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Rocha Fernandes Y, Visconti TADC, Dall'Agnol MK, Ardengh AO, Veras MDO, Valentim ESDS, Lera dos Santos ME, Matuguma SE, Bernardo WM, de Moura EGH. Covered Self-Expanding Metal Stents Versus Multiple Plastic Stents in Treating Biliary Strictures Post-Orthotopic Liver Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. DEN OPEN 2026; 6:e70143. [PMID: 40416587 PMCID: PMC12101909 DOI: 10.1002/deo2.70143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2025] [Revised: 04/24/2025] [Accepted: 04/30/2025] [Indexed: 05/27/2025]
Abstract
Objectives Anastomotic biliary strictures are a common complication following orthotopic liver transplantation (post-OLT), impacting morbidity and graft survival. This meta-analysis evaluates the efficacy, safety, and cost-effectiveness of covered self-expanding metal stents (cSEMS) versus multiple plastic stents (MPS) for treating post-OLT strictures. Methods A systematic review was conducted in PubMed, Cochrane Central, Embase, Scholar, and SciELO. We analyzed randomized controlled trials (RCTs) comparing cSEMS and MPS in post-OLT biliary strictures. Outcomes included stricture resolution, recurrence, endoscopic retrograde cholangiopancreatography sessions, adverse events, and cost. Standardized mean differences (SMDs) and risk ratios (RRs) were calculated with 95% confidence intervals (CIs). Cost-effectiveness analysis covered direct and indirect expenses. Results Five RCTs with 269 patients were analyzed. No significant differences were found between cSEMS and MPS in terms of stricture resolution (RR = 1.01; 95% CI [0.90, 1.13]; p = 0.91), recurrence rates (RR = 2.23; 95% CI [0.74, 6.75]; p = 0.15), adverse events (RR = 0.80; 95% CI [0.41, 1.54]; p = 0.50), stent migration (RR = 1.55; 95% CI [0.69, 3.50]; p = 0.29), number of endoscopic retrograde cholangiopancreatography sessions (SMD = -2.18; 95% CI [-5.28, 0.91]; p = 0.12), number of stents (SMD = -2.33; 95% CI [-22.26, 17.59]; p = 0.38), treatment time (SMD = -1.60; 95% CI [-4.24, 1.05]; p = 0.15), and cost ($10,344 vs. $18,003; p = 0.19). Conclusion cSEMS and MPS demonstrate similar efficacy and safety for post-OLT biliary strictures. Both strategies are viable, with selection based on cost, anatomy, and institutional resources.
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Affiliation(s)
- Ygor Rocha Fernandes
- Department of GastroenterologyHospital das ClínicasUniversity of São Paulo Medical School (HCFMUSP)Sao PauloBrazil
| | | | - Marcelo Klotz Dall'Agnol
- Department of GastroenterologyHospital das ClínicasUniversity of São Paulo Medical School (HCFMUSP)Sao PauloBrazil
| | - André Orsini Ardengh
- Department of GastroenterologyHospital das ClínicasUniversity of São Paulo Medical School (HCFMUSP)Sao PauloBrazil
| | - Matheus de Oliveira Veras
- Department of GastroenterologyHospital das ClínicasUniversity of São Paulo Medical School (HCFMUSP)Sao PauloBrazil
| | | | | | - Sergio Eiji Matuguma
- Department of GastroenterologyHospital das ClínicasUniversity of São Paulo Medical School (HCFMUSP)Sao PauloBrazil
| | - Wanderley Marques Bernardo
- Faculty of MedicineUniversity of São PauloSao PauloBrazil
- Medical Guidelines Program, Brazilian Medical AssociationSao PauloBrazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy UnitClinical Hospital of Faculty of Medicine of the University of São PauloSao PauloBrazil
- Graduate Program in GastroenterologyFaculty of Medicine of the University of São PauloSao PauloBrazil
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Ferrante N, Bhamidimarri KR, Amin S. Endohepatology: Applications in Liver Transplant. Clin Liver Dis 2025; 29:253-271. [PMID: 40287270 DOI: 10.1016/j.cld.2024.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2025]
Abstract
The term "endohepatology" was coined over the last 15 years to describe the integration of interventional endoscopy and hepatology for the management of patients with chronic liver disease. In this article, we will review the diagnostic and therapeutic applications of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among liver transplantation candidates and recipients.
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Affiliation(s)
- Nicole Ferrante
- Division of Digestive Health and Liver Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
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Ünal E, Esen Ü, Uysal A, Çiftçi TT, Akinci D, Parlak E. Combined endoscopic-percutaneous approach for magnetic compression anastomosis in post-transplant anastomotic biliary strictures. Eur Radiol 2025:10.1007/s00330-025-11634-w. [PMID: 40287869 DOI: 10.1007/s00330-025-11634-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 03/09/2025] [Accepted: 04/01/2025] [Indexed: 04/29/2025]
Abstract
OBJECTIVES To investigate long-term outcomes of combined endoscopic-percutaneous methods for endoscopically unmanageable anastomotic biliary strictures in living donor liver recipients. MATERIALS AND METHODS This retrospective single-center study included 144 patients referred for biliary stricture between November 2017 and May 2023. Eighty-eight patients (leak = 8, non-anastomotic stricture = 3, treatment refused = 12, successful ERCP = 65) were excluded. Patients initially underwent percutaneous biliary drainage. Patients for whom percutaneous intervention was successful in traversing stricture were followed up with fully-covered self-expandable metallic stents and/or plastic catheter stents. However, in case of failure, magnetic compression anastomosis (MCA) was performed. RESULTS A total of 56 patients (mean age, 59 years ±11; 35 men) comprised the study group. Percutaneous intervention was successful in traversing the stricture in 26/56 patients. Among the remaining 30 patients, 26 were eligible for MCA, which was performed successfully in 24 patients (92%). The mean duration from magnet placement to internalization was 7.71 ± 2.77 days (95% CI: 6.54-8.88). Altogether, in 47 patients (24 of whom underwent MCA), percutaneous drains were removed following biliary stenting. The mean follow-up was 1082.5 ± 668.2 days (95% CI: 907.49-1257.51). In 19 patients (40%), recurrent stricture was evident at ERCP during a median follow-up of 90 (IQR: 60-210) days following stent removal. The recurrent stricture rate following MCA (n = 6/24) was significantly lower compared to patients in whom MCA was not performed (n = 13/23; p = 0.026). Overall, stent type had no significant effect on patency (p = 0.189). CONCLUSION Percutaneous biliary procedures are essential for endoscopically unmanageable post-transplant anastomotic biliary strictures. MCA seems to provide higher patency rates even in patients with total biliary occlusion. KEY POINTS Question What steps can be taken when endoscopy fails in the treatment of post-transplant anastomotic biliary strictures? Findings Percutaneous biliary access and magnetic compression anastomosis can be applied to increase graft survival in the setting of endoscopically unmanageable post-transplant biliary strictures. Clinical relevance Impassable biliary obstructions are unfortunate complications and not uncommon in liver transplant recipients. Magnetic compression anastomosis is an alternative minimally invasive method of treatment for complete biliary occlusions.
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Affiliation(s)
- Emre Ünal
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey.
| | - Ümran Esen
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey
| | - Aycan Uysal
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey
| | - Türkmen Turan Çiftçi
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey
| | - Devrim Akinci
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, 06100, Turkey
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Barakat M, Saumoy M, Forbes N, Elmunzer BJ. Complications of Endoscopic Retrograde Cholangiopancreatography. Gastroenterology 2025:S0016-5085(25)00527-X. [PMID: 40120770 DOI: 10.1053/j.gastro.2025.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 03/13/2025] [Accepted: 03/15/2025] [Indexed: 03/25/2025]
Abstract
Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.
