.2 vs. 4.4 ± 3; p=0.7). There was also a trend towards no difference in the mean number of ERCP when SEMS were left in place more than 6 months versus for shorter periods of time (3.7 ± 3.1 vs 4.6 ± 3.6 ; p=0.55).Acute procedural adverse events included: pancreatitis n=4 (13%), post-ERCP abdominal pain n=3 (10%), bleeding n=2 (6.5%) and perforation n=1 (3%). Delayed procedure-related adverse events were cholangitis n=9 (29%), stricture development n=6 (19%), stenosis n=5 (16%) and stent migration n=9 (56%). Success of endoscopic stenting for refractory anastomotic strictures in post-liver transplant patients does not appear to be affected by various stenting paradigms in the long term. Specifically, SEMS are no better than plastic stents in this unique patient population.

Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness.

Background and Objectives:Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN.Methods:Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12).Results:Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter.Conclusion:The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis.

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome). We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with≥10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model. Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I 2=15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I 2=50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P=0.51). WPR for AE was 13% (9, 20%), (I 2=64%). AE were 10% more in WON as compared to PP (P=0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I 2=50%). Pooled MD for number of endoscopic sessions was -0.84 (-1.69, 0.01). LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

Endoscopic treatment of anastomotic biliary stricture after adult deceased donor liver transplantation with multiple plastic stents versus self-expandable metal stents: a systematic review and meta-analysis.

Anastomotic biliary strictures (ABSs) occur in up to 15% of patients after liver transplantation (LT). The aim of this study was to compare the efficacy and safety of self-expandable metal stents (SEMS) versus multiple plastic stents (MPS). Databases were searched through April 2017. The outcome measures were technical success, stricture resolution, recurrence and complications. We synthesized the findings descriptively and performed a meta-analysis. Three randomized controlled trials and one retrospective cohort study were identified, including 179 MPS and 119 SEMS patients. Outcome data were pooled in a meta-analysis that showed an advantage of SEMS in terms of the number of ERCP procedures (mean difference: 1.69 ERCP; 95% CI, 1-2.39; P < 0.00001) and treatment days (mean difference: 40.2 days; 95% CI, 3.9-76.4; P = 0.03), with no differences in terms of ABS resolution or recurrence. Fourteen case series reported MPS outcomes and fifteen reported SEMS outcomes, including 647 and 419 patients, respectively. Based on low-quality evidence, we cannot draw any reliable conclusions on the superiority of MPS or SEMS strategies. Even though shorter treatment times and fewer ERCP procedures support the use of SEMS, whether one technique has well-defined advantages over the other remains unclear.

Self-expanding Metal Stents (SEMS) Does Not Offer Benefit Over Multiple Plastic Stents (MPS) for Post-Liver Transplant Anastomotic Biliary Strictures: A Systematic Review and Meta-Analysis

Introduction: Liver transplant course is often complicated by anastomotic biliary strictures requiring early intervention and stent placement to preserve graft function. Multiple plastic stents (MPS) are routinely used however their comparative efficacy against self-expanding metal stents (SEMS) is not known. Our aim was to perform systematic review and meta-analysis to compare SEMS vs MPS for post-liver transplant anastomotic biliary strictures. Methods: Following electronic databases were used for literature search: Pubmed, embase, google scholar and Cochrane review. Studies comparing SEMS and MPS for post liver transplant anastomotic biliary strictures only were included. Benign biliary stricture other than post-transplant and suspicious malignant stricture causing obstruction were excluded. Pooled rates of stricture resolution, stricture recurrence and pancreatitis rates were compared for SEMS vs MPS. Outcomes were reported as pooled odds ratio (OR) with 95% confidence intervals (CI) with statistical significance (p Results: Four eligible studies were found with 146 patients undergoing SEMS placement (average follow up: 19.2 month) vs 207 undergoing MPS placement (average follow up 19.7 months). Median of 2 ERCP were required in SEMS while 4-4.5 ERCPs were required in SEMS group. Pooled rate of stricture resolution for SEMS vs MPS: 88% vs 93%, pooled OR 0.57, 95% CI 0.28-1.18, I2 51%, p 0.13. SEMS has statistically significant higher rate of stricture recurrence compared to MPS (26% vs 7.3%) with pooled OR 3.89, 95%CI 2.03-7.44, p < 0.01. There was higher rate of pancreatitis with SEMS compared to MPS (13% vs 3.3%, pooled OR 4.22, 95% CI 1.62-10.99, p < 0.01). Conclusion: This meta-analysis of available literature shows that SEMS does not offer benefit over MPS for post-liver transplant anastomotic biliary strictures.Figure: STRICTURE RESOLUTION.Figure: STRICTURE RECURRENCE.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals.

