Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)

Tabibian, James H.; Asham, Emad H.; Han, Steven; Saab, Sammy; Tong, Myron J.; Goldstein, Leonard; Busuttil, Ronald W.; Durazo, Francisco A.

doi:10.1016/j.gie.2009.10.023

« Previous Next »Gastrointestinal Endoscopy
Volume 71, Issue 3 , Pages 505-512, March 2010

Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)

Current affiliations: Dumont-UCLA Liver Transplant Center (J.H.T., E.H.A., S.H., S.S., M.J.T., L.G., R.W.B., F.A.D.), Los Angeles, California, Johns Hopkins Medical Institution (J.H.T.), Osler Medical Residency Program, Baltimore, Maryland, USA

Received 14 May 2009; accepted 14 October 2009.

Los Angeles, California, USA

Background

The optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established.

Objective

To review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution.

Design

Retrospective study.

Setting

Tertiary-care center.

Patients

Eighty-three patients with a diagnosis of ABS.

Interventions

ERCP with balloon dilation and maximal stenting.

Main Outcome Measurements

Stricture resolution, stricture recurrence, and complication rates.

Results

Of 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP.

Limitations

Retrospective study, single endoscopist.

Conclusions

Our maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment.

Abbreviations: ABS, anastomotic biliary stricture, CBD, common bile duct, CDCD, choledochocholedochostomy, HJ, hepaticojejunostomy, OLT, orthotopic liver transplantation