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Optimal drainage of anastomosis stricture after living donor liver transplantation

Surgical Endoscopy volume 35, pages 6307–6317 (2021)Cite this article

A Correction to this article was published on 13 May 2021

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Abstract

Background

Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD).

Methods

Patients with biliary ASs after an LDLT (mean age: 57.3 years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3–4 months. Patients were followed-up for at least 1-year post-stent removal.

Results

Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2 months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4 months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59).

Conclusions

EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.

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References

  1. Jain A, Reyes J, Kashyap R, Dodson SF, Demetris AJ, Ruppert K, Abu-Elmagd K, Marsh W, Madariaga J, Mazariegos G, Geller D, Bonham CA, Gayowski T, Cacciarelli T, Fontes P, Starzl TE, Fung JJ (2000) Long-term survival after liver transplantation in 4,000 consecutive patients at a single center. Ann Surg 232:490–500

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Mazzaferro V, Bhoori S, Sposito C, Bongini M, Langer M, Miceli R, Mariani L (2011) Milan criteria in liver transplantation for hepatocellular carcinoma: an evidence-based analysis of 15 years of experience. Liver Transpl 17(Suppl 2):S44-57

    Article  PubMed  Google Scholar 

  3. Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, Montalto F, Ammatuna M, Morabito A, Gennari L (1996) Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 334:693–699

    Article  CAS  PubMed  Google Scholar 

  4. Lee SG, Moon DB, Hwang S, Ahn CS, Kim KH, Song GW, Jung DH, Ha TY, Park GC, Jung BH (2015) Liver transplantation in Korea: past, present, and future. Transplant Proc 47:705–708

    Article  CAS  PubMed  Google Scholar 

  5. Chan CH, Telford JJ (2012) Endoscopic management of benign biliary strictures. Gastrointest Endosc Clin N Am 22:511–537

    Article  PubMed  Google Scholar 

  6. Greif F, Bronsther OL, Van Thiel DH, Casavilla A, Iwatsuki S, Tzakis A, Todo S, Fung JJ, Starzl TE (1994) The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation. Ann Surg 219:40–45

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Thethy S, Thomson B, Pleass H, Wigmore SJ, Madhavan K, Akyol M, Forsythe JL, James Garden O (2004) Management of biliary tract complications after orthotopic liver transplantation. Clin Transplant 18:647–653

    Article  PubMed  Google Scholar 

  8. Rerknimitr R, Sherman S, Fogel EL, Kalayci C, Lumeng L, Chalasani N, Kwo P, Lehman GA (2002) Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 55:224–231

    Article  PubMed  Google Scholar 

  9. Gondolesi GE, Varotti G, Florman SS, Muñoz L, Fishbein TM, Emre SH, Schwartz ME, Miller C (2004) Biliary complications in 96 consecutive right lobe living donor transplant recipients. Transplantation 77:1842–1848

    Article  PubMed  Google Scholar 

  10. Chang JH, Lee I, Choi MG, Han SW (2016) Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 22:1593–1606

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Sharma S, Gurakar A, Jabbour N (2008) Biliary strictures following liver transplantation: past, present and preventive strategies. Liver Transpl 14:759–769

    Article  PubMed  Google Scholar 

  12. Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Harada N, Ijichi H, Yonemura Y, Ikeda T, Shimada M, Maehara Y (2006) Biliary strictures in living donor liver transplantation: incidence, management, and technical evolution. Liver Transpl 12:979–986

    Article  PubMed  Google Scholar 

  13. Tringali A, Barbaro F, Pizzicannella M, Boškoski I, Familiari P, Perri V, Gigante G, Onder G, Hassan C, Lionetti R, Ettorre GM, Costamagna G (2016) Endoscopic management with multiple plastic stents of anastomotic biliary stricture following liver transplantation: long-term results. Endoscopy 48:546–551

    Article  PubMed  Google Scholar 

  14. Tabibian JH, Asham EH, Han S, Saab S, Tong MJ, Goldstein L, Busuttil RW, Durazo FA (2010) Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc 71:505–512

    Article  PubMed  Google Scholar 

  15. Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V (2001) Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 54:162–168

    Article  CAS  PubMed  Google Scholar 

  16. Kao D, Zepeda-Gomez S, Tandon P, Bain VG (2013) Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review. Gastrointest Endosc 77:679–691

    Article  PubMed  Google Scholar 

  17. Kaffes A, Griffin S, Vaughan R, James M, Chua T, Tee H, Dinesen L, Corte C, Gill R (2014) A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Ther Adv Gastroenterol 7:64–71