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals. Retrospective analysis of collected database of patients (n=18; age 40.94±8.43years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals. Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3±0.79 and time to resolution was 4.4±1.3weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2weeks. EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

Therapeutic effect of fully covered self-expandable metal stents on benign biliary stricture

Objective To evaluate the efficacy and safety of fully covered self-expandable metal stents (FCSEMS) implanted by endoscopic retrograde cholangiopancreatography (ERCP) for patients with benign biliary stricture (BBS). Methods The clinical data of 38 patients with BBS underwent ERCP and FCSEMS placement between January 2012 and January 2016 were retrospectively recorded. Success rate of BBS, adverse events related to ERCP and stricture recurrence were analyzed. Results A total of 38 patients underwent FCSEMS placement with a mean time of stent in dwelling for 8 months (range: 3-13months). During follow-up after the stent was removed, death of 1 patient after liver transplantation was due to unrelated cause. The mean follow-up time was 13 months (range: 2-52 months) for other patients. Stricture recurrence occurred in 6 patients, including 2 cases of gallstone-related biliary strictures, 1 case of chronic pancreatitis-related biliary strictures, 2 cases of liver transplantation-related biliary strictures, and 1 case of post surgical-related biliary strictures. Stricture resolution occurred in 31 cases with 83.8% (31/37) success rate, including 90.0% (18/20) gallstone-related biliary strictures, 75.0% (3/4) chronic pancreatitis-related biliary strictures, 80.0% (8/10) liver transplantation-related biliary strictures, and 66.7% (2/3) post surgical-related biliary strictures. The incidence of post-ERCP complications was 21.1% (8/38), including mild pancreatitis in 5 case, hyperamylasemia in 2 cases, cholangitis in 1 case. All patients were cured by conservative treatment. Conclusion FCSEMS are effective and safe for BBS. Further studies are needed to assess the indwelling time of FCSEMS, whether FCSEMS are superior to multiple plastic stents and the different efficacy of FCSEMS for BBS caused by different etiology. Key words: Cholangiopancreatography, endoscopic retrograde; Bile ducts, stenosis; Efficiency; Safety; Fully covered self-expandable metal stent

Endoscopic management of biliary strictures after living donor liver transplantation.

Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.

Sa1374 Efficacy and Safety of Lumen-Apposing Metal Stents in EUS Guided Transmural Drainage of Pancreatic Fluid Collections: Are They Better Than Multiple Plastic Stents? a Systematic Review and Meta-Analysis

Sa1374 Efficacy and Safety of Lumen-Apposing Metal Stents in EUS Guided Transmural Drainage of Pancreatic Fluid Collections: Are They Better Than Multiple Plastic Stents? a Systematic Review and Meta-Analysis

Sa1424 Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis With Multiple Plastic Stents: Results in 48 Patients

Sa1424 Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis With Multiple Plastic Stents: Results in 48 Patients

Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial

Biliary anastomotic stricture occurs in 15% to 20% of patients after deceased orthotopic liver transplantation (OLT). It is usually treated endoscopically with multiple plastic stents (MPSs), although the use of fully covered self-expandable metal stents (cSEMSs) is emerging. This study aims to compare the efficacy and safety of cSEMSs versus MPSs in these patients. A single-center, open-label, randomized clinical trial was performed. Patients were randomized to single cSEMSs for 6 months or to MPS placement, exchanged every 3 months over 1 year. The primary outcome was stricture resolution. Crossover therapy was considered for failure or recurrence. Secondary outcomes were sustained improvement, morbidity, and mortality. Between October 2009 and January 2014, 162 patients with post-OLT biliary adverse events were assessed for eligibility. Sixty-four were prospectively randomized (1:1) to cSEMSs or MPSs. Baseline characteristics were comparable. Technical success was 100%. Median follow-up was 36.4 and 32.9 months for the cSEMS and MPS groups, stricture resolution at last stent removal was achieved in 83.3% and 96.5% (P= .19), and stricture recurrence was observed in 32% and 0%, respectively (P< .01). Adverse events occurred in 23.3% and 6.4% of ERCPs in the cSEMS and MPS groups, respectively (P< .01), with 13.3% of acute pancreatitis in the cSEMS group and 2.1% in the MPS group (P< .01). cSEMSs were comparable with MPSs regarding post-OLT biliary anastomotic stricture resolution. cSEMSs allowed fewer procedures and had a positive effect on cost. Duration of treatment with cSEMSs should be further investigated. Sphincterotomy should be considered for all patients. (Clinical trial registration number: NCT 01148199.).

