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Background
Anastomotic biliary strictures (AS) after orthotopic liver transplantation (OLT) belong to the most common biliary complications and cause the biggest morbidity burden after OLT. Metal stents for benign biliary strictures are gaining acceptance with many published series. Traditional metal stent designs seem to have poor durability in AS...
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Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly performed minimally invasive procedures for the diagnosis and treatment of biliary and pancreatic diseases. Hepatic hematoma secondary to ERCP is a rare and potentially serious complication with few cases described in the literature. Objective: The objec...
Background
Post-transplant anastomotic biliary strictures remain refractory to endoscopic therapy in a considerable number of cases. The aim of this meta-analysis was to compare fully-covered self-expandable metal and plastic stents in the management of post-transplant biliary strictures.
Methods
A meta-analysis was performed using a random effect...
Citations
... However, the unique intraductal fully covered SEMS (FCSEMS) with an antimigration waist named Kaffes stent (Niti-S Kaffes, Taewoong Medical, Gyeonggi-do, South Korea) was already in use at our centre, with good anecdotal outcomes and other groups reporting excellent PTAS resolution and reduced risk of stent migration [18][19][20]. Routinely, this stent was replaced at 3 monthly intervals at our centre prior to COVID-19, similarly to the plastic stenting protocol. ...
BACKGROUND
Endoscopic management is the first-line therapy for post-liver-transplant anastomotic strictures. Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months, data on safety and duration for metal stents in this setting is scarce. Due to limited access to endoscopic retrograde cholangiopancreatography (ERCP) during the coronavirus disease 2019 pandemic in our centre, there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy. This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.
AIM
To compare the safety and efficacy profile of different stenting durations using Kaffes stents.
METHODS
Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query. Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records. The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months. Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for ≤ 120 d or > 120 d.
RESULTS
During the study period, a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course. In 33 ERCPs, the stent was removed or exchanged on a 3-month interval. No pancreatitis, perforations or deaths occurred. Minor post-ERCP complications were similar between the 3-month (abdominal pain and intraductal migration) and 6-month (abdominal pain, septic shower and embedded stent) groups - 6.1% vs 9.1% respectively, P = 0.40. All strictures resolved at the end of the stenting course, but the stenting course was variable from 3 to 22 months. The recurrence rate for stenting courses lasting for up to 120 d was 71.4% and 21.4% for stenting courses of 121 d or over (P = 0.03). There were 28 patients that were treated with a single ERCP with Kaffes, 21 with removal after 120 d and 7 within 120 d. There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course (71.0% vs 10.0%, P = 0.01).
CONCLUSION
Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.
... During the last decade, a new type of SEMS has been developed to overcome the increased migration rates of SEMS and MPS, and to prevent the incomplete resolution of posttransplant strictures [9,10]. Intraductal (ID)-SEMS are fullycovered stents with shorter length and a central waist, offering a theoretical anti-migration mechanism by anchoring into the bile duct, and bearing a long string deployed in the duodenum that allows stent retrieval [9]. ...
... During the last decade, a new type of SEMS has been developed to overcome the increased migration rates of SEMS and MPS, and to prevent the incomplete resolution of posttransplant strictures [9,10]. Intraductal (ID)-SEMS are fullycovered stents with shorter length and a central waist, offering a theoretical anti-migration mechanism by anchoring into the bile duct, and bearing a long string deployed in the duodenum that allows stent retrieval [9]. Although a few meta-analyses evaluated the efficacy of SEMS and MPS in post-LT biliary strictures, none of them compared the potential differences in the results between these stents and ID-SEMS [7,[11][12][13]. ...
... Disease duration was typically less than 1 year in most patients evaluated. This is consistent with the data that demonstrates that most post-transplant anastomotic strictures present within the first year after transplantation [22]. ...
... However, it has been demonstrated previously that rates of stricture resolution are higher in patients' post-liver transplant compared to those with chronic pancreatitis [5,6,16,31,32]. In patients with anastomotic strictures post orthotopic liver transplants, the use of fully covered SEMS has been shown to have stricture resolution rates as high as 100%, with low rates of complications (6.5%) [22]. Success in patients with chronic pancreatitis is typically much lower. ...
... This is concordant with that shown in the literature of 16-40% rates of stent migration [8,14,28,30,33]. Many companies have attempted to mitigate this risk with the use of a variety of techniques including anti-migration flares [14,22,28]. Despite these advances, the rate of migration remains significantly higher than plastic stents of 0-8.6%. ...
Background
Benign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures.
