Introduction

Biliary strictures are a recognised complication of liver transplant. The criteria for proceeding with Endoscopic Retrograde Cholangiography [ERC] remains a subject of contention. This study seeks to explore management strategies of anastomotic strictures, compare rates of successful remodelling and complication rates.

Aims & Methods

All patients with a post-liver transplant stricture who underwent ERC in a tertiary centre between 2016 and 2023 were included. Categorical divisions were made between patients with a single anastomotic stricture and multi-focal or hilar strictures. Time for stricture development, pre and post-ERC liver serum markers, frequency of procedures performed, percentage successfully remodelled by ERC, percentage referred for surgical intervention and associated adverse events were retrospectively recorded.

Results

During the specified period, 107 patients with prior liver transplant (70 male, 37 female, median age 55.5 (IQR 15)) with a biliary stricture were referred for ERC. 88/107 had a single anastomotic stricture whereas 19 had multi-focal or hilar strictures. Median time from transplant to radiological discovery of biliary stricture was 5 months with 71% occurring within 12 months.
Patients with a diagnosis of a single anastomotic stricture (n=88) underwent a total of 237 total ERCs (mean 2.6 per patient). There was a significant improvement in liver function profile and bilirubin after ERC (unpaired t-test - p<0.01). The number of remodelled strictures was 64/88 (72.7%). There were 32 ERC associated complications (13.5%); 10 cholangitis, 9 pancreatitis, 13 other. Ten patients were referred for surgical intervention (11.4%).
Patients with multi-focal / hilar strictures (n=19) underwent a total of 45 ERCs (mean 2.4 per patient). There was a non-significant improvement in bilirubin (P=0.096) and ALP (P= 0.184) after ERC and a significant improvement in ALT (P<0.02). The number of remodelled strictures was 7/19 (36.8%). There were 8 ERC associated complications (17.8%), 7 cholangitis and 1 pancreatitis. Five patients were referred for surgical intervention (26.3%).
Single anastomotic strictures, when compared to multi-focal strictures, were associated with a higher re-modelling rate (x², p= 0.003) and reduced need for surgical intervention (x², p = 0.089).

Conclusion

ERC is efficacious in managing single anastomotic strictures but significantly less effective in multi-focal proximal strictures. A significant complication rate in this cohort needs to be taken into consideration when planning intervention. However, the majority of these patients can be managed via ERC without the need for surgical intervention.

References

Jarlot-Gas C, Muscari F, Mokrane FZ, et al. Management of anastomotic biliary stricture after liver transplantation and impact on survival. HPB (Oxford). 2021;23(8):1259-1268. doi:10.1016/j.hpb.2020.12.008

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method for treating common bile duct (CBD) stones. However, in a small number of patients with suspected or confirmed choledocholithiasis on imaging, ERCP results may appear normal. Since the procedure carries considerable risks, such cases should be minimized.

Aims & Methods

This study aimed to analyse the incidence of reported normal ERCPs in cases of biliary stone disease and evaluate the impact of focused EUS in reducing unnecessary procedures.
Data were retrospectively collected from the endoscopy and patient record system, as well as a prospectively maintained database of all ERCP procedures at a UK teaching hospital during a 4.5-year period, from 1/1/2020 to 30/4/2024, with a 30-day additional follow-up period. Variables were assessed by mean with standard deviation (SD) or median with interquartile range (IQR).

Results

There were 3,217 ERCPs performed during the study period, of which 1,636 (50.8%) were performed for biliary stone disease. 124 ERCPs were reported as normal/no stones (7.6%). The most recent imaging was MRCP for 73/124 patients followed by CT for 23/124 and abdominal ultrasound (USS) for 16/124. The median days for imaging-to-ERCP was 8 (4;24).
89/124 patients had a dilated CBD and 11/124 had a confirmed CBD stone on the most recent imaging modality. 90/124 patients had an abnormal ALP and 62/124 had an abnormal bilirubin level. The median days of the most recent liver function tests to ERCP were 2 (1;12).
8/124 patients had a procedural complication. 3 had post-ERCP pancreatitis, 3 a post sphincterotomy bleed, 1 had mild cholangitis and 1 had a small post-sphincterotomy perforation.
From 2020, there has been a gradual increase in the combined single session EUS/ERCP procedures for CBD stones. Figure 1. demonstrates the significant reduction of the reportedly “normal” ERCPs as the number of the combined procedures increased. Around 1/3 of the combined procedures do not proceed to an ERCP.

