Biliary Leak in Post-Liver-Transplant Patients: Is There Any Place for Metal Stent?

Abstract

Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population.

Management issues in post living donor liver transplant biliary strictures

“…However, most of the data is in post DDLT strictures [46,47] . The smaller size of donor liver ducts as well as very short common duct stump and discrepancy between recipient and donor duct size make it unsuitable for use in LDLT strictures.…”

Covered metal stents in endoscopic therapy of biliary complications after liver transplantation

“…2) [35,36], an approach that is highly successful (>90%) in the case of minor leaks, although major leaks still require hepatojejunostomy in both LT and non-LT patients. CSEMS were initially proposed as rescue therapy for leaks refractory to conventional treatment because of their larger diameter, long-term patency and removability [9,33,[37][38][39].…”

“…There are few studies of LT patients affected by leaks without AS. In the largest of these studies [37], 31 LT patients with major leaks (22 anastomotic and nine non-anastomotic) not responding to plastic stenting (n = 8) or with comorbidities contraindicating multiple procedures (n = 23) were managed by placing different fully (n = 28) or partially CSEMS (n = 3), which were removed within four months. The success rates >6 months after stent removal ranged from 70 to 100%, but secondary strictures occurred in up to 33% of the patients receiving partially CSEMS, 35% of those receiving a fully CSEMS with fins, and 10% of those receiving a fully CSEMS with flared ends.…”

“…Tissue ingrowth at the level of the proximal metal meshes was assessed by cholangioscopy. Minor complications were cholangitis (5.6%) and stent migration (5.6%) [37]. However, the use of fully CSEMS has now become more favoured than partially CSEMS to reduce ingrowth at uncovered sites and facilitate removal.…”

“…Unexpectedly, the main challenge when using a CSEMS to treat isolated leaks is not migration but secondary strictures. Frequently asymptomatic distal migration of a fully CSEMS has only been reported in 8% of cases and not required retreatment, whereas strictures secondary to CSEMS treatment have been observed overall in 27% of patients [37,39], although they can be successfully managed by means of repeat endoscopic treatment (MPS or CSEMS).…”