Introduction
Biliary complications following liver transplantation are the leading source of morbidity, graft failure and are associated with 10% mortality rate. Internal biliary stents were reported to decrease the risk of biliary complications when used in high-risk liver transplant recipients with small bile duct diameter.
Aims & Methods
The aim of the study was to assess the prophylactic effect of internal biliary stents (BS) on the incidence of biliary complications, graft loss, overall mortality and to study risk factors for biliary complications. Furthermore, we aimed to examine the prophylactic effect of internal biliary stent in the subgroup of patients with primary sclerosing cholangitis. We performed a large-volume single-center study including all adult patients who underwent deceased-donor liver transplantation either with end-to-end choledococholedocostomy or hepaticojejunostomy between 2005-2021.
Results
Out of 1447 liver transplant recipients (1555 liver transplantations), 456 (29%) were eligible for biliary stenting (size of the recipient or/and donor duct smaller < 6mm). The incidence of biliary complications between the patients with internal biliary stents and the control group was comparable (24% vs. 23%, p= 0,7). Five, ten and fifteen-year graft survival rates were significantly lower among patients with biliary complications regardless of the presence of biliary stents (p<0.01), whereas patient long- term survival did not differ between the groups. In multivariate analysis, thrombosis of the hepatic artery was the only risk factor for all types of biliary complications (p < 0,001). In total 171 patients with primary sclerosing cholangitis as an indication for liver transplantation were included, from which 61 of them (35,7%) received internal biliary stent. The incidence of biliary complications between these patients and the control group was similar (16% vs. 21%, p= 0,5), overall mortality and graft survival did not differ between the groups. Biliary reconstruction was performed as end-to-end choledococholedocostomy in 76 patients and hepaticojejunostomy in 95 patients, anastomotic stricture occurred in a majority of patients with end-to-end choledococholedocostomy (21% v.s. 3 %, p = 0.001), other types of biliary complications were comparable.
Conclusion
Biliary stenting in liver transplant recipients with a narrow bile duct resulted in a similar incidence of biliary complications when compared to recipients with a normal duct and no stents, suggesting its protective role. During a long-term follow-up, graft loss was significantly higher among patients with biliary complications regardless of the presence of internal biliary stents, mortality was comparable.
References
1) Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr. 2021 Jan;10(1):76-92.
2) Elkomos, B.E., Abdelaal, A. Do We Need to Use a Stent in Biliary Reconstruction to Decrease the Incidence of Biliary Complications in Liver Transplantation? A Systematic Review and Meta-Analysis. J Gastrointest Surg 27, 180–196 (2023).
3) Girard E, Risse O, Abba J, Medici M, Leroy V, Chirica M, Letoublon C. Internal biliary stenting in liver transplantation. Langenbecks Arch Surg. 2018 Jun;403(4):487-494.
4) Nemes B, Gámán G, Doros A. Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 2015 Apr;9(4):447-66.
5) Spicák J, Ryska M, Trunecka P, Skála I, Stirand P, Bĕlina F, Sperl J, Hrncárková H, Taimr P, Vítko S, Filip K. The role of ERCP in management of biliary complications after liver transplantation. Ann Transplant. 2001;6(2):29-32.
6) Esfeh JM, Eghtesad B, Hodgkinson P, Diago T, Fujiki M, Hashimoto K, Quintini C, Aucejo F, Kelly D, Winans C, Vogt D, Miller C, Zein N, Fung J. Duct-to-duct biliary reconstruction in patients with primary sclerosing cholangitis undergoing liver transplantation. HPB (Oxford). 2011 Sep;13(9):651-5.