Methods
This was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016–2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval.
Results
A total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64).
Conclusions
This study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180–365 days.
... The majority of strictures are nowadays treated with endoscopic retrograde cholangiopancreatography (ERCP), which involves dilation and stenting at the level of the stricture, as opposed to the initial years following the introduction of liver transplantation, when roughly 70% of patients who experienced biliary complications returned to the operating room for therapeutic management [2,[46][47][48]. Repeated sessions of dilations and biliary stenting are usually required to achieve an effective therapeutic response. ...
... This objective is achieved by increasing the number or diameter of the biliary prostheses used (plastic stents) successively at each session. This therapeutic plan lasts approximately one year [46][47][48][49]. The number of endoscopic dilation sessions also depends on the type of stenosis. ...
The last decades have brought impressive advances in liver transplantation. As a result, 21 there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, 22 immunosuppressive therapies and radiologically guided treatments have led to an improvement in 23 the prognosis of these patients. However, the risk of complications remains significant, the manage-24 ment of liver transplant patients requiring multidisciplinary teams. The most frequent and severe 25 complications are biliary and vascular complications. Compared to vascular complications, biliary 26 complications have higher incidence rates, but a better prognosis. The early diagnosis and selection 27 of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. 28 The development of minimally invasive techniques allows avoiding surgical reinterventions with 29 their associated risks. Liver retransplantation remains the last therapeutic solution for graft dys-30 function, one of the main problems in this case being the low number of donors. 31
... Compared to PSs, SEMSs prolong the duration of bile duct patency and reduce the need for reintervention. Additionally, ABS treatment success rates with metallic stents range from 75% to 100%, [17][18][19] and the recurrence rates are low (15%-24%). 17,18 In this study, we aimed to evaluate the long-term efficacy and safety of non-flared, fully covered, selfexpandable metallic stents (FCSEMSs) for the treatment of ABSs after LDLT that are not resolved with conventional endoscopic treatments using plastic stents and balloon dilatation. ...
... Additionally, ABS treatment success rates with metallic stents range from 75% to 100%, [17][18][19] and the recurrence rates are low (15%-24%). 17,18 In this study, we aimed to evaluate the long-term efficacy and safety of non-flared, fully covered, selfexpandable metallic stents (FCSEMSs) for the treatment of ABSs after LDLT that are not resolved with conventional endoscopic treatments using plastic stents and balloon dilatation. ...
... 23,24 To address these problems, the temporary placement of FCSEMSs for ABSs after LDLT has increased recently. 18,25,26 Some reports suggest that FCSEMSs have better stricture resolution and recurrence rates than PSs, 19,27,28 as large-diameter FCSEMSs can induce stricture resolution in a single session. The FCSEMS patency period is longer than that of PSs and is more cost-effective because of the reduced number of ERCP procedures required. ...
Objectives:
Anastomotic biliary strictures (ABSs) are common complications following living donor liver transplantation (LDLT). We evaluated the feasibility of a novel removable, intraductal, fully covered, self-expandable metallic stent (FCSEMS) for the treatment of ABSs following LDLT.
Methods:
Nine patients with duct-to-duct ABSs that developed following LDLT were prospectively enrolled in this study. We placed a short FCSEMS with a long lasso and middle waist formation in each patient's ABS above the papilla and removed it 16 weeks later.
Results:
The FCSEMS placements were successful in all nine cases. Four patients experienced mild cholangitis, which was resolved with conservative treatment. Additionally, there was one case of distal migration. The FCSEMSs were successfully removed from all the patients, and the clinical success rate was 100%. Stricture recurrence occurred in one (11.1%) patient during the follow-up period.
Limitations:
The small number and lack of comparison with other types of FCSEMSs and plastic stents.
Conclusions:
Intraductal placement of FCSEMSs is useful for treating refractory ABSs after LDLT, although further studies are required with larger sample sizes.
... To reduce the risk of FCSEMS migration, an FCSEMS with an antimigration waist can be used that can be fully released intraductally due to the presence of a long wire that reaches the duodenum and allows easy subsequent removal. This stent has demonstrated a migration rate reduced to 0-3% (146,147). FCSEMS with antimigration fins have also been developed and have shown promising results (145). ...
