Advertisement

Self-Expandable Metallic Stent Is More Cost Efficient Than Plastic Stent in Treating Anastomotic Biliary Stricture

  • Sunguk JangEmail author
  • Tyler Stevens
  • Rocio Lopez
  • Prabhleen Chahal
  • Amit Bhatt
  • Madhu Sanaka
  • John J. Vargo
Original Article
  • 29 Downloads

Abstract

Background

Anastomotic bile duct stricture (ABS) is one of the most common complications after liver transplantation. Current practice of endoscopic retrograde cholangiopancreatography (ERCP) with multiple plastic stent (MPS) insertion often requires multiple sessions before achieving stricture resolution. We aimed to compare the efficacy of fully covered self-expandable metallic stent (FCSEMS) with MPS method while simultaneously analyzing the relative healthcare cost between the two methods in the management of ABS.

Methods

Liver transplant patients with ABS who received ERCP with stent placement were identified by query of our endoscopic database. Comparative analyses between the group of patients treated with ERCP with MPS and the group treated with FCSEMS were performed. The costs to achieve stricture resolution, and the rates of stricture resolution, recurrence and complications were also compared.

Results

A total of 158 patients underwent ERCP with stent insertion for the management of ABS. Of those, 49 patient received FCSEMS for their ABS while 109 patients were treated with MPS only. Our cost analysis showed early utilization of FCSEMS can deliver up to 25% savings in the total procedure cost while providing comparable rates of stricture resolution. The rates of technical success, stricture recurrence and adverse outcomes, and stricture free durations were also comparable between the two groups.

Conclusion

While providing efficacy and safety rates comparable to ERCP-MPS, the incorporation of FCSEMS at early stage of ABS management could provide a substantial savings by reducing the number of ERCP session to achieve stricture resolution. Optimization of the timing and duration of FCSEMS indwelling time needs further validation.

Keywords

Endoscopic retrograde cholangiopancreatography Liver transplant Biliary stricture Stent 

Notes

Author’s contribution

SJ was involved in study conception and design, acquisition and interpretation of data, drafting of manuscript, critical revision of the manuscript for important intellectual content, and final approval of manuscript. TS contributed to study design, analysis and interpretation of data, and critical revision of the manuscript for important intellectual content, and final approval of manuscript. RL was involved in statistical analysis and interpretation and critical revision of the manuscript for important intellectual content. AB was involved in acquisition and analysis of data, critical revision of the manuscript for important intellectual content, and final approval of manuscript. PC contributed to acquisition and analysis of data, critical revision of the manuscript for important intellectual content, and final approval of manuscript. MS was involved in acquisition of data, critical revision of manuscript for important intellectual content, and final approval of manuscript. JV contributed to study design, analysis of data, critical revision of the manuscript for important intellectual content, and final approval of manuscript.

Compliance with ethical standards

Conflict of interest

Dr. Jang reports conflict of interest with consulting service arrangement with Boston Scientific, outside the submitted work. Dr. Stevens reports conflict of interest with consulting service arrangement with Boston Scientific and AbbVie Pharmaceutical. Dr. Bhatt declares no conflict of interest. Dr. Sanaka declares no conflict of interest. Dr. Chahal declares no conflict of interest. Dr. Vargo declares no conflict of interest. Ms. Lopez declares no conflict of interest.

Supplementary material

10620_2019_5665_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 13 kb)