Conclusion

Current guidelines recommend CBD stone extraction for all patients deemed fit for the procedure. Our findings indicate that performing single-session combined EUS/ERCP in carefully selected cases can reduce unnecessary ERCPs in centres offering both services, thereby minimizing patient risk.

References

1. Vila JJ, Fernández-Urién I, Carrascosa J. EUS and ERCP: A rationale categorization of a productive partnership. Endosc Ultrasound. 2021 Jan-Feb;10(1):25-32. doi: 10.4103/eus.eus_58_20. PMID: 33353903; PMCID: PMC7980694.
2. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149. doi: 10.1055/a-1075-4080. Epub 2019 Dec 20. PMID: 31863440.
3. Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, Barthet M, Domagk D, Dumonceau JM, Gigot JF, Hritz I, Karamanolis G, Laghi A, Mariani A, Paraskeva K, Pohl J, Ponchon T, Swahn F, Ter Steege RWF, Tringali A, Vezakis A, Williams EJ, van Hooft JE. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(5):472-491. doi: 10.1055/a-0862-0346. Epub 2019 Apr 3. PMID: 30943551.

Introduction

Anastomotic biliary strictures represent a significant burden after orthotopic liver transplantation, with challenging endoscopic treatment. The selection of the optimal approach regarding type of stents remains controversial due to the absence of strong evidence. The European Society of Gastrointestinal Endoscopy recommends stricture remodeling using multiple plastic stents (MPS),¹ whereas the American College of Gastroenterology supports the use of fully covered self-expandable metal stents (FC-SEMS),² as for every benign biliary stricture. In the absence of cumulative comparisons and considering the development of intraductal SEMS (ID-SEMS), which are promising for this type of strictures, this systematic review with meta-analysis aimed to evaluate the potential differences in the performance of the available stents in post-transplant anastomotic biliary strictures management.

Aims & Methods

The systematic research was performed in MEDLINE, Cochrane, and Scopus databases until April 2023 for comparative studies evaluating the successful stricture management using MPS and SEMS, including FC-SEMS and ID-SEMS. The primary outcome was stricture resolution after completion of therapy, documented by cholangiogram or cross-sectional imaging. Secondary outcomes included stricture recurrence (clinical and biochemical relapse with imaging confirmation) during the follow-up period, stent migration and adverse events. Quality assessment was based on the Newcastle-Ottawa scale. Meta-analyses were based on random effects model and the results were reported as odds ratios (OR), with 95% Confidence Intervals (95%CI). Subgroup analyses by type of metal stent were performed to explore the diversity among the results of different studies.

Results

Nine studies with an overall number of 687 patients were included in our analysis, with three of them being randomized controlled trials. Metal stents were placed in 251 cases (82 ID-SEMS and 169 FC-SEMS) and MPS in 436. Considering the primary outcome, metal and plastic stents did not differ significantly in stricture resolution with OR: 0.99 (95%CI: 0.48-2.01; I²=35%). Stricture recurrence and migration rates were also comparable between the two arms [OR: 1.71 (95%CI: 0.87-3.38; I²=55%) and OR: 0.73 (95%CI: 0.32-1.68; I²=56%) respectively]. All of these outcomes presented with moderate heterogeneity. Finally, the difference between adverse events rates was non-significant [OR: 1.47 (95%CI: 0.89-2.43; I²=24%)]. Interestingly, in the subgroup analysis ID-SEMS provided significantly higher complete resolution rates with low heterogeneity compared to the MPS [OR: 3.48 (95%CI: 0.89-13.62; I²=5%)], whereas the comparison between FC-SEMS and MPS did not reach significance [OR: 0.76 (95%CI: 0.42-1.39; I²=11%)]. Relative recurrence rates did not differ between subgroups [for ID-SEMS vs MPS, OR: 1.01 (95%CI: 0.51-2.03; I²=0%; for FC-SEMS vs MPS, OR:2.39 (95%CI: 0.87-6.56; I²=66%)]. On the other hand, migration rates were significantly lower for ID-SEMS compared to MPS, with OR: 0.28 (95%CI: 0.11-0.70; I²=0%), and equivalent for FC-SEMS and MPS [OR: 1.25 (95%CI: 0.54-2.88; I²=40%)]. Complication rates were similar for ID-SEMS and MPS [OR: 0.90 (90%CI: 0.28-2.84; I²=47%)], but their prevalence after FC-SEMS were significantly higher compared to MPS [OR: 1.76 (95%CI: 1.06-2.93; I²=0%)].