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Affiliation(s)
- Monique Barakat
- Divisions of Pediatric and Adult Gastroenterology & Hepatology, Departments of Pediatrics and Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Health, Princeton, New Jersey
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
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Baraldo S, Meine GC, Santo PAE, Barbosa EC, Nau AL, Keane MG, Chavan R, Kuo YT, Ligresti D. Fully covered self-expandable metal stents versus multiple plastic stents for the treatment of post-orthotopic liver transplant anastomotic biliary strictures: An updated systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2025; 39:721-729. [PMID: 39702566 DOI: 10.1007/s00464-024-11467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Accepted: 12/01/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND AND AIMS The most common adverse event (AE) of orthotopic liver transplantation (OLT) is anastomotic biliary stricture (ABS). Management varies widely between centers, and it is not clear whether a combination of endoscopic dilation of the stenosis followed by multiple plastic stents (MPS) or placement of a fully covered self-expandable metal stent (fcSEMS) is better for the management of post-OLT ABS. This systematic review and meta-analysis aimed to compare the efficacy, safety, and cost of fcSEMS versus MPS in the treatment of post-OLT ABS. METHODS We searched PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) comparing fcSEMS with MPS for the treatment of patients with post-OLT ABS and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model, and I2 statistics were used to evaluate heterogeneity. RESULTS The study included 5 RCTs (245 patients). There was no statistically significant difference between fcSEMS and MPS in stricture resolution (RR 0.99; 95% CI 0.88 to 1.11; p = 0.86), stricture recurrence (RR 2.22; 95% CI 0.73 to 6.75; p = 0.16), treatment cost (MD - 5.31 thousand dollars 95% CI -12.76 to 2.13; p = 0.16), and AEs (RR 0.87; 95% CI 0.27 to 2.83; p = 0.82). However, fcSEMS reduced the number of ERCP sessions (MD - 1.7 sessions; CI 95% - 2.9 to - 0.5; p = 0.005) and treatment duration (MD-95.7 days; 95% CI -184.5 to -6.9; p = 0.03) compared with MPS. CONCLUSION fcSEMS and MPS had similar efficacy and safety in patients with ABS post-OLT. However, fcSEMS was associated with fewer ERCP sessions and shorter treatment duration.
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Affiliation(s)
- Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, R. Antenor Duarte Vilela, 1331 - Dr. Paulo Prata, Barretos, Sao Paulo, 14784 400, Brazil.
| | - Gilmara Coelho Meine
- Division of Gastroenterology, Department of Internal Medicine, Feevale University, Novo Hamburgo, Brazil
| | - Paula Arruda Espirito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of Sao Carlos, Sao Carlos, Brazil
| | | | - Angélica Luciana Nau
- Department of Pediatric Gastroenterology, Jaraguá Hospital, Jaraguá do Sul, Brazil
| | - Margaret G Keane
- Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Radhika Chavan
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Ahmedabad, Gujarat, India
| | - Yu-Ting Kuo
- Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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6
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Hu LH, Zhang PP, Yang T, Lv YW. Which is cheaper: a fully covered metallic stent or a choledochoscope? Endoscopy 2024; 56:E695-E696. [PMID: 39111759 PMCID: PMC11305857 DOI: 10.1055/a-2351-2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Affiliation(s)
- Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ting Yang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yan-Wei Lv
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, China
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7
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Gu J, Zorron Cheng Tao Pu L, Ng J, Be KH, Vaughan R, Chandran S, Efthymiou M. Procedure-related readmissions following endoscopic retrograde cholangiopancreatography in a liver transplant cohort. JGH Open 2024; 8:e70008. [PMID: 39364059 PMCID: PMC11447839 DOI: 10.1002/jgh3.70008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 07/01/2024] [Accepted: 07/09/2024] [Indexed: 10/05/2024]
Abstract
Background and Aim Data on post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events and readmission rates in liver transplantation (LT) patients remain scarce. This study determined the 30-day procedure-related readmission rate following ERCP in an LT cohort at an Australian tertiary academic center. Methods All unplanned readmissions within 30 days following ERCP in orthotopic LT patients between December 2012 and August 2021 were retrospectively identified. Demographic data, procedure variables, and readmission characteristics were also collected. Results Forty-five procedure-related readmissions were identified (3.3%) from a total of 1369 ERCP procedures. This included 33 cases of cholangitis (2.4%), 7 cases of nonspecific abdominal pain (0.5%), 5 cases of mild post-ERCP pancreatitis (0.5%), and 3 cases of bleeding (0.2%). No procedure-related mortality was observed. Conclusion The procedure-related readmission rate following ERCP in this LT cohort was 3.3%, which is likely lower than comparable studies carried out on the overall population.
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Affiliation(s)
- Jennifer Gu
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | | | - Jonathan Ng
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Kim H Be
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Rhys Vaughan
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Sujievvan Chandran
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
- Department of MedicineMonash University, Peninsula Health CampusFrankstonVictoriaAustralia
| | - Marios Efthymiou
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Samanta A, Srivastava A, Mohindra S, Yadav R, Poddar U, Sen Sarma M, Kumar B. Successful Hemostasis Using Fully Covered Self-Expanding Metallic Stent for Spontaneous Hemobilia in a Child With Portal Cavernoma Cholangiopathy. ACG Case Rep J 2024; 11:e01473. [PMID: 39176220 PMCID: PMC11340921 DOI: 10.14309/crj.0000000000001473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/16/2024] [Indexed: 08/24/2024] Open
Abstract
Portal cavernoma cholangiopathy refers to changes in the intrahepatic and extrahepatic biliary ducts in patients with extrahepatic portal venous obstruction. Spontaneous hemobilia in the setting of portal cavernoma cholangiopathy is extremely rare, and it poses diagnostic as well as therapeutic challenge. Here, we report the case of a 10-year-old girl with extrahepatic portal venous obstruction, who presented with hemobilia. Computed tomography angiography of abdomen and endoscopic ultrasound confirmed the presence of pericholedochal, paracholedochal, and intracholedochal varices. Hemostasis was achieved with the placement of a fully covered self-expanding metallic stent into the common bile duct. Fully covered self-expanding metallic stent is safe and effective for control of bleeding in children presenting with hemobilia.
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Affiliation(s)
- Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rajanikant Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Basant Kumar
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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10
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Lim C, Ng J, Sarraf B, Vaughan R, Efthymiou M, Zorron Cheng Tao Pu L, Chandran S. Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures. World J Transplant 2024; 14:91081. [PMID: 38947975 PMCID: PMC11212593 DOI: 10.5500/wjt.v14.i2.91081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 06/13/2024] Open
Abstract
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.