References

  1. 1.
    Sharma S, Gurakar A, Jabbour N. Biliary strictures following liver transplantation: past, present and preventive strategies. Liver Transpl. 2008;14:759–769.CrossRefGoogle Scholar
  2. 2.
    Verdonk RC, Buis CI, Porte RJ, et al. Anastomotic biliary strictures after liver transplantation: causes and consequences. Liver Transpl. 2006;12:726–735.CrossRefGoogle Scholar
  3. 3.
    Welling TH, Heidt DG, Englesbe MJ, et al. Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient, and technical factors. Liver Transpl. 2007;14:73–80.CrossRefGoogle Scholar
  4. 4.
    Shin MJ, Cho JW. Advances in endoscopic management of biliary complications after living donor liver transplantation: comprehensive review of the literature. World J Gastroenterol. 2016;22:6173–6191.CrossRefGoogle Scholar
  5. 5.
    Ryu CH, Lee SK. Biliary strictures after liver transplantation. Gut Liver. 2011;5:133–142.CrossRefGoogle Scholar
  6. 6.
    Chaput U, Scatton O, Bichard P, et al. Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study. Gastrointest Endosc. 2010;72:1167–1174.CrossRefGoogle Scholar
  7. 7.
    Thuluvath PJ, Pfau PR, Kimmey MB, et al. Biliary complications after liver transplantation: the role of endoscopy. Endoscopy. 2005;37:857–863.CrossRefGoogle Scholar
  8. 8.
    Holt AP, Thorburn D, Mirza D, et al. A prospective study of standardized nonsurgical therapy in the management of biliary anastomotic strictures complicating liver transplantation. Transplantation. 2007;84:857–863.CrossRefGoogle Scholar
  9. 9.
    Albert JG, Filmann N, Elsner J, et al. Long-term follow-up of endoscopic therapy for stenosis of the biliobiliary anastomosis associated with orthotopic liver transplantation. Liver Transpl. 2013;19:586–593.CrossRefGoogle Scholar
  10. 10.
    Poley JW, Lekkerkerker MN, Bruno MJ, et al. Clinical outcome of progressive stenting in patients with anastomotic strictures after orthotopic liver transplantation. Endoscopy. 2013;45:567–570.CrossRefGoogle Scholar
  11. 11.
    Morelli J, Mulcahy HE, Draganov P, et al. Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement. Gastrointest Endosc. 2003;58:374–379.CrossRefGoogle Scholar
  12. 12.
    Kao D, Zepeda-Gomez S, Bain VG, et al. Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review. Gastrointest Endosc. 2013;77:679–691.CrossRefGoogle Scholar
  13. 13.
    Tabibian JH, Asham EH, Han S, et al. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy. Gastrointest Endosc. 2010;71:505–512.CrossRefGoogle Scholar
  14. 14.
    Fernández-Simon A, Díaz-Gonzalez A, Cárdenas A, et al. Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis. 2014;18:913–926.CrossRefGoogle Scholar
  15. 15.
    Kahaleh M, Behm B, Clarke BW, et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? Gastrointest Endosc. 2008;67:446–454.CrossRefGoogle Scholar
  16. 16.
    Mahajan A, Ho H, Sauer B, et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc. 2009;70:303–309.CrossRefGoogle Scholar
  17. 17.
    Coté GA, Slivka A, Tarnasky P, et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: a randomized clinical trial. JAMA. 2016;315:1250–1257.CrossRefGoogle Scholar
  18. 18.
    Tarantino I, Traina M, Mocciaro F, et al. Fully covered metallic stents in biliary stenosis after orthotopic liver transplantation. Endoscopy. 2012;44:246–250.CrossRefGoogle Scholar
  19. 19.
    Vandenbroucke F, Plasse M, Dagenais M, et al. Treatment of post liver transplantation bile duct stricture with self-expandable metallic stent. HPB (Oxf). 2006;8:202–205.CrossRefGoogle Scholar
  20. 20.
    Traina M, Tarantino I, Barresi L, et al. Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: a preliminary study. Liver Transpl. 2009;15:1493–1498.CrossRefGoogle Scholar
  21. 21.
    Pfau P, Pleskow D, Banerjee S, et al. Status evaluation report: Pancreatic and biliary stent. Gastrointest Endosc. 2013;77:319–327.CrossRefGoogle Scholar
  22. 22.
    García-Pajares F, Sánchez-Antolín G, Pelayo SL, et al. Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation. Transpl Proc. 2010;42:2966–2969.CrossRefGoogle Scholar
  23. 23.
    Jang S, Parsi M, Vargo J, et al. Efficacy and optimal duration of metallic stent in the management of refractory anastomotic stricture after liver transplantation. Clin Gastroenterol Hepatol. 2017;15:1776–1781.CrossRefGoogle Scholar
  24. 24.
    Martins FP, De Paulo GA, Contini M, et al. Metal versus plastic stent for anastomotic biliary strictures after liver transplantation: a randomized controlled trial. Gastrointest Endosc. 2018;87:131–140.CrossRefGoogle Scholar
  25. 25.
    Kaffes A, Griffin S, Vaughan R, et al. A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Ther Adv Gastroenterol. 2014;7:64–71.CrossRefGoogle Scholar
  26. 26.
    Williams T. Understanding hospital charges, costs and payments. https://strategicdynamicsfirm.com/understanding-hospital-charges-costs-and-payments. Retrieved December 14, 2015.
  27. 27.
    Andrews W, Cameron D. Disparity in medical billing. http://www.washingtonpost.com/wp-srv/special/national/actual-cost-of-medical-care/. Retrieved May 8, 2013.
  28. 28.
    Martin-Gomez LM, Sobrino-Rodriguez S, Alamo-Martinez JM, et al. Use of fully covered self-expandable stent in biliary complications after liver transplantation: A case series. Transpl Proc. 2010;42:2975–2977.CrossRefGoogle Scholar
  29. 29.
    DaVee T, Irani S, Baron T, et al. Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents. Surg Endosc. 2016;30:2332–2341.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Gastroenterology and Hepatology, Digestive Disease InstituteCleveland ClinicClevelandUSA
  2. 2.Department of Quantitative SciencesCleveland ClinicClevelandUSA

Personalised recommendations