Nowadays, stenting malignant biliary stenosis (extrahepatic or hilar), benign biliary stenosis, and pancreatic duct stenosis in chronic pancreatitis as well as stenting for prophylaxis of post- endoscopic retrograde cholangiopancreatography pancreatitis and for failed extraction of biliary stones or endoscopic papillectomy are the many common challenges for a bilio-pancreatic endoscopist. The purpose of this review is to provide a practical approach to bilio-pancreatic stenting indications and techniques. Having a thorough understanding of stenting indications and techniques, for a bilio-pancreatic endoscopist means being able to develop a tailored approach for each clinical scenario depending on the type of stent used. Biliary stents, in fact, vary in diameter, length, and composition, making it possible to give each patient personalized treatment.
... They are shorter in length with a tapered anti-migration waist and removal wires that are subsequently deployed into the duodenum, potentially reducing the risk of stent migration compared to FCSEMS. 13 In small case series, they have been shown to be effective in treating post-LT AS. 12,13 They may confer a lower risk of post-ERCP pancreatitis in comparison to FCSEMS in benign biliary strictures. 12,14 We report on the experience with IDSEMS across the UK in the management of AS. 15 All patients undergoing deployment of IDSEMS in a transplant setting between December 2016 and January 2021 were included. ...
... They are shorter in length with a tapered anti-migration waist and removal wires that are subsequently deployed into the duodenum, potentially reducing the risk of stent migration compared to FCSEMS. 13 In small case series, they have been shown to be effective in treating post-LT AS. 12,13 They may confer a lower risk of post-ERCP pancreatitis in comparison to FCSEMS in benign biliary strictures. 12,14 We report on the experience with IDSEMS across the UK in the management of AS. 15 All patients undergoing deployment of IDSEMS in a transplant setting between December 2016 and January 2021 were included. ...
... In keeping with previous studies using IDSEMS, our study showed there was high stricture resolution after index stenting. 12,13 Similar to FCSEMS, IDSEMS may have a role when stricture resolution has not been achieved after plastic stenting. 21 Although 35% of our cohort were stent experienced, in those that were stent naive, 80% had resolution of the AS at endoscopic re-evaluation. ...
Background
Fully covered intraductal self-expanding metal stents (IDSEMS) have been well described in the management of post-liver transplant (LT) anastomotic strictures (ASs). Their antimigration waists and intraductal nature make them suited for deployment across the biliary anastomosis.
Objectives
We conducted a multicentre study to analyse their use and efficacy in the management of AS.
Design
This was a retrospective, multicentre observational study across nine tertiary centres in the United Kingdom.
Methods
Consecutive patients who underwent endoscopic retrograde cholangiopancreatography with IDSEMS insertion were analysed retrospectively. Recorded variables included patient demographics, procedural characteristics, response to therapy and follow-up data.
Results
In all, 162 patients (100 males, 62%) underwent 176 episodes of IDSEMS insertion for AS. Aetiology of liver disease in this cohort included hepatocellular carcinoma ( n = 35, 22%), followed by alcohol-related liver disease ( n = 29, 18%), non-alcoholic steatohepatitis ( n = 20, 12%), primary biliary cholangitis ( n = 15, 9%), acute liver failure ( n = 13, 8%), viral hepatitis ( n = 13, 8%) and autoimmune hepatitis ( n = 12, 7%). Early AS occurred in 25 (15%) cases, delayed in 32 (20%) cases and late in 95 (59%) cases. Age at transplant was 54 years (range, 12–74), and stent duration was 15 weeks (range, 3 days–78 weeks). In total, 131 (81%) had complete resolution of stricture at endoscopic re-evaluation. Stricture recurrence was observed in 13 (10%) cases, with a median of 19 weeks (range, 4–88 weeks) after stent removal. At removal, there were 21 (12%) adverse events, 5 (3%) episodes of cholangitis and 2 (1%) of pancreatitis. In 11 (6%) cases, the removal wires unravelled, and 3 (2%) stents migrated. All were removed endoscopically.
Conclusion
IDSEMS appears to be safe and highly efficacious in the management of post-LT AS, with low rates of AS recurrence.
... An FC-SEMS consists of an implantable metal stent and a flexible introducer system (Niti-S biliary stent, Taewoong Medical Co Ltd., South Korea). This stent has a central antimigration waist and a 10-cm radiopaque nylon string incorporated into the distal end of the stent to facilitate endoscopic retrieval [31]. The length of the stent was determined according to the length of the biliary stricture. ...
... In this study, we used intraductal FC-SEMSs designed for BBS with characteristics such as an antimigration waist, a short stent length, and a long removal string. This appears to be a suitable stent, especially for strictures of the upper CBD or common hepatic duct, and they had a low rate of migration in cases of ASs after OLT [17,31]. Many studies have compared the outcomes of endoscopic treatment using a FC-SEMS and a PS; however, few studies have compared the usefulness of PTBD [29]. ...