    Article  Google Scholar 

  18. Coté GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G, Fogel E, Lehman G, McHenry L, Romagnuolo J, Menon S, Siddiqui UD, Watkins J, Lynch S, Denski C, Xu H, Sherman S (2016) Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: a randomized clinical trial. JAMA 315:1250–1257

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. Tal AO, Finkelmeier F, Filmann N, Kylänpää L, Udd M, Parzanese I, Cantù P, Dechêne A, Penndorf V, Schnitzbauer A, Friedrich-Rust M, Zeuzem S, Albert JG (2017) Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial. Gastrointest Endosc 86:1038–1045

    Article  PubMed  Google Scholar 

  20. Martins FP, De Paulo GA, Contini MLC, Ferrari AP (2018) Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial. Gastrointest Endosc 87:131.e131-131.e113

    Article  Google Scholar 

  21. Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK (2020) Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study. Br J Radiol 93:20191046

    Article  PubMed  PubMed Central  Google Scholar 

  22. Lo CM (2012) Deceased donation in Asia: challenges and opportunities. Liver Transpl 18(Suppl 2):S5-7

    Article  PubMed  Google Scholar 

  23. Rela M, Reddy MS (2017) Living donor liver transplant (LDLT) is the way forward in Asia. Hepatol Int 11:148–151

    Article  PubMed  Google Scholar 

  24. Rao HB, Prakash A, Sudhindran S, Venu RP (2018) Biliary strictures complicating living donor liver transplantation: problems, novel insights and solutions. World J Gastroenterol 24:2061–2072

    Article  PubMed  PubMed Central  Google Scholar 

  25. Tsujino T, Isayama H, Sugawara Y, Sasaki T, Kogure H, Nakai Y, Yamamoto N, Sasahira N, Yamashiki N, Tada M, Yoshida H, Kokudo N, Kawabe T, Makuuchi M, Omata M (2006) Endoscopic management of biliary complications after adult living donor liver transplantation. Am J Gastroenterol 101:2230–2236

    Article  PubMed  Google Scholar 

  26. Sato T, Kogure H, Nakai Y, Hamada T, Takahara N, Mizuno S, Kawaguchi Y, Akamatsu N, Kaneko J, Hasegawa K, Tada M, Tsujino T, Isayama H, Koike K (2019) Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation. Liver Int 39:1954–1963

    Article  PubMed  Google Scholar 

  27. Verdonk RC, Buis CI, Porte RJ, van der Jagt EJ, Limburg AJ, van den Berg AP, Slooff MJ, Peeters PM, de Jong KP, Kleibeuker JH, Haagsma EB (2006) Anastomotic biliary strictures after liver transplantation: causes and consequences. Liver Transpl 12:726–735

    Article  PubMed  Google Scholar 

  28. Zimmerman MA, Baker T, Goodrich NP, Freise C, Hong JC, Kumer S, Abt P, Cotterell AH, Samstein B, Everhart JE, Merion RM (2013) Development, management, and resolution of biliary complications after living and deceased donor liver transplantation: a report from the adult-to-adult living donor liver transplantation cohort study consortium. Liver Transpl 19:259–267

    Article  PubMed  PubMed Central  Google Scholar 

  29. You MS, Paik WH, Choi YH, Shin BS, Lee SH, Ryu JK, Kim YT, Suh KS, Lee KW, Yi NJ, Hong SK (2019) Optimal biliary drainage for patients with biliary anastomotic strictures after right lobe living donor liver transplantation. Liver Transpl 25:1209–1219

    PubMed  Google Scholar 

  30. Albert JG, Filmann N, Elsner J, Moench C, Trojan J, Bojunga J, Sarrazin C, Friedrich-Rust M, Herrmann E, Bechstein WO, Zeuzem S, Hofmann WP (2013) Long-term follow-up of endoscopic therapy for stenosis of the biliobiliary anastomosis associated with orthotopic liver transplantation. Liver Transpl 19:586–593

    Article  PubMed  Google Scholar 

  31. Aepli P, St John A, Gupta S, Hourigan LF, Vaughan R, Efthymiou M, Kaffes A (2017) Success and complications of an intra-ductal fully covered self-expanding metal stent (ID-FCSEMS) to treat anastomotic biliary strictures (AS) after orthotopic liver transplantation (OLT). Surg Endosc 31:1558–1563

    Article  PubMed  Google Scholar 

  32. Covey AM, Brown KT (2008) Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol 11:14–20

    Article  PubMed  Google Scholar 

  33. Kaffes A (2019) Benign biliary strictures: how we are evolving to the perfect endoscopic strategy. Endoscopy 51:1115–1116