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Affiliation(s)
- Chee Lim
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Jonathan Ng
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Babak Sarraf
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Leonardo Zorron Cheng Tao Pu
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne Heidelberg, VIC 3084, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne Parkville, VIC 3052, Australia
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11
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Canakis A, Gilman AJ, Baron TH. Management of biliary complications in liver transplant recipients using a fully covered self-expandable metal stent with antimigration features. Minerva Gastroenterol (Torino) 2024; 70:181-186. [PMID: 37162469 DOI: 10.23736/s2724-5985.23.03343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Following liver transplant (LT) with duct-to-duct anastomosis, biliary strictures and leaks are typically managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting. While multiple side-by-side plastic stents are typically used for management of anastomotic strictures, fully covered self-expandable metal stents (FCSEMS) can be used to decrease the number of ERCPs with longer periods of stent patency. The risk of migration can limit their use. FCSEMS with antimigration fins to manage benign biliary complications following LT may provide stricture resolution with limited adverse events (AEs). METHODS Single center retrospective study of LT patients who required FCSEMS from 1/2014 to 4/2022. Primary outcomes included stricture resolution and recurrence. Secondary outcomes were stent migration, occlusion, removability, and number of ERCPs. RESULTS Forty-three patients (mean age 55.5 years) with anastomotic strictures (N.=37), bile leaks (N.=4) or both (N.=2) were included. The median time from LT to FCSEMS placement was 125 days. Within one year of LT, 31 patients required intervention; early intervention at less than 30 and 90 days was needed in 7 and 19 patients, respectively. The median length of follow-up was 816.5 days. Stricture resolution was seen in 35 patients (81%) after a median stent dwell time of 130.5 days; recurrence occurred in 8 patients. There were three instances of partial stent migration that did not require reintervention or interfere with removability. The mean number of ERCPs required was 2.5. CONCLUSIONS The use of a FCSEMS with antimigration features yields effective stricture resolution with longer stent dwell times and fewer ERCPs.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew J Gilman
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA -
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12
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Cho SH, Lee HS, Huh G, Oh D, Song TJ, Seo DW, Lee SK. Long-term outcomes of fully covered self-expandable metal stents for refractory biliary strictures after living donor liver transplantation: a retrospective study at a tertiary center. Surg Endosc 2024; 38:3223-3230. [PMID: 38649493 DOI: 10.1007/s00464-024-10837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Endoscopic multiple plastic stents are an established first-line treatment for anastomotic biliary stricture (ABS) management after liver transplantation (LT). Fully covered self-expandable metallic stents (FCSEMSs) have recently been used with favorable outcomes, but long-term treatment outcomes remain an issue for ABS. We evaluated the long-term outcomes of FCSEMS for the management of refractory ABS after LT. METHODS We reviewed the prospectively collected and maintained endoscopic retrograde cholangiography database at Asan Medical Center to retrieve consecutive post-LT ABS cases that underwent an endoscopic FCSEMS placement between August 2009 and August 2019 after MPS placement failure. RESULTS A total of 34 patients were enrolled in this study. Technical success had been achieved in all subjects (100%). The median stent placement duration was 3.1 months (IQR 2.7-6.1). Stricture resolution was achieved in 26 patients (clinical success 76.5%, 95% confidence interval 62-91). Early adverse events developed in 3 patients (8.8%), including distal stent migration. Late adverse events occurred in 9 patients (26.5%), including cholangitis (n = 7, 20.6%) and asymptomatic distal stent migration (n = 2, 5.9%). The median follow-up period was 57.9 months (IQR 51.9-64.3). Stricture recurrence occurred in 3 of 26 patients who achieved clinical success (11.5%). CONCLUSIONS FCSEMS placement appears to be an effective and advisable intervention for refractory ABS as it can provide persistent stricture improvement over the long-term.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho Seung Lee
- Department of Internal Medicine, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Gunn Huh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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13
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Bofill A, Cárdenas A. A practical approach to the endoscopic management of biliary strictures after liver transplantation. Ann Hepatol 2024; 29:101186. [PMID: 38035999 DOI: 10.1016/j.aohep.2023.101186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
Biliary tract complications are an important cause of morbidity and mortality after liver transplantation (LT) occurring in 5% to 25% of patients. The most common biliary complication in LT recipients are strictures representing approximately half of these biliary adverse events. Bile duct strictures can be divided into anastomotic biliary strictures (ABS) and non-anastomotic biliary strictures (NABS) depending on their location in the biliary tree, being ABS the most encountered type. Several risk factors identified in previous studies can predispose to the development of ABS and NABS, especially those related to surgical techniques and donor characteristics. Magnetic resonance cholangiopancreatography (MRCP) is the recommended noninvasive imaging test for detecting post-LT biliary strictures, given its high sensitivity and specificity. Once the diagnosis of a biliary stricture after LT has been made, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy with good short and long-term results. Biliary sphincterotomy plus balloon dilation (BD) with placement of multiple plastic stents (MPS) has been the classic endoscopic approach for treating ABS, although fully-covered metallic stents (FCSEMS) have emerged as an alternative thanks to shorter total duration of stenting and fewer endoscopic procedures compared to MPS. In this review, we provide a practical update on the management of biliary strictures after LT, focusing our attention on the available evidence in the endoscopic therapy.
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Affiliation(s)
- Alex Bofill
- GI Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain
| | - Andrés Cárdenas
- GI and Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
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14
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Kawasaki Y, Hijioka S, Nagashio Y, Ohba A, Maruki Y, Takeshita K, Takasaki T, Yagi S, Agarie D, Hagiwara Y, Hara H, Okamoto K, Yamashige D, Fukuda S, Kuwada M, Kondo S, Morizane C, Ueno H, Okusaka T. Study protocol for a prospective, multicentre, phase II trial on endoscopic treatment using two fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy. BMJ Open 2023; 13:e078967. [PMID: 38072497 PMCID: PMC10729169 DOI: 10.1136/bmjopen-2023-078967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION The current endoscopic treatment for postoperative benign hepaticojejunostomy anastomotic stricture (HJAS) has a high technical success rate and is highly effective in the short term. However, long-term results have shown a high rate of stenosis recurrence, which indicates an insufficient response to treatment. Three prospective studies on fully covered self-expandable metallic stent (FC-SEMS) treatment for benign HJAS used the stenosis resolution rate as the primary endpoint, and no study has yet used the long-term non-stenosis rate (at 12 months) as the primary endpoint. METHODS AND ANALYSIS We launched the 'saddle-cross study', which will be conducted as a multicentre, prospective intervention of endoscopic treatment using two modified FC-SEMSs (BONASTENT️ M-Intraductal) that have been improved for benign stenosis in patients with benign HJAS, with the long-term non-restenosis rate (at 12 months) as the primary endpoint. This study aims to evaluate the long-term non-restenosis rate (at 12 months) and safety of the saddle-cross technique for benign HJAS. We plan to enrol 50 participants. ETHICS AND DISSEMINATION This study has been approved by the Certified Review Board of the National Cancer Center, Japan (CRB3180009). The results will be reported at various conferences and published in international peer-reviewed journals.
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Affiliation(s)
- Yuki Kawasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
- Showa University Koto Toyosu Hospital, Koto-ku, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Yoshikuni Nagashio
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Akihiro Ohba
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Kotaro Takeshita
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Tetsuro Takasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shin Yagi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Daiki Agarie
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Yuya Hagiwara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Hidenobu Hara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Kohei Okamoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Daiki Yamashige
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Souma Fukuda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Masaru Kuwada
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Hideki Ueno
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
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15
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Kida A, Yoshio T, Minami H, Asai J, Kakinoki K, Urabe T, Yamashita T. Successful endoscopic treatment of multiple large intrahepatic bile duct stones with benign choledochojejunal anastomotic stenosis. Endoscopy 2023; 55:E914-E915. [PMID: 37442161 PMCID: PMC10344624 DOI: 10.1055/a-2120-1694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Affiliation(s)
- Akihiko Kida
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
| | - Takatoshi Yoshio
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Hironori Minami
- Department of Surgery, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Jun Asai
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Kaheita Kakinoki
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Takeshi Urabe
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Japan
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16
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Colombo M, Forcignanò E, Da Rio L, Spadaccini M, Andreozzi M, Giacchetto CM, Carrara S, Maselli R, Galtieri PA, Pellegatta G, Capogreco A, Massimi D, Khalaf K, Hassan C, Anderloni A, Repici A, Fugazza A. Endoscopic management of benign biliary strictures: Looking for the best stent to place. World J Clin Cases 2023; 11:7521-7529. [DOI: 10.12998/wjcc.v11.i31.7521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/10/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023] Open
Abstract
Benign biliary strictures (BBS) might occur due to different pancreaticobiliary conditions. The etiology and location of biliary strictures are responsible of a wide array of clinical manifestations. The endoscopic approach endoscopic retrograde cholangiopancreatography represents the first-line treatment for BBS, considering interventional radiology and surgery when endoscopic treatment fails or it is not suitable. The purpose of this review is to provide an overview of possible endoscopic treatments for the optimal management of this subset of patients.
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Affiliation(s)
- Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Edoardo Forcignanò
- Department of Surgical Sciences, University of Turin, Torino 10124, Piemonte, Italy
| | - Leonardo Da Rio
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Marta Andreozzi
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Carmelo Marco Giacchetto
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Antonio Capogreco
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Davide Massimi
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto M5B1T8, Ontario, Canada
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Andrea Anderloni
- Endoscopy Unit, First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia 27100, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20089, Milan, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Milan, Italy
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17
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Sissingh NJ, de Vries BA, Inderson A, van Hoek B, van der Heide F, van Hooft JE. Response. Gastrointest Endosc 2023; 98:464-466. [PMID: 37597935 DOI: 10.1016/j.gie.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Boudewijn A de Vries
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans van der Heide
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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18
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Han S, Obando JV, Bhatt A, Bucobo JC, Chen D, Copland AP, Das KK, Girotra M, Kahn A, Krishnan K, Sakaria SS, Saumoy M, Trikudanathan G, Trindade AJ, Yang J, Law RJ, Lichtenstein DR. Biliary and pancreatic stents. IGIE 2023; 2:240-253. [DOI: 10.1016/j.igie.2023.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
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19
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Trieu JA, Baron TH. Is scheduled endoscopic dilation of biliary strictures after liver transplantation truly effective? Gastrointest Endosc 2023; 97:1171. [PMID: 37208046 DOI: 10.1016/j.gie.2023.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Judy A Trieu
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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20
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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21
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Gheorghe G, Diaconu CC, Bungau S, Bacalbasa N, Motas N, Ionescu VA. Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:850. [PMID: 37241082 PMCID: PMC10221850 DOI: 10.3390/medicina59050850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.