Conclusion

The comparison between metal stents and MPS did not result to significant differences in any outcome. However, ID-SEMS appeared superior to MPS in stricture resolution and migration rates, whereas FC-SEMS provided comparable outcomes to MPS.

References

1. Dumonceau JM, Tringali A, Papanikolaou I, Blero D, Mangiavillano B, Schmidt A, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017. Endoscopy. 2018 Sep 7;50(09):910–30.
2. Elmunzer BJ, Maranki JL, Gómez V, Tavakkoli A, Sauer BG, Limketkai BN, et al. ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures. American Journal of Gastroenterology. 2023 Mar;118(3):405–26.

Introduction

Biliary adverse events manifest in approximately 25% of liver transplant recipients. Among these, anastomotic biliary strictures (ABS) are the most prevalent, occurring in approximately 6%‐12% of cases and can be successfully managed endoscopically.

Aims & Methods

Our study aims to present the evolution of method and long-term results of placing multiple plastic stents to treat ABS after orthotopic liver transplantation (OLT). All consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for liver transplantation-related biliary complications at our Endoscopy Unit between July 1994 and September 2022 were retrospectively identified. The analysis focused only on the patients diagnosed with ABS undergoing dilatation by a progressively increasing number of plastic stents. Follow-up after stent removal was obtained by office visit, telephone contact with the patient or referring physician and extended to this year or until patient succumbed.

Results

Two hundred and ninety-five patients referred by 4 Liver Transplant Units underwent ERCP in need of endoscopic treatment for biliary complications after liver transplantation. However only 151 represented our intention-to-treat group with ABS. Out of these, 21 patients were excluded because of split liver transplantation, the use of metallic stents or incomplete endoscopic treatment. The mean age of the remaining 130 patients was 56 ± 9 years old and included 107 males and 23 females. We divided these patients in 2 groups according to similar timeframes, 28 ABS patients being treated before 2008 and 102 patients after 2008. In the first group the median number of stents was 4 (range 2-7), with a median of 3 ERCPs (range 2-5) per patient. Patients treated after 2008 received a median number of 6 stents (range 3-9) (p = .000, Mann-Whitney U), with a median of 4 ERCPs (range 3-7) (p = .002, Mann-Whitney U). The mean treatment duration was 15.3 ± 16.7 months in the first group and 14 ± 10 months in the second. Stricture recurrence was noted in 14.2% of patients treated before 2008 versus 4.9% after 2008. Nevertheless, the follow-up period was 10.6 ± 7.5 years for the first group and 4.7 ± 4 years in the second group.

Conclusion

The endoscopic treatment with multiple plastic stents proved to be effective for the majority of patients with ABS after OLT. In the last decade, the endoscopists shifted towards a more aggressive treatment strategy, with an increased number of stents and a reduced period between stent replacement procedures. This intensive approach seems also to underline a lower stricture recurrence rate however a longer follow-up period needs to be considered for the patients treated after 2008.