Application value of biliary stent in endoscopic retrograde cholangio pancreatography for treatment of benign biliary stricture after liver transplantation

Objective To explore the application value of plastic biliary stent and fully covered self-expandable metallic stent (FCSEMS) in endoscopic retrograde cholangio pancreatography (ERCP) for treatment of benign biliary stricture after liver transplantation. Methods The retrospective cross-sectional study was conducted. The clinical data of 54 patients with benign biliary stricture after liver transplantation undergoing ERCP treatment who were admitted to the First Affiliated Hospital of Xi′an Jiaotong University between January 2010 and August 2016 were collected. Among 54 patients, 44 had simple anastomotic stricture and 10 had non-anastomotic stricture. All the patients underwent stent implantation by ERCP. Patients with stricture within 1 month postoperatively initially selected single plastic stent or endoscopic nasobiliary drainage (ENBD), and then changed into multiple plastic stents at the second stent replacement. Patients with stricture after 1 month postoperatively selected multiple plastic stents, multiple plastic stents after balloon dilation or FCSEMS. Observation indicators: ERCP situations, stent implantation, time of stent indwelling, postoperative complications, stent dislocation, treatment outcome and follow-up situations. Patients were followed up by outpatient examination and telephone interview up to November 2016. Clinical symptoms of patients were observed within 1 month postoperatively and liver function and abdominal ultrasound were retested. Liver function and remission degree of biliary stricture were monitored regularly once every 3 months. Measurement data were described as average (range). Results All the patients underwent successful ERCP, of which 53 completed the process of ERCP and 1 rejected treatment due to economic problems. All the 54 patients received 140 times ERCPs with an average of 2.59 times per person, 21 times ENBDs, 11 times FCSEMSs and 108 times plastic stent implantations (including 35 times single stent implantations, 46 times double stents implantations, 23 times 3-stents implantations and 4 times 4-stents implantations). All the 54 patients were followed up for 3-143 months, with an average time of 73 months. Of 44 with anastomotic stricture, 34 received plastic stent implantation and 98 times ERCPs, with an average number of stent implantation of 2 (range, 1-4) and an average time of stent indwelling of 10.7 months (range, 9.0-13.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 4 persons every time, 7 persons every time, 10 persons every time and 3 persons every time, respectively; 26 patients were cured and 5 were improved, with an effective rate of 91.2% (31/34); 3 patients with noneffective treatment continued to undergo ERCP and 3 patients had recurrence of anastomotic stricture. Among 10 patients with initial FCSEMS implantation, 12 times ERCPs were performed, with an average time of stent indwelling of 7.6 months (range, 6.0-12.0 months); postoperative biliary infection, hyperamylasemia and stent dislocation were detected in 1 person every time, 1 person every time and 1 person every time, respectively; 8 patients were cured, with an effective rate of 8/10; of 2 patients with persistent stricture, 1 patient received contrast examination after stent removal, showing a comparative stricture in level 1 branch of intrahepatic duct and considering combined ischaemia, and then underwent the second implantation using multiple plastic stents; the other patient had elevated level of jaundice at 3 months after stents removal and received ERCP, showing anastomotic inflammatory polyp, and then underwent FCSEMS implantation again. Ten patients with non-anastomotic stricture received plastic stent implantation and 30 times ERCPs, with an average number of stent implantation of 3 (range, 2-4) and an average time of stent indwelling of 11.3 months (range, 10.0-14.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 2 persons every time, 5 persons every time, 2 persons every time and 1 person every time, respectively; 3 patients were cured and 3 were improved, with an effective rate of 6/10; of 4 patients with noneffective treatment, 2 died of gradually deteriorating liver function and 2 underwent the second liver transplantation. Conclusions Stent implantation in ERCP is safe and effective for treatment of benign biliary stricture after liver transplantation, single plastic stent should be used in the early period (within 1 month) and multiple plastic stents should be used in the later period. Although FCSEMS has a higher displacement rate, it should be recommended due to a better clinical effect, lower incidence of complications and simple operation. For patients with non-anastomotic stricture, plastic stent should be used for extrahepatic biliary stricture, with a good clinical effect, and there is worse effect in stent implantation through ERCP for multiple intrahepatic biliary strictures. Key words: Benign bile duct stricture; Liver transplantation; Plastic bile duct stent; Fully covered self-expandable metallic stent

Management of biliary anastomotic strictures after liver transplantation.