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Affiliation(s)
- Gina Gheorghe
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Internal Medicine Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | - Nicolae Bacalbasa
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Natalia Motas
- Institute of Oncology “Profesor Doctor Alexandru Trestioreanu” Bucharest, 022328 Bucharest, Romania;
- Department of Thoracic Surgery, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
| | - Vlad-Alexandru Ionescu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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22
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Kohli DR, Amateau SK, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, Coelho-Prabhu N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: summary and recommendations. Gastrointest Endosc 2023; 97:607-614. [PMID: 36797162 DOI: 10.1016/j.gie.2022.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 02/18/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of post-transplant strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent for extrahepatic strictures. In patients with unclear diagnoses or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be ensured.
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Affiliation(s)
- Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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23
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Amateau SK, Kohli DR, Desai M, Chinnakotla S, Harrison ME, Chalhoub JM, Coelho-Prabhu N, Elhanafi SE, Forbes N, Fujii-Lau LL, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence. Gastrointest Endosc 2023; 97:615-637.e11. [PMID: 36792483 DOI: 10.1016/j.gie.2022.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 02/17/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.
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Affiliation(s)
- Stuart K Amateau
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Medical Center, Spokane, Washington, USA
| | - Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - M Edwyn Harrison
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jean M Chalhoub
- Department of Gastroenterology and Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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24
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Sissingh NJ, de Vries BA, Inderson A, van Hoek B, van der Heide F, van Hooft JE. Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation. Gastrointest Endosc 2023; 97:704-712.e2. [PMID: 36460088 DOI: 10.1016/j.gie.2022.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fully covered metal stents (FCSEMSs) are increasingly used for treatment of biliary anastomotic strictures (ASs) after liver transplantation (LT), requiring fewer endoscopic interventions than does treatment with multiple plastic stents (MPSs). Previous studies, however, have reported adverse events such as stent migration and pancreatitis. The intraductal FCSEMS (ID-FCSEMS) potentially avoids these disadvantages. This study aimed to assess the efficacy and safety of ID-FCSEMSs compared with MPSs for AS. METHODS The cohorts of LT patients treated for AS with endoscopic stenting between 2010 and 2019 from 2 Dutch liver transplantation centers were retrospectively analyzed. Patients treated with ID-FCSEMSs or MPSs were included. RESULTS 80 patients (44 with ID-FCSEMSs vs 36 with MPSs) were included, with a median follow-up time of 52 versus 64 months (P = .183). Stricture resolution was 93% in the ID-FCSEMS versus 97% in the MPS group (P = 1.000) after a median of 19 and 26 weeks, respectively (P = .031). The median number of ERCPs was 2 in the ID-FCSEMS group versus 4 in the MPS group (P < .001). Stricture recurrence occurred in 33% of ID-FCSEMS versus 29% of MPS patients (P = .653) after a median of 24 and 55 weeks (P = .403). Stent migration occurred in 16% of ID-FCSEMS versus 39% of MPS patients (P = .020). Post-ERCP fever was observed in 34% of ID-FCSEMS patients compared with 14% of MPS patients (P = .038). No significant differences were found in pancreatitis rate between the groups, being 6.8% for ID-FCSEMSs and 5.6% for MPSs (P = .816). CONCLUSION ID-FCSEMSs for the treatment of AS after LT provides similar stricture resolution and recurrence rates as MPSs, though with a significant reduction of procedures needed.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Boudewijn A de Vries
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans van der Heide
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands.
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25
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Komatsu N, Ozawa E, Fukushima M, Sawase H, Nagata K, Miuma S, Miyaaki H, Soyama A, Hidaka M, Eguchi S, Nakao K. Fully covered metallic stents for anastomotic biliary strictures after living donor liver transplantation. DEN OPEN 2023; 3:e225. [PMID: 36998348 PMCID: PMC10043358 DOI: 10.1002/deo2.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Naohiro Komatsu
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Eisuke Ozawa
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masanori Fukushima
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hironori Sawase
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kazuyoshi Nagata
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Satoshi Miuma
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Akihiko Soyama
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Masaaki Hidaka
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Susumu Eguchi
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Kazuhiko Nakao
- Department of Gastroenterology and HepatologyNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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26
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Zhang W, Sun H, Dong D, Li Y. Safety and feasibility of a novel recanalization technique using guidewire puncture under cholangioscopy for complete biliary stricture after liver transplantation. Sci Rep 2023; 13:4874. [PMID: 36966204 PMCID: PMC10039916 DOI: 10.1038/s41598-023-31475-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/13/2023] [Indexed: 03/27/2023] Open
Abstract
Cholangioscopy is reportedly useful for selective guidewire placement across difficult biliary strictures, but few methods are available for complete stricture of biliary anastomosis. This study aimed to propose a guidewire puncture technique to recanalize totally obstructed anastomosis and discuss its safety and feasibility. From January 2015 to December 2021, a total of 11 patients with complete biliary anastomotic stricture after liver transplantation were enrolled. These patients underwent peroral single operator cholangioscopy (SpyGlass), whereas two failed cases on SpyGlass finally underwent percutaneous transhepatic cholangioscopy (PTCS). The steps of the recanalization technique were as follows: the stricture was viewed carefully to detect the closure point (CP) of the scar endoscopically, then the CP was targeted by the hard tip of the guidewire and broke through under guidance of the cholangioscope and fluoroscope. Complete occlusions were confirmed by SpyGlass in all cases. A total of 13 hard-tip guidewire punctures were performed under cholangioscopy, and ten punctures were successful (technical success rate, 76.9% [10/13]). After recanalization of the occluded anastomosis, plastic stent or metallic stent was deployed in three and seven patients, respectively. No procedure-related complications occurred during or after the cholangioscopy-assisted guidewire puncture. After a mean follow-up of 12 months, stents had been removed in five patients. The other six patients were still receiving stent treatment. This study demonstrated that the guidewire puncture technique under cholangioscopy is safe and feasible for complete stricture of biliary anastomosis, and the success rate is satisfactory.
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Affiliation(s)
- Wei Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an, 710061, China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, China
| | - Hao Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi Province, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an, 710061, China
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, China
| | - Yu Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi Province, China.
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an, 710061, China.
- Shaanxi Province Center for Regenerative Medicine and Surgery Engineering Research, Xi'an, 710061, China.
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27
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ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. Am J Gastroenterol 2023; 118:405-426. [PMID: 36863037 DOI: 10.14309/ajg.0000000000002190] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/13/2022] [Indexed: 03/04/2023]
Abstract
A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.
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28
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Long-Term Results of Endoscopic Metal Stenting for Biliary Anastomotic Stricture after Liver Transplantation. J Clin Med 2023; 12:jcm12041453. [PMID: 36835988 PMCID: PMC9961020 DOI: 10.3390/jcm12041453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
(1) Background: Anastomotic biliary stricture (ABS) is a well-known complication of liver transplantation which can lead to secondary biliary cirrhosis and graft dysfunction. The goal of this study was to evaluate the long-term outcomes of endoscopic metal stenting of ABS in the setting of deceased donor liver transplantation (DDLT). (2) Methods: Consecutive DDLT patients with endoscopic metal stenting for ABS between 2010 and 2015 were screened. Data on diagnosis, treatment and follow-up (until June 2022) were collected. The primary outcome was endoscopic treatment failure defined as the need for surgical refection. (3) Results: Among the 465 patients who underwent LT, 41 developed ABS. It was diagnosed after a mean period of 7.4 months (+/-10.6) following LT. Endoscopic treatment was technically successful in 95.1% of cases. The mean duration of endoscopic treatment was 12.8 months (+/-9.1) and 53.7% of patients completed a 1-year treatment. After a mean follow-up of 6.9 years (+/-2.3), endoscopic treatment failed in nine patients (22%) who required surgical refection. Conclusions: Endoscopic management with metal stenting of ABS after DDLT was technically successful in most cases, and half of the patients had at least one year of indwelling stent. Endoscopic treatment long-term failure rate occurred in one fifth of the patients.