Introduction

Biliary leaks are a well-recognized complication following liver transplantation (LT). Despite advancements in ERCP techniques, there remains variability in treatment success, Considering the peculiarities of this patient group, characterized by specific post-surgical anatomy, variations in endoductal pressure, and immunosuppressive therapy. This study was conducted to identify predictive factors influencing the healing of biliary leaks and the development of post-leak strictures, with the goal of refining management strategies and enhancing patient outcomes.

Aims & Methods

A retrospective analysis was performed on 34 LT patients who developed biliary leaks and were managed with ERCP within 24 hours from diagnosis. Variables included: the type of biliary stricture (anastomotic vs. non-anastomotic), presence of clinical symptoms (pain, fever, jaundice), time interval between multiple ERCPs to reach leak healing, characteristics of the stents (number, diameter in French, and length in cm), and leak parameters (high-grade vs. low-grade, early vs. late leak onset). Statistical analyses included Chi-square and Fisher's exact tests for categorical variables, Student's t-test and Mann-Whitney U test were used for continuous variables. The significance threshold was p<0.05.

Results

Among 34 patients with post-liver transplant biliary leaks, the overall healing rate was 94.1% (32/34). Early leaks (≤4 weeks) had longer healing times than late leaks (>4 weeks) (21.1 vs. 13.0 days). Strictures developed in 54.5% of patients (18/33). All strictures occurred in high-grade leaks: 66.7% in early high-grade and 60.0% in late high-grade groups. No strictures were observed in any low-grade leak, regardless of timing.
Based on cholangiographic appearance, high-grade leaks (visible before full biliary opacification) accounted for all strictures and often required multiple ERCPs. Low-grade leaks (visible only after full opacification) never led to strictures and typically healed after a single procedure. Notably, no strictures occurred in low-grade leaks, regardless of timing, while all strictures developed in patients with high-grade leaks, both early and late.
Shorter healing times were associated with the presence of symptoms, use of 10 Fr vs. 7 Fr stents, and intervals <1 month between ERCPs. In contrast, use of multiple stents, pre-existing NAS, and early high-grade leaks were linked to prolonged healing courses or non-resolution with standard ERCP strategy. The Kehr tube showed no significant impact.

Conclusion

Leak grade and timing are key predictors of post-transplant biliary leak healing. High-grade leaks, especially when early, were associated with delayed recovery and the need for multiple ERCPs, while low-grade leaks followed a consistently favorable course. Faster healing was also observed in symptomatic patients, with the use of 10 Fr stents and short ERCP intervals (<1 month). Strictures occurred exclusively in high-grade leaks, further supporting the prognostic relevance of cholangiographic grading. Incorporating leak grade and timing into early ERCP decision-making can accelerate healing, reduce complications, and significantly improve post-transplant outcomes.

References

1. Girotra, M., Soota, K., Klair, J. S., Dang, S. M., Aduli Mohit Girotra, F., Aduli, F., & Endoscopic, A. F. (2015). Endoscopic management of post-liver transplant biliary complications. World Journal of Gastrointestinal Endoscopy, 7(5), 446
2. Moy, B. T., & Birk, J. W. (2019). A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. Journal of Clinical and Translational Hepatology, 7(1), 61–71
3. Lee, H. W., Shah, N. H., & Lee, S. K. (2017). An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clinical Endoscopy, 50(5), 451– 463
4. Sendino, O., Fernández-Simon, A., Law, R., Abu Dayyeh, B., Leise, M., Chavez- Rivera, K., Cordova, H., Colmenero, J., Crespo, G., Rodriguez de Miguel, C., Fondevila, C., Llach, J., Navasa, M., Baron, T., & Cárdenas, A. (2018). Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers. United European Gastroenterology Journal, 6(1), 89–96
5. Oh, D., Lee, S. K., Song, T. J., Park, D. H., Lee, S. S., Seo, D. W., & Kim, M. H. (2015). Endoscopic management of bile leakage after liver transplantation. Gut and Liver, 9(3), 417–423

Introduction

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 COVID-19 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.

Aims & Methods

To compare the safety and efficacy profile of different stenting durations using Kaffes stents.
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.