Background
Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD).Methods
Patients with biliary ASs after an LDLT (mean age: 57.3 years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3–4 months. Patients were followed-up for at least 1-year post-stent removal.ResultsOf the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2 months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4 months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59).ConclusionsEBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.
... The incidence of BBS is about 1% for open cholecystectomy, 0.23-0.42% for laparoscopic cholecystectomy, 3-46% for CP, 5-15% for deceased LT, and 28-32% for living-donor transplantation [8][9][10][11][12]. BBS may lead to elevation of serum bilirubin, impairment of liver function, and bacterial growth in the biliary tree. ...
Introduction:
Biodegradable biliary stents (BDBSs), fully covered self-expanded metal stents (FCSEMSs) and multiple plastic stents (MPSs) were common stents in endoscopic treatment of benign biliary stricture (BBS).
Aim:
To evaluate the effectiveness of these 3 stents in BBS management.
Material and methods:
The PubMed, Web of Science, Cochrane Library, and Wiley Library databases were searched for studies that provided data about BBS and stent therapy.
Results:
We found that BDBSs were associated with the highest clinical success rate (0.76, 95% CI: 0.71-0.80), followed by MPSs (0.69, 95% CI: 0.63-0.74), and FCSEMSs (0.67, 95% CI: 0.63-0.71). BDBSs also had a relatively high probability of technical success, at 1.00 (95% CI: 1.00-1.00), superior to MPSs (0.95, 95% CI: 0.88-0.99) and FCSEMSs (0.90, 95% CI: 0.85-0.94). The treatment success rate for BDBSs (1.00, 95% CI: 1.00-1.00) was also higher than for MPSs (0.88, 95% CI: 0.72-0.98) and FCSMESs (0.82, 95% CI: 0.76-0.87). However, BDBSs had the highest stricture recurrence rate (0.21, 95% CI: 0.16-0.26), compared with FCSEMSs (0.11, 95% CI: 0.08-0.15) and MPSs (0.07, 95% CI: 0.03-0.13).
Conclusions:
Patients with BBS are likely to receive a satisfied outcome when treated with BDBSs.
... [19,20] The recently developed covered metallic stents may be better for maintaining mid-to long-term patency, and, in addition, they are easier to remove. [21][22][23][24][25] However, in contrast to uncovered devices, covered metallic stents do not integrate into the surrounding tissue and this may in turn be associated with higher migration rates away from their original insertion location. Previous studies of covered stent placement for benign biliary strictures have reported an incidence of stent migration ranging from 2.8% to 25%. ...
... Previous studies of covered stent placement for benign biliary strictures have reported an incidence of stent migration ranging from 2.8% to 25%. [21][22][23][24][25] Biodegradable stents are increasingly being used in the heart and other areas to provide adequate support for stenosis. As these stents degrade completely, the complications associated with stenting are reduced. ...
Percutaneous balloon dilatation for benign biliary-enteric anastomosis stricture has been the most widely used alternative to endoscopic treatment. However, patency results from the precedent literature are inconsistent.
The objective of this study was to evaluate the safety and feasibility of repeated balloon dilatation with long-term biliary drainage for the treatment of benign biliary-enteric anastomosis strictures.
Data from patients with benign biliary-enteric anastomosis strictures who underwent percutaneous transhepatic cholangiography (PTC), repeated balloon dilatation with long-term biliary drainage (repeated-dilatation group; n = 23), or PTC and single balloon dilatation with long-term biliary drainage (single-dilatation group; n = 26) were reviewed. Postoperative complications, jaundice remission, and sustained anastomosis patency were compared between the groups.
All procedures were successful. No severe intraoperative complications, such as biliary bleeding and perforation, were observed. The jaundice remission rate in the first week was similar in the 2 groups. During the 26-month follow-up period, 3 patients in the repeated-dilatation group had recurrences (mean time to recurrence: 22.84 ± 0.67 months, range: 18–26 months). In the single-dilatation group, 15 patients had recurrences (mean time to recurrence = 15.28 ± 1.63 months, range: 3–18 months). The duration of patency after dilatation was significantly better in the repeated-dilatation group (P = .01). All patients with recurrence underwent repeat PTC followed by balloon dilatation and biliary drainage.
Repeated balloon dilatation and biliary drainage is an effective, minimally invasive, and safe procedure for treating benign biliary-enteric anastomosis strictures, and provides significantly higher patency rates than single dilatation.