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29
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Yang H, Yang Z, Hong J. Post-ERCP pancreatitis occurs more frequently in self-expandable metallic stents than multiple plastic stents on benign biliary strictures: a meta-analysis. Ann Med 2022; 54:2439-2449. [PMID: 36799364 PMCID: PMC9467625 DOI: 10.1080/07853890.2022.2105395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes. CONCLUSIONS Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement. METHODS A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity. RESULTS Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, p = .64; and OR = 2.3, 95%CI: 0.68-7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, p = .07). SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.
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Affiliation(s)
- Hui Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenzhen Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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30
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Kawasaki Y, Hijioka S, Nagashio Y, Ohba A, Maruki Y, Maehara K, Yoshinari M, Hisada Y, Harai S, Kitamura H, Murashima Y, Koga T, Kawahara S, Kondo S, Morizane C, Ueno H, Ushio J, Tamada K, Sugawara S, Sone M, Takamoto T, Nara S, Ban D, Esaki M, Arai Y, Shimada K, Saito Y, Okusaka T. A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video). Surg Endosc 2022; 36:9001-9010. [PMID: 35817882 DOI: 10.1007/s00464-022-09358-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 05/16/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents. METHODS This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021. RESULTS The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25-122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%). CONCLUSIONS The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.
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Affiliation(s)
- Yuki Kawasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
| | - Yosikuni Nagashio
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Akihiro Ohba
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Kosuke Maehara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Motohiro Yoshinari
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yuya Hisada
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shota Harai
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hidetoshi Kitamura
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Yumi Murashima
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Takehiko Koga
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Shun Kawahara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Syunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Hideki Ueno
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Jun Ushio
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kiichi Tamada
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
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Sharma ZD, Karunakaran M, Bansal RK, Gandhi A, Singh MK, Soin AS, Puri R, Sud R. Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy. ANZ J Surg 2022; 93:911-917. [PMID: 36262090 DOI: 10.1111/ans.18123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. METHODS A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. RESULTS Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents. CONCLUSIONS Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.
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Affiliation(s)
- Zubin Dev Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Monish Karunakaran
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.,Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.,College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon, India
| | - Ashish Gandhi
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Rajesh Puri
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Randhir Sud
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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Kim JH, Ha DH, Han ES, Choi Y, Koh J, Joo I, Kim JH, Cho DW, Han JK. Feasibility and safety of a novel 3D-printed biodegradable biliary stent in an in vivo porcine model: a preliminary study. Sci Rep 2022; 12:15875. [PMID: 36151222 PMCID: PMC9508112 DOI: 10.1038/s41598-022-19317-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/26/2022] [Indexed: 11/24/2022] Open
Abstract
To assess the feasibility and safety of a novel 3D-printed biodegradable biliary stent using polycaprolactone (PCL) in an in vivo porcine model. In this animal study using domestic pigs, biodegradable radiopaque biliary stents made of polycaprolactone (PCL) and barium sulfate were produced using 3D printing and surgically inserted into the common bile duct (CBD) of pigs (stent group, n = 12). Another five pigs were allocated to the control group that only underwent resection and anastomosis of the CBD without stent insertion. To check the position and status of the stents and stent-related complications, follow-up computed tomography (CT) was performed every month. The pigs were sacrificed 1 or 3 months after surgery, and their excised CBD specimens were examined at both the macroscopic and microscopic levels. Three pigs (one in the stent group and two in the control group) died within one day after surgery and were excluded from further analysis; the remaining 11 in the stent group and 3 in the control group survived the scheduled follow-up period (1 month, 5 and 1; and 3 months, 6 and 2 in stent and control groups, respectively). In all pigs, no clinical symptoms or radiologic evidence of biliary complications was observed. In the stent group (n = 11), stent migration (n = 1 at 3 months; n = 2 at 1 month) and stent fracture (n = 3 at 2 months) were detected on CT scans. Macroscopic evaluation of the stent indicated no significant change at 1 month (n = 3) or fragmentation with discoloration at 3 months (n = 5). On microscopic examination of CBD specimens, the tissue inflammation score was significantly higher in the stent group than in the control group (mean ± standard deviation (SD), 5.63 ± 2.07 vs. 2.00 ± 1.73; P = 0.039) and thickness of fibrosis of the CBD wall was significantly higher than that of the control group (0.46 ± 0.12 mm vs. 0.21 ± 0.05 mm; P = 0.012). Despite mild bile duct inflammation and fibrosis, 3D-printed biodegradable biliary stents showed good feasibility and safety in porcine bile ducts, suggesting their potential for use in the prevention of postoperative biliary strictures.
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Affiliation(s)
- Jae Hyun Kim
- Department of Radiology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea
| | - Dong-Heon Ha
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, Republic of Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jiwon Koh
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea
| | - Dong-Woo Cho
- Department of Mechanical Engineering, Pohang University of Science and Technology, Pohang, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea.
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Pinheiro LW, Martins FP, De Paulo GA, Contini MLC, Ferrari AP, Della Libera E. Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture. World J Gastrointest Endosc 2022; 14:547-554. [PMID: 36186946 PMCID: PMC9516474 DOI: 10.4253/wjge.v14.i9.547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/19/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.
AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.
METHODS This study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.
RESULTS Three patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.
CONCLUSION In this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.
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Affiliation(s)
- Larissa Wermelinger Pinheiro
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
| | - Fernanda Prata Martins
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | | | | | - Angelo Paulo Ferrari
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | - Ermelindo Della Libera
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
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Abstract
PURPOSE OF REVIEW To summarize the current status and future perspectives of the endoscopic management of biliary strictures. RECENT FINDINGS In addition to conventional diagnostic modalities, such as cross-sectional imaging and endoscopic ultrasonography (EUS), per-oral cholangioscopy is helpful for indeterminate biliary strictures. It allows direct visualization of the biliary tract and targeted biopsy. For distal malignant biliary obstruction (MBO), a self-expandable metal stent (SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) is a standard of care. EUS-guided biliary drainage (EUS-BD) is an emerging alternative to percutaneous transhepatic biliary drainage in cases with failed ERCP. EUS-BD is also an effective salvage option for perihilar MBO, which can not be managed via ERCP or percutaneous transhepatic biliary drainage. Preoperative drainage is necessary for most jaundiced patients as neoadjuvant chemotherapy is widely administered for resectable and borderline resectable pancreatic cancer, and a SEMS is preferred in this setting, too. For benign biliary strictures, a covered SEMS can improve stricture resolution and reduce the number of endoscopic sessions as compared to plastic stents. SUMMARY ERCP and EUS play a central role in the diagnosis and drainage for both malignant and benign biliary strictures.
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Feasibility and Safety of ERCP in the Treatment of Biliary Strictures after Liver Transplantation: With a Report of 37 Cases. Gastroenterol Res Pract 2022; 2022:4498443. [PMID: 36052377 PMCID: PMC9427298 DOI: 10.1155/2022/4498443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Liver transplantation (LT) is an effective treatment option for patients with end-stage liver disease; biliary complications are important cause of death in posttransplant patients. Endoscopic retrograde cholangiopancreatography (ERCP) has an irreplaceable role in the diagnosis and treatment of patients with biliary tract disease. Methods. The clinical data of patients with biliary strictures (BS) after LT treated with ERCP admitted to the Third Xiangya Hospital of Central South University from September 2016 to October 2021 were reviewed; the changes in temperature, bilirubin, and albumin before and after treatment and postoperative complications were analyzed. Results. A total of 41 patients were included in the study, and biliary stents were successfully placed in 37 cases (90.2%), while 4 cases (9.8%) were unsuccessful due to complete BS. Patients with ERCP guided biliary stenting had a significant improvement in bilirubin index compared to the preoperative period (
). 27 patients (73.0%) had complete relief of symptoms after 1 ERCP-guided treatment, and 10 patients (27.0%) developed BS again at different times after the first ERCP treatment, among which 8 patients developed BS again within 1 year after the first treatment and 2 patients developed BS again after 1 year after the first treatment. The incidence of endoscopy-related adverse events was 35.14%, with no serious adverse events. Conclusion. ERCP-guided biliary stenting was an effective and safety treatment for BS after LT.
