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ENDOSCOPIC TREATMENT OF BILIARY STRICTURE AFTER ORTHOTOPIC LIVER TRANSPLANTATION
Paola Violi, Luca Bortolasi*, Amedeo Carraro, Angelo Cerofolini, Andrea Munari, Umberto Montin, Umberto Tedeschi
Surgery, AOUI Verona, VR, Verona, Italy
Liver transplantation (OLTx) represents the gold standard therapy for end-stage liver disease caused by chronic hepatic diseases, hepatocellular carcinoma, congenital or acquired metabolic disease of adult or pediatric patients. Biliary complications after OLTX show an increasing trend that can reach 40% and might present as anastomotic stricture, bile leak or ischemic type lesion; while the first ones are primarily related to technical-surgical causes, many factors are involved in determining the last. Anastomotic strictures are besides divided in anastomotic (AS) and non-anastomotic (NAS).
The aim of this retrospective study is to analyze the efficacy of endoscopic treatment of biliary stenosis with different strategies: single vs multiple plastic stent vs self-expandable metal stent (SEMS).
Between January 2004 and December 2014, at the Department of General Surgery and Liver Transplantation of the University Hospital of Verona (Italy), 223 liver transplantations were performed in 217 patients; 47 pts (21,6%) had biliary stricture: 18 pts with AS and 29 pts with NAS (Table 1). Mean follow up time was 55 months. Differences between the groups were analyzed with chi-square test and survival analysis with Kaplan-Meier method; p-value was considered significant <0.05.
We compared three groups of patients divided by endoscopic treatment performed: single plastic stent group vs multiple plastic stents vs SEMS group. The variables considered were: success rate (defined as complete resolution of the symptoms), mean treatment time and mean number of procedures in successful cases, number of pts referred for surgical treatment (failed cases) and number of deaths related to biliary complications (Table 2). No statistical significant differences between the groups were shown, nevertheless SEMS group showed a better successful rate compared to the other groups; neither SEMS group nor multiple stent group showed failure of treatment that required surgical management. Five-year survival was 75%, 55% and 25% for multiple stents, SEMS and single stents, respectively.
Aggressive endoscopic approach has a key role in the treatment of biliary stricture after OLTx. Multiple stents and SEMS show better outcome, in particular none of these patients underwent biliary surgery or were re-transplanted, versus single stent; however definitive conclusion cannot be drawn seen the small numbers of the samples. Eventually it is important to underline that in biliary complication post OLTx it is mandatory a multidisciplinary management between transplant surgeon, gastroenterologist, endoscopist and radiologist in order improve organ survival and therefore patient outcome.
Table1
| Type of biliary complication | n. pts (%) | | Anastomotic stricture | 18 (38.3%) | Non-anastomotic stricture:
- extrahepatic bile duct
- biliary confluence
- intrahepatic biliary duct | 29 (61.7%)
- 12 (41.1%)
- 7 (24.1%)
- 10 (34.4%) | | Kinking extrahepatic bile duct | 3 (10.6%) | | Low grade stenosis | 15 (31.9%) | | High grade stenosis | 15 (31.9%) | | Complete stenosis | 17 (36.2%) | | Maximum stricture length (median, min-max) | 14.5 mm (4-40) |
Table 2 | | Single plastic stent (22 pts) | Multiple plastic stents (11 pts) | SEMS (14 pts) | p-value | | Success rate | 9/22 (41%) | 3/11 (27%) | 8/14 (57%) | 0.328 | | Mean treatment time in successful cases (min-max) | 15.4 mos. (1.9-46.2) | 12.4 mos. (6.7-16) | 16.1 mos. (3.3-28.5) | 0.877 | | Mean number of procedures in successful cases (min-max) | 6.7 (2-14) | 5.3 (3-7) | 7.4 (4-13) | 0.688 | | Number of pts referred for surgical approach (failed caes) | 4/22 (18.2%) | 0 | 0 | 0.083 | | Number of pts dead for biliary complication | 3/22 (13.6%) | 0 | 3/14 (21.4%) | 0.277 |
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