Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation

Phillips, Melissa S.; Bonatti, Hugo; Sauer, Bryan G.; Smith, Larissa L.; Javaid, Mahvesh Rana; Kahaleh, Michel; Schmitt, Timothy M.

doi:10.1055/s-0030-1256389

Cited by 50 publications

(29 citation statements)

References 21 publications

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“…These examinations were scheduled by treating physicians to evaluate possible late bile duct injury several months after stent removal. Concerns have been raised in literature [3,25,29] about the development of late strictures several months after FCS-EMS removal, and this was the main cause for the referral of patients to a control ERCP. Patients contacted the authors for further information about the development of late strictures and possible methods for diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, after long-term follow-up, no patients exhibited signs of FCSEMS-related complications. We believe that most of the FCSEMS-associated complications are related to the duration of stenting, especially the nearly 10 % stricture rate of the literature [3,25,29], which is a major concern before additional FCSEMS placement for a refractory biliary leak. The association between short-term stenting and the absence of complications strongly support this hypothesis.…”

Section: Discussionmentioning

confidence: 99%

“…This was a retrospective study where stent removal was not scheduled according to specific endpoints. In the leak group, no patients with bile leaks after cadaveric orthotopic liver transplantation or with large leaks following partial cholecystectomy were included; these types of leaks can be problematic, leading to increased stenting durations [22,25,29,31]. Nevertheless, in a report of three patients outlining the SEMS treatment of bile leaks after open subtotal cholecystectomy, Baron et al [22] noted a dramatic decrease of bile output in a short period of time, suggesting that these leaks can also be treated with shortterm stenting.…”

Section: Discussionmentioning

confidence: 99%

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Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Canena

Liberato²,

Horta

et al. 2012

Surg Endosc

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Background Fully covered self-expandable metal stents (FCSEMS) have been used as a rescue therapy for several benign biliary tract conditions (BBC). Long-term stent placement commonly occurs, and prolonged FCSEMS placement is associated with the majority of the complications reported. This study evaluated the duration of stenting and the efficacy and safety of temporary FCSEMS placement for three BBCs: refractory biliary leaks, postsphincterotomy bleeding, and perforations. Methods This was a retrospective case series with longterm follow-up of 25 patients who underwent FCSEMS placement for BBCs. This study included 17 patients with postcholecystectomy refractory biliary leaks who had previously undergone unsuccessful sphincterotomy and plastic stent placement, 4 patients with difficult-to-control postsphincterotomy bleeding, and 4 patients with a perforation following endoscopic sphincterotomy. Stents were removed according to clinical evidence of problem resolution. The review included stenting duration, safe FCSEMS removal, clinical efficacy, complications, and long-term outcomes. During the follow-up period, ERCP and cholangioscopy procedures were performed to exclude the possibility of bile duct lesion development. Results Complete resolution of the initial condition was achieved in all patients. Patients with biliary leaks had a median stent duration time of 16 days (range 7-28 days). Patients with bleeding had stents removed after a median time of 6 days (range 3-15 days). Patients with perforations had their stents removed after a median time of 29.5 days (range 21-30 days). There were no complications related to stenting. Conclusions Temporary placement of a FCSEMS for 30 days or less is an effective rescue therapy for refractory biliary leaks, difficult-to-control post-endoscopic sphincterotomy bleeding, and perforations. Duration of stenting should be different for each type of condition. Stents can be safely removed, and short-term stenting is associated with the absence of early and late complications.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Canena

Liberato²,

Horta

et al. 2012

Surg Endosc

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“…While FCSEMS may be effective for bile leaks, some stents carry a risk of new stricture formation in LT recipients, thus more information is needed in these patients. 25 A number of studies indicate that the location of the bile leak is a key factor predicting ERCP-directed treatment success. Pfau et al 4 described a significantly lower success rate of endoscopic treatment of anastomotic leaks (42.9%) compared with T-tube-related leaks (95.2%).…”