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Kirstein MM, Voigtländer T. Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie. Zentralbl Chir 2022; 147:398-406. [DOI: 10.1055/a-1857-5775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ZusammenfassungBiliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser
machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach
Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach
Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein
exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen
und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten
wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten
Verfahren.
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Affiliation(s)
| | - Torsten Voigtländer
- Gastroenterologie, Deutsches Rotes Kreuz Krankenhaus Clementinenhaus Hannover, Hannover, Deutschland
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Conigliaro R, Pigò F, Bertani H, Greco S, Burti C, Indriolo A, Di Sario A, Ortolani A, Maroni L, Tringali A, Barbaro F, Costamagna G, Magarotto A, Masci E, Mutignani M, Forti E, Tringali A, Parodi MC, Assandri L, Marrone C, Fantin A, Penagini R, Cantù P, Di Benedetto F, Ravelli P, Vivarelli M, Agnes S, Mazzaferro V, De Carlis L, Andorno E, Cillo U, Rossi G. Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group. Liver Int 2022; 42:1861-1871. [PMID: 35302273 DOI: 10.1111/liv.15246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/05/2022] [Accepted: 03/08/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND STUDY AIM The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.
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Affiliation(s)
- Rita Conigliaro
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Flavia Pigò
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
| | - Helga Bertani
- Azienda Ospedaliero Universitaria - Ospedale Civile di Baggiovara, Modena, Italy
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Kubesch A, Görnert F, Filmann N, Bojunga J, Zeuzem S, Jung M, Friedrich-Rust M, Walter D. Impact of a shorter replacement interval of plastic stents on premature stent exchange rate in benign and malignant biliary strictures. J Gastroenterol Hepatol 2022; 37:1076-1082. [PMID: 35261084 DOI: 10.1111/jgh.15824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/23/2022] [Accepted: 02/21/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The main disadvantage of plastic stents is the high rate of stent occlusion. The usual replacement interval of biliary plastic stents is 3 months. This study aimed to investigate if a shorter interval of 6-8 weeks impacts the median premature exchange rate (mPER) in benign and malignant biliary strictures. METHODS All cases with endoscopic retrograde cholangiopancreatography (ERCP) and plastic stent placement were retrospectively analyzed since establishing an elective replacement interval of every 6-8 weeks at our institution and mPER was determined. RESULTS A total of 3979 ERCPs (1199 patients) were analyzed, including 1262 (31.7%) malignant and 2717 (68.3%) benign cases, respectively. The median stent patency (mSP) was 41 days (range 14-120) for scheduled stent exchanges, whereas it was 17 days (1-75) for prematurely exchanged stents. The mPER was significantly higher for malignant (28.1%, 35-50%) compared with benign strictures (15.2%, 10-28%), P < 0.0001, respectively. mSP was significantly shorter in cases with only one stent (34 days [1-87] vs 41 days [1-120]) and in cases with only a 7-Fr stent (28 days [2-79]) compared with a larger stent (34 days [1-87], P = 0.001). Correspondingly, mPER was significantly higher in cases with only one stent (23% vs 16.2%, P < 0.0001) and only a 7-Fr stent (31.3% vs 22.4%, P = 0.03). CONCLUSION A shorter replacement interval does not seem to lead to a clinically meaningful reduction of mPER in benign and malignant strictures. Large stents and multiple stenting should be favored as possible.
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Affiliation(s)
- Alica Kubesch
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Fabian Görnert
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jörg Bojunga
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Michael Jung
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
| | - Dirk Walter
- Department of Internal Medicine I, Johann Wolfgang Goethe University Hospital, Frankfurt, Germany
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Sandru V, Stan-Ilie M, Plotogea OM, Vladut C, Ungureanu BS, Balan GG, Gheonea DI, Constantinescu G. Endoscopic Management of Biliary Strictures after Orthotopic Liver Transplantation: A Single Center Experience Study. Diagnostics (Basel) 2022; 12:1221. [PMID: 35626376 PMCID: PMC9140460 DOI: 10.3390/diagnostics12051221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/17/2022] [Accepted: 05/12/2022] [Indexed: 12/04/2022] Open
Abstract
Background and Aim. Endoscopic therapy is the method of choice in the management of biliary strictures after orthotopic liver transplantation (OLT). Even though the mainstay approach for OLT stricture complications is represented by consecutive procedures of multiple plastic stents (MPS) insertion, a valuable alternative is the use of fully covered self-expandable metal stents (FCSEMS). The aim of the study was to compare MPS with FCSEMS used in the management of OLT biliary strictures, in terms of clinical outcomes and complications. Material and Methods. This is a retrospective, single-center study conducted between February 2014 and November 2019 in the Clinical Emergency Hospital of Bucharest, Romania. We enrolled all consecutive patients who developed biliary strictures after OLT and were treated by endoscopic retrograde cholangiopancreatography (ERCP) either with MPS or FCSEMS. Results. Thirty-six patients were included in the study, 27 patients had MPS and nine patients had FCSEMS. 106 ERCP procedures were performed and 159 stents were inserted. The mean number of ERCP procedures required per patient was significantly higher for MPS than for FCSEMS (3.34 ± 1.46 vs. 2.11 ± 0.33, p < 0.001). In the FCSEMS group only one patient had three procedures, due to stent migration. Difficult cannulation was encountered in 22 patients, 18 patients from MPS group and four patients from FCSEMS group. Dilation was performed in 20 (77%) MPS patients and in four FCSEMS patients (44%). Overall, we used 159 stents for stricture resolution, 149 plastic stents and 10 FCSEMS. Mean number of stents inserted was significantly lower in the FCSEMS group compared to MPS group (1.16 ± 0.40 vs. 5.73 ± 2.64, p < 0.001). Conclusions. Stricture resolution using FCSEMS is comparable to MPS and even has some advantages. In line with prior studies, FCSEMS are effective, with fewer complications and similar outcome compared to plastic stents. Other particular aspects should be further assessed, especially long-term follow up of FCSEMS and their cost efficiency.
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Affiliation(s)
- Vasile Sandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Madalina Stan-Ilie
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Oana-Mihaela Plotogea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalina Vladut
- Department of Gastroenterology, Prof. Dr. Agrippa Ionescu Clinical Emergency Hospital, 011356 Bucharest, Romania;
| | - Bogdan Silviu Ungureanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Gheorghe G. Balan
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania;
- Institute of Gastroenterology and Hepatology, “St. Spiridon” Emergency Hospital, 700111 Iasi, Romania
| | - Dan Ionut Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Gabriel Constantinescu
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania; (V.S.); (M.S.-I.); (O.-M.P.); (G.C.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Kida A, Shirota Y, Arihara F, Asai J, Matsuda K, Kakinoki K, Matsuda M, Sakai A, Terada M, Urabe T. Biliary stones or ulcers at the choledochojejunal anastomotic site involving the jejunal mucosa at stent removal may be recurrent factors in patients with benign choledochojejunal anastomotic stenosis undergoing endoscopic biliary stenting using fully-covered self-expandable metal stents. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1044-1053. [PMID: 35561097 DOI: 10.1002/jhbp.1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/24/2022] [Accepted: 04/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Temporary fully-covered self-expandable metal stent (FCSEMS) placement is performed for benign choledochojejunal anastomotic stenosis (bCJS). However, recurrence may develop after stricture resolution. We investigated endoscopic biliary stenting using FCSEMS for bCJS. METHODS Sixteen bCJS patients with FCSEMS placement were retrospectively analyzed. FCSEMS was removed endoscopically after 2 months. Technical success, stricture resolution, recurrence, and adverse events were evaluated. RESULTS The technical success rate for FCSEMS placement was 94% (15/16). Biliary stones were detected and extracted in 4 patients. FCSEMS removal was successfully performed on 14 patients, excluding 1 with stent migration. At FCSEMS removal, stricture resolution was noted in 14 patients; however, 4 had anastomotic ulcers. The median follow-up was 319 days. Three patients with a history of repeated plastic stent placement had no recurrence. Four out of 15 patients (27%) had recurrence, and three had no recurrence after additional interventions. Biliary stones before first FCSEMS placement (p=0.003) or anastomotic ulcers at FCSEMS removal (p=0.018) were associated with recurrence. CONCLUSIONS Although FCSEMS placement was useful for stricture resolution, recurrence was detected in patients with biliary stones before first FCSEMS placement or anastomotic ulcers at FCSEMS removal. Anastomotic ulcers are a risk factor for recurrence and only detected by endoscopy.