    Article  PubMed  Google Scholar 

  34. Abu-Gazala S, Olthoff KM (2019) Current status of living donor liver transplantation in the United States. Annu Rev Med 70:225–238

    Article  CAS  PubMed  Google Scholar 

  35. Shukla A, Vadeyar H, Rela M, Shah S (2013) Liver transplantation: east versus west. J Clin Exp Hepatol 3:243–253

    Article  PubMed  PubMed Central  Google Scholar 

  36. Deviere J, Nageshwar Reddy D, Puspok A, Ponchon T, Bruno MJ, Bourke MJ, Neuhaus H, Roy A, Gonzalez-Huix Llado F, Barkun AN, Kortan PP, Navarrete C, Peetermans J, Blero D, Lakhtakia S, Dolak W, Lepilliez V, Poley JW, Tringali A, Costamagna G (2014) Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 147:385–395 (quiz e315)

    Article  PubMed  Google Scholar 

  37. Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P (2013) Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 13:253–265

    Article  CAS  PubMed  Google Scholar 

  38. Koksal AS, Eminler AT, Parlak E, Gurakar A (2017) Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 31:207–217

    Article  Google Scholar 

  39. Kasahara M, Egawa H, Takada Y, Oike F, Sakamoto S, Kiuchi T, Yazumi S, Shibata T, Tanaka K (2006) Biliary reconstruction in right lobe living-donor liver transplantation: comparison of different techniques in 321 recipients. Ann Surg 243:559–566

    Article  PubMed  PubMed Central  Google Scholar 

  40. Egawa H, Inomata Y, Uemoto S, Asonuma K, Kiuchi T, Fujita S, Hayashi M, Matamoros MA, Itou K, Tanaka K (2001) Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 25:1300–1307

    Article  CAS  PubMed  Google Scholar 

  41. Shah SA, Grant DR, McGilvray ID, Greig PD, Selzner M, Lilly LB, Girgrah N, Levy GA, Cattral MS (2007) Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center. Am J Transplant 7:161–167

    Article  CAS  PubMed  Google Scholar 

  42. Welling TH, Heidt DG, Englesbe MJ, Magee JC, Sung RS, Campbell DA, Punch JD, Pelletier SJ (2008) Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient, and technical factors. Liver Transpl 14:73–80

    Article  PubMed  Google Scholar 

  43. van Boeckel PG, Vleggaar FP, Siersema PD (2009) Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review. BMC Gastroenterol 9:96

    Article  PubMed  PubMed Central  Google Scholar 

  44. Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K (2017) Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 10:297–311

    Article  PubMed  Google Scholar 

  45. Kato H, Kawamoto H, Tsutsumi K, Harada R, Fujii M, Hirao K, Kurihara N, Mizuno O, Ishida E, Ogawa T, Fukatsu H, Yamamoto K, Yagi T (2009) Long-term outcomes of endoscopic management for biliary strictures after living donor liver transplantation with duct-to-duct reconstruction. Transpl Int 22:914–921

    Article  PubMed  Google Scholar 

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Acknowledgements

Thanks to my friend Wookyong Kwon for encouraging me to write this article.

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Author notes

  1. Dong Jin Joo and Moon Jae Chung have contributed equally to this work.

  2. Min Je Sung and Jung Hyun Jo contributed equally to this work as primary authors.

Authors and Affiliations

  1. Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea

    Min Je Sung, Jung Hyun Jo, Hee Seung Lee, Jeong Youp Park, Seungmin Bang, Seung Woo Park, Si Young Song & Moon Jae Chung

  2. Division of Gastroenterology, Department of Internal Medicine CHA Bundang Medical Center, CHA University, Gyeonggi-do, Republic of Korea

    Min Je Sung

  3. Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea

    Dong Jin Joo

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Correspondence to Dong Jin Joo or Moon Jae Chung.

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No authors have any financial relationships with any pharmaceutical or device company. Dr. Min Je Sung, Jung Hyun Jo, Hee Seung Lee, Jeong Youp Park, Seungmin Bang, Seung Woo Park, Si Young Song, Dong Jin Joo, and Moon Jae Chung have no conflicts of interest or financial ties to declare.

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Sung, M.J., Jo, J.H., Lee, H.S. et al. Optimal drainage of anastomosis stricture after living donor liver transplantation. Surg Endosc 35, 6307–6317 (2021). https://doi.org/10.1007/s00464-021-08456-4

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Keywords

  • Anastomotic biliary stricture
  • Endoscopic biliary stenting
  • Intra-ductal fully covered self-expanding metal stent
  • Plastic stent
  • Percutaneous transhepatic drainage