Section: Discussionmentioning

confidence: 99%

Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers

Sendino

Fernandez-Simon

Law

et al. 2017

United European Gastroenterology Journal

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Background: Bile leak after liver transplantation (LT) is commonly treated with endoscopic retrograde cholangiopancreatography (ERCP); however, there are limited data regarding the optimal treatment strategy. Objective: We aimed to examine the role of ERCP in LT recipients with bile leaks at two large institutions. Methods: We reviewed all ERCPs performed in LT recipients with bile leak and duct-to-duct biliary anastomosis at two high-volume transplant centers. Results: Eighty patients were included. Forty-seven (59%) patients underwent ERCP with plastic stent placement (with or without sphincterotomy) and 33 patients (41%) underwent sphincterotomy alone. Complete resolution was obtained in 94% of the stent group vs. 58% of the sphincterotomy group (p < 0.01). There was no difference in three-month survival among both groups. Percutaneous transhepatic therapy and surgery were required in 4% and 6% in the stent group vs. 12% and 42% in the sphincterotomy group, respectively (p ¼ 0.22 and p < 0.001). The only predictive factor of bile leak resolution was stent placement. Conclusion: ERCP with plastic stent placement is highly successful and more effective than sphincterotomy alone for post-LT bile leak treatment. These results indicate that ERCP and plastic stent placement should be considered the standard of care for the treatment of bile leaks in LT.

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“…De novo strictures have occurred in the bile duct even after the implantation of an FCSEMS lacking flared ends [8], suggesting that the entire bile duct wall covered by a stent can be damaged by the abrupt, high radial force generated by the expansion of the FCSEMS or a disproportionately greater stent diameter relative to the smaller luminal diameter. An FCSEMSinduced second stricture can occur at both stent margins with an incidence of 8-16 % [6,9].…”

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confidence: 99%

Covered Self-Expandable Metal Stents for the Treatment of Benign Biliary Strictures After Liver Transplantation: When and How?

Lee

2013

Dig Dis Sci

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Benign biliary strictures (BBS) may complicate biliary surgery including liver transplantation (LT) [1]. The firstline management of BBS, including anastomotic strictures after LT, now incorporates endoscopic therapy, mostly consisting of stenting [2]. Although originally designed for endoscopic palliation of malignant biliary strictures, the self-expandable metallic stent (SEMS) is a valid alternative to surgery for BBS. Patients with malignant biliary strictures who undergo treatment with metal stents have a limited life expectancy due to the poor prognosis of the underlying disease. Therefore, for patients with BBS who have a normal life expectancy, the indications for metal stent placement should differ from those applied to malignant biliary strictures.Metal stents can be divided into uncovered SEMS, partially covered SEMS, and fully covered SEMS (FCS-EMS). Non-removable uncovered SEMS cannot be used for BBS due to their limited patency, since reactive hyperplastic tissue may extend through the metal mesh. Partially covered SEMS can be used for BBS to decrease the rate of stent migration; however, the uncovered portion can embed in the bile duct wall. FCSEMS are a good first choice because of their easy removal and long duration of patency due to lack of tissue hyperplasia and implantation into the biliary tree. Since frequent spontaneous stent migration is a major adverse event associated with FCS-EMS, an anchoring system such as flared ends or anchoring fins has been developed [3].In this issue of Digestive Diseases and Sciences, Kahaleh's group reports the retrospectively analyzed outcomes of covered SEMS for 55 patients with anastomotic strictures after LT [4]. Twenty-seven of 55 (49.1 %) patients were treated with plastic stents prior to covered SEMS. The authors applied three different types of covered SEMS: partially covered SEMS (19 patients), FCSEMS with anchoring fins (21 patients), and FCSEMS with flared ends (15 patients). Endoscopic biliary sphincterotomy was performed in all patients. Although the authors endeavored to center the stent within the stricture, success was not universal. All covered SEMS were removed after 3-4 months. The technical success rate was 100 %, but the clinical success rate, as measured by stricture resolution, was unsatisfactory (60-74 %). Even after covered SEMS placement, three (5.5 %) patients eventually required surgery to resolve their biliary strictures. Notably, the stentrelated adverse event rate involving migration and occlusion was 7-24 %. Five patients with early stent occlusion required repeat stenting. Indeed, the clinical success rate of endoscopic stenting with multiple plastic stents is reportedly 87-94 % [5].The location of the stricture is usually the most proximal aspect of the common hepatic duct in anastomotic strictures after LT, especially after living-related LT recipients, in whom the strictured segment is usually short. To achieve effective stenting with covered SEMS, the stent should be centered within the strictured bile duct segment, which ...

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Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation

Abstract: FCSEMS treat biliary leaks effectively, but carry a relatively high stricture risk in patients who have received liver transplants. FCSEMS cannot be recommended for management of biliary leaks following liver transplantation at this point.

Cited by 50 publications

References 21 publications

Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations

Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers

Covered Self-Expandable Metal Stents for the Treatment of Benign Biliary Strictures After Liver Transplantation: When and How?

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