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Affiliation(s)
- Akihiko Kida
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan.,Department of Gastroenterology, JA, Toyama Kouseiren Takaoka Hospital, 5-10 Eirakuchou, Takaoka, Toyama 933-0843, Japan
| | - Yukihiro Shirota
- Department of Gastroenterology, Saiseikai Kanazawa Hospital, 13-6 Akatsuchimachi, Kanazawa, Ishikawa 920-0353, Japan
| | - Fumitaka Arihara
- Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama 930-8550, Japan
| | - Jun Asai
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan
| | - Koichiro Matsuda
- Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama 930-8550, Japan
| | - Kaheita Kakinoki
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan
| | - Mitsuru Matsuda
- Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama 930-8550, Japan
| | - Akito Sakai
- Department of Internal Medicine, Toyama Prefectural Central Hospital, 2-2-78 Nishinagae, Toyama, Toyama 930-8550, Japan
| | - Mitsuhiro Terada
- Department of Gastroenterology, JA, Toyama Kouseiren Takaoka Hospital, 5-10 Eirakuchou, Takaoka, Toyama 933-0843, Japan
| | - Takeshi Urabe
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan
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Kamal F, Ali Khan M, Lee-Smith W, Sharma S, Acharya A, Imam Z, Jowhar D, Esswein J, Kothadia J, Aziz M, Chandan S, Arain M, Howden CW, Ismail MK. Metal versus plastic stents in the management of benign biliary strictures: systematic review and meta-analysis of randomized controlled trials. Eur J Gastroenterol Hepatol 2022; 34:478-487. [PMID: 35170533 DOI: 10.1097/meg.0000000000002352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Benign biliary strictures (BBS) are usually treated with endoscopic retrograde cholangiopancreatography (ERCP) with the placement of multiple plastic stents (MPS) or a covered self-expandable metal stent (CSEMS). In this meta-analysis, we compared the efficacy and safety of MPS and CSEMS in the management of BBS. We reviewed several databases from inception to 28 April 2021 to identify RCTs that compared MPS with CSEMS in the management of BBS. Our outcomes of interest were stricture resolution, stricture recurrence, adverse events, stent migration and mean number of ERCPs to achieve stricture resolution. Data were analyzed using a random-effects model. We included eight RCTs with 524 patients. We found no significant difference in the rate of stricture resolution (risk ratio, 1.02; 95% CI, 0.96-1.10), stricture recurrence (risk ratio, 1.68; 95% CI, 0.72-3.88) or adverse events (risk ratio, 1.17; 95% CI, 0.73-1.87) between groups. Mean number of ERCPs was significantly lower in the CSEMS group (SMD, -1.99; 95% CI, -3.35 to -0.64). The rate of stent migration was significantly higher in the CSEMS group. CSEMS are comparable in efficacy and safety to MPS in the management of BBS but require fewer ERCPs to achieve stricture resolution.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of California- San Francisco, San Francisco, California
| | - Muhammad Ali Khan
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Sachit Sharma
- Department of Medicine
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia
| | - Ashu Acharya
- Department of Medicine, University of Toledo, Toledo, Ohio
| | - Zaid Imam
- Division of Gastroenterology, William Beaumont Hospital, Royal Oak, Michigan
| | | | | | - Jiten Kothadia
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Muhammad Aziz
- Division of Gastroenterology, University of Toledo, Toledo, Ohio
| | - Saurabh Chandan
- Division of Gastroenterology, Creighton University Medical Center, Omaha, Nebraska
| | - Mustafa Arain
- Division of Gastroenterology, University of California, San Francisco, California, USA
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mohammad K Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee
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Giri S, Jearth V, Sundaram S. Covered Self-Expanding Metal Stents Versus Multiple Plastic Stents for Benign Biliary Strictures: An Updated Meta-Analysis of Randomized Controlled Trials. Cureus 2022; 14:e24588. [PMID: 35651420 PMCID: PMC9138190 DOI: 10.7759/cureus.24588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/05/2022] Open
Abstract
Optimal endoscopic management of benign biliary strictures (BBS) has been a matter of debate with choice of stent remaining largely at the discretion of the endoscopist. In this systematic review and meta-analysis, we compared self-expanding metal stents with multiple plastic stents for benign biliary strictures. A comprehensive search of literature from 2000 till September 2021 was done of various databases for randomized controlled trials evaluating stent placement for benign biliary strictures. Our primary aim was to compare outcomes of endoscopic therapy for BBS using covered self-expandable metal stents (cSEMS) and multiple plastic stents (MPS) in terms of stricture resolution, number of ERCP sessions, recurrence of stricture, stent migration, and moderate-severe adverse events. Eight randomized controlled trials (534 patients) were included in the meta-analysis. cSEMS were comparable to MPS for stricture resolution (risk ratio {RR}: 1.0, 95% CI: 0.89-1.08, p=1.00), recurrence of stricture (RR: 0.73, 95% CI: 0.35-1.53, p=0.13), stent migration (RR: 0.90, 95% CI: 0.54-1.52, p=0.26), and moderate-severe adverse events (RR: 1.04, 95% CI: 0.67-1.61, p=0.19) with low to moderate heterogeneity among studies. cSEMS required fewer sessions of ERCP for stricture resolution (mean difference: 1.88, 95% CI: 0.91-2.85, p<0.00001) but with significant heterogeneity among studies. No difference in stricture resolution was seen in subgroup analysis between anastomotic strictures, chronic pancreatitis, or bile duct injury. cSEMS are comparable to MPS in patients with benign biliary strictures in terms of stricture resolution, recurrence, and adverse effects, needing fewer sessions of ERCP. Larger studies comparing cost-effectiveness of cSEMS and MPS in BBS are needed.
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Affiliation(s)
- Suprabhat Giri
- Gastroenterology and Hepatology, Nizam's Institute of Medical Sciences, Hyderabad, IND
| | - Vaneet Jearth
- Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Sridhar Sundaram
- Gastroenterology and Hepatology, Tata Memorial Hospital, Mumbai, IND
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Yoon SB, Kim J, Paik CN, Jang DK, Lee JK, Yoon WJ, Kim JW, Lee TH, Jang JY. Endoscopic and Percutaneous Biliary Interventions after Liver Transplantation: Nationwide Data in Korea. Gut Liver 2022; 16:300-307. [PMID: 34238768 PMCID: PMC8924799 DOI: 10.5009/gnl20379] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND/AIMS Biliary complications including biliary strictures and bile leaks are the most common complications that occur after liver transplantation (LT). Endoscopic treatment with endoscopic retrograde cholangiography (ERC) is considered the first-line treatment, and percutaneous transhepatic cholangiography (PTC) can serve as an alternative or rescue therapy. However, nationwide clinical data on the frequency of ERC and PTC following LT have not yet been investigated. METHODS Using the nationwide claims database, we investigated patients who underwent LT between 2012 and 2014 in Korea and followed them until 2015. We analyzed the prevalence and characteristics of patients and biliary procedures, including ERC and PTC implemented after LT. RESULTS A total of 3,481 patients underwent LT during the 3-year study period. Among them, 3.0% of patients underwent biliary intervention postoperatively during the same hospitalization period, and 21.4% of patients received biliary intervention later on after initially being discharged from the hospital following LT. A total of 16.9% and 12.1% of patients underwent ERC and PTC after LT, respectively. The median period from LT to the first biliary intervention was 7.8 months (interquartile range, 3.5 to 14.6 months), and these patients underwent an average of 3.2±2.8 biliary procedures during the follow-up period. Patients undergoing living donor LT were more than twice as likely to undergo biliary procedures as those undergoing deceased donor LT (25.5% vs 12.1%). CONCLUSIONS Approximately one-fourth of patients in Korea who underwent LT subsequently underwent ERC or PTC. Compared with deceased donor LT patients, those undergoing living donor LT underwent more biliary interventions and were more difficult to treat.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jungmee Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Nyol Paik
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Won Jae Yoon
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung-Wook Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae-Young Jang
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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Jang SI, Chung TR, Cho JH, Lee KH, Joo SM, Choi JH, Kim SI, Lee DK. Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation. Dig Endosc 2021; 33:840-848. [PMID: 33043522 DOI: 10.1111/den.13871] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/08/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs. METHODS Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. RESULTS A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%). CONCLUSIONS The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.