Biliary strictures constitute 40% to 60% of the biliary complications after liver transplantation. They are more common after living donor related liver transplantation (LDLT) than orthotopic liver transplantation (OLT). Balloon dilation followed by multiple plastic stent insertion leads to a mean resolution rate of 84% in the treatment of ASs after OLT. Endoscopic treatment of ASs after LDLT is more difficult because of the small size of the ASs, their multiple number and peripheral location. Balloon dilation followed by multiple plastic stent insertion had a mean resolution rate of 53%. Percutaneous transhepatic biliary drainage was required in 16% to 44% of the patients. Refractory cases with complete biliary obstruction and severe stenosis, in whom the stricture could not be traversed with a guidewire, can be treated by magnetic compression anastomosis as a rescue therapy, if the anatomy of the bile ducts is suitable. In this review, we will focus on the endoscopic treatment of ASs, with special emphasis to refractory cases.

Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial

Treatment of anastomotic biliary strictures (ABSs) after orthotopic liver transplantation by endoscopic insertion of multiple plastic stents (MPSs) is well established. The use of covered self-expandable metal stents (cSEMSs) for this indication is less investigated. In an open-label, multicenter, randomized trial, patients with confirmed ABSs were randomly assigned 1:1 to receive either an MPS or a cSEMS. The primary endpoint was the number of endoscopic interventions until ABS resolution. Secondary endpoints were frequency of adverse events, treatment success rates, and time to treatment success and recurrence of ABS during follow-up of at least 1 year. Fifty-eight patients were included between 2012 and 2015, and 48 patients completed follow-up. Patients receiving MPS (n= 24) underwent a median of 4 (range, 3-12) endoscopic retrograde cholangiography examinations, whereas those in the cSEMS group (n= 24) underwent a median of 2 (range, 2-12) sessions until ABS resolution (P< .001). A median of 8 (range, 2-32) stents was used until ABS resolution within the MPS group and 1 (range, 1-24) in the cSEMS group (P< .0001). cSEMS migration occurred in 8 (33.3%) patients. Treatment duration did not differ significantly. Initial treatment success rates were high with 23 (95.8%) in the MPS group and 24 (100%) for cSEMSs (P= 1). Five (20.8%) patients in both groups showed stricture recurrence after a median follow-up of 500 days (range, 48-1317 days). cSEMSs for treatment of ABSs needed less endoscopic interventions to achieve similar efficacy as MPS and might become a new treatment standard. However, the optimal duration of cSEMS therapy and cost-efficacy have to be evaluated. (Clinical trial registration number: NCT01393067.).

OC.11.4: Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis with Multiple Plastic Stents: Results in 48 Patients

OC.11.4: Endoscopic Dilation of Pancreatic Duct Strictures in Chronic Pancreatitis with Multiple Plastic Stents: Results in 48 Patients

Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a “step - up” approach: A single centre experience

BackgroundWalled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of “step-up” endoscopic transmural approach for treatment of WON. MethodsRetrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided “step up” transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. ResultsPatients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). Conclusions“Step up” endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.

Comparative Study between Plastic and Metallic Stents for Biliary Decompression in Patients with Distal Biliary Obstruction.

This paper presents a retrospective comparison of plastic versus metallic stents in the drainage of malignant distal biliary obstructions. We compared single plastic stents (SPS), multiple plastic stents (MPS), and metallic stents (SEMS) regarding clinical decrease of TB < 2.0 mg/dL, long-term patency, and adverse event. 58 patients (38 women) with MDBO were included. Diagnoses were 44 pancreatic adenocarcinoma (74.6%), 9 metastasis (15.5%), 3 pancreatic neuroendocrine tumors (5.1%), and 2 adenocarcinoma in the major papilla (3.4%). The number of patients included in the SPS, MPS, and SEMS was 17, 6, and 35, respectively. Comparing the survival curves with respect to obstruction, we observed a lower mean permeability of the SPS compared to that of the MPS with p < 0.003 and of the SEMS group (p < 0.01). There was no statistical difference between the use of MPS, despite the small number of patients compared to the use of SEMS (p < 0.13) to reach the satisfactory levels of bilirubin.

Case series on endoscopic simultaneous multiple plastic stent dilatation of strictures following iatrogenic bile duct injury

Case series on endoscopic simultaneous multiple plastic stent dilatation of strictures following iatrogenic bile duct injury