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Affiliation(s)
- Sung Ill Jang
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Ryong Chung
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Moon Joo
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hye Choi
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sae In Kim
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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45
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Tao H, Wang P, Sun B, Zhou X, Xie J. One-step Percutaneous Transhepatic Cholangioscopy Combined With High-frequency Needle-knife Electrotomy in Biliary Strictures After Liver Transplantation. Surg Laparosc Endosc Percutan Tech 2021; 31:787-793. [PMID: 33935263 DOI: 10.1097/sle.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endoscopic management is the mainstay for biliary strictures after liver transplantation. However, this method is often failed in cases associated with hepatolithiasis or refractory strictures. The aim of this study is to investigate whether 1-step percutaneous transhepatic biliary cholangiography (PTC) combined with high-frequency needle-knife electrotomy can be an alternative method in biliary strictures after liver transplantation that could not be treated by endoscopic management. METHODS Clinical data of 14 patients suffering from biliary strictures after liver transplantation from June 2014 to January 2018 were retrospectively analyzed. One-step PTC combined with high-frequency needle-knife electrotomy was used to resolve the strictures. RESULTS One-step PTC was successfully performed in all 14 patients. In 10 of 12 (83.3%) patients with hepatolithiasis, the stones were removed completely. Stricture resolution was detected in 13 of 14 (92.9%) patients at first postoperative choledochoscopy. Three mild adverse events occurred (cholangitis, 2 patients; delayed hemobilia, 1 patient), but were resolved with conservative treatment. The follow-up after supporting catheter removal was 15.7±4.5 months. Only 1 patient (8.3%) had stone recurrence and no stenosis occurred during supporting-catheter-free follow-up. CONCLUSIONS One-step PTC combined with high-frequency needle-knife electrotomy seems to be a useful for treating biliary strictures after liver transplantation.
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Affiliation(s)
- Haisu Tao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Ping Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Beiwang Sun
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xinghua Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiafen Xie
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Cantù P, Santi G, Rosa R, Parzanese I, Macchini F, Tenca A, Fanetti I, Invernizzi F, Donato MF, Lampertico P, Reggiani P, Rossi G, Vecchi M, Penagini R. Cost analysis of a long-term randomized controlled study in biliary duct-to-duct anastomotic stricture after liver transplantation. Transpl Int 2021; 34:825-834. [PMID: 33730421 DOI: 10.1111/tri.13867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Multiple plastic stent (MPS) for biliary anastomotic stricture (AS) after liver transplantation requires multiple procedures with consequent costs. To compare the success, adverse events and treatment-related costs of fully covered self-expandable metal stents (FCSEMS) versus MPS. Thirty liver transplant (LT) patients with clinically relevant naïve AS were prospectively randomized to FCSEMS or MPS, with stent numbers increased at 3-month intervals. Treatment costs per patient were calculated for endoscopic retrograde cholangiopancreatography (including all devices and stents) and overall hospital stay. Radiological success was achieved in 73% of FCSEMS (median indwelling period of 6 mos) and 93% of MPS patients (P = NS) (median period of 11 mos). AS recurrence occurred in 36% of FCSEMS and 7% of MPS patients (P = NS), and AS re-treatment was needed in 53% and 13% (P < 0.01), respectively, during follow-up of 60 (34-80) months. Stents migrated after 29% and 2.6% of FCSEMS and MPS procedures, respectively (P < 0.01). Including re-treatments, long-term clinical success was achieved in 28/30 (93%) patients. Overall treatment-related costs were similar between groups. In the subgroup of LT patients in clinical remission after first-line treatment, treatment costs were 41% lower per FCSEMS patient compared with MPS patients. FCSEMS did not perform better than MPS. FCSEMS migration increased the rate of re-treatment and costs.
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Affiliation(s)
- Paolo Cantù
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulio Santi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Rosa
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Parzanese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Macchini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Tenca
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Clinic of Gastroenterology, Department of Medicine, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Ilaria Fanetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Invernizzi
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Francesca Donato
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pietro Lampertico
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
| | - Paolo Reggiani
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Rossi
- Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy.,General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi, Milan, Italy
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Lee TH, Moon JH, Lee YN, Jo SJ, Park JK, Yang JK, Cha SW, Cho YD, Park SH. Efficacy of a modified short fully covered self-expandable metal stent for perihilar benign biliary strictures. J Gastroenterol Hepatol 2021; 36:1057-1063. [PMID: 32926577 DOI: 10.1111/jgh.15258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/03/2020] [Accepted: 09/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self-expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent-induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. METHODS Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5-6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow-up period were measured. RESULTS Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138-196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow-up period (median 635 days) after stent removal, only one recurrence developed. CONCLUSIONS Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution.
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Affiliation(s)
- Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Seok Jung Jo
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Jae Keun Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Sang-Woo Cha
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul Hospital, Seoul, Korea
| | - Young Deok Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul Hospital, Seoul, Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
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Martins FP, Seleti SMR, Contini ML, DE Paulo GA, Ferrari AP. IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT? ARQUIVOS DE GASTROENTEROLOGIA 2021; 57:347-353. [PMID: 33237212 DOI: 10.1590/s0004-2803.202000000-67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 07/31/2020] [Indexed: 02/11/2025]
Abstract
BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.
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Attwell A, Han S, Kriss M. Endoscopic retrograde cholangiopancreatography and liver biopsy in the evaluation of elevated liver function tests after liver transplantation. World J Hepatol 2021; 13:132-143. [PMID: 33584992 PMCID: PMC7856863 DOI: 10.4254/wjh.v13.i1.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/02/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Abnormal liver function tests (LFTs) in post-liver transplant (LT) patients pose a challenge in the timing and selection of diagnostic modalities. There are little data regarding the accuracy of endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy (LB) in diagnosing post-transplant complications.
AIM To evaluate the diagnostic performance of ERCP and LB in patients with non-vascular post-LT complications.
METHODS This single-center retrospective study evaluated patients undergoing both ERCP and LB for evaluation of elevated LFTs within 6 mo of LT from 2000 to 2017. Diagnostic operating characteristics including accuracy, sensitivity and specificity for various diagnoses were calculated for ERCP and LB. The R factor (ratio of alkaline phosphatase to alanine aminotransferase) was also calculated for each patient.
RESULTS Of the 1284 patients who underwent LT, 91 patients (74.7% males, mean age of 51) were analyzed. Anastomotic strictures (AS, 24.2%), acute cellular rejection (ACR, 11%) and concurrent AS/ACR (14.3%) were the most common diagnoses. ERCP carried an accuracy of 79.1% (95%CI: 69.3-86.9), LB had an accuracy of 93.4% (95%CI: 86.2-97.5), and the combination of the two had an accuracy of 100% (95%CI: 96-100). There was no difference between patients with AS and ACR in mean R factor (AS: 1.9 vs ACR: 1.1, P = 0.24). Adverse events did not differ between the two tests (ERCP: 3.1% vs LB: 1.1%, P = 0.31).
CONCLUSION In patients with abnormal LFTs after LT without vascular complications, the combination of LB and ERCP carries low risk and improves diagnostic accuracy over either test alone.
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Affiliation(s)
- Augustin Attwell
- Department of Medicine, University of Colorado-Denver, Denver, CO 80203, United States
| | - Samuel Han
- Department of Medicine, Ohio State University Wexler Medical School, Columbus, OH 43210, United States
| | - Michael Kriss
- Department of Medicine, University of Colorado Medical School, Aurora, CO 80045, United States
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Das R, Slivka A. Fully covered metal stents versus plastic stents: The new kid on the block or the old standby? Gastrointest Endosc 2020; 92:1225-1227. [PMID: 33236994 DOI: 10.1016/j.gie.2020.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/06/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Rohit Das
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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