Aims
Biliary complications after liver transplantation (LT) occur between 5% and 25% of patients in some studies. Out of those, biliary strictures (BS) are the most frequent. Such can be divided into anastomotic or non-anastomotic and early or late regarding to its location in the biliary tract and time of onset. Standard treatment is the placement of a fully-covered self-expanding metal stent (FC-SEMS) via endoscopic retrograde cholangiopancreatography (ERCP) for six months, although there are no clear recommendations in guidelines. However, some patients present a BS recurrence after FC-SEMS withdrawal. Although risk factors for BS have been studied, no studies analyse risk factors for recurrence.
Methods
We collected, retrospectively, our center’s ERCP data from January 2012 to July 2023. Out of 2647 ERCPs, 1036 of them identified BS. After careful revision of those, 136 procedures were done on LT recipients with BS. Out of those, patients who were treated with FC-SEMS were selected as the study population.
50 patients were included in this study, 33 presenting recurrence of BS (case group) while 17 did not develop a recurrence (control group). Patient selection is summarized in Figure 1. Factors related to the surgical procedure (use of biliary T-tube), patient (sex, age, LT indication, cardiovascular risk factors) and transplant (AB0 incompatibility, DSA incompatibility, CMV serological incompatibility, early biliary leak, early BS, hepatic artery stenosis, early post-LT infection and early post-LT CMV infection) were considered. Early BS was considered when the diagnosis was established within the first month after the LT after literature review, as well as the other early factors, although it has not been formally defined.
Results
Early BS was associated with a higher risk of recurrence with an OR 4.89 (CI 95%: 1.39 - 17.16). Other factors such as early CMV infection, early biliary leak or arterial hepatic pathology showed strong, but not statistically significant associations.
| Patients with recurrent BS after first ERCP (n=33) | Patients without recurrent BS after first ERCP (n=17) | Calculated Odds Ratio (IC 95%) | |
| Sex (M/F) | 26 / 7 | 14 / 3 |
0.79 (0.18 - 3.57) |
| Cardiovascular risk factors | 15/33 | 10/17 |
0.59 (0.18 - 1.91) |
| CMV incompatibility in serological test | 3/33 | 1/17 |
1.60 (0.15 - 16.67) |
| Hepatic artery stenosis | 14/33 | 5/17 |
1.77 (0.51 - 6.18) |
| Use of T-tube | 4/33 | 5/17 |
0.33 (0.08 - 1.45) |
| Early biliary leak | 10/33 | 2/17 |
3.26 (0.62 - 17.01) |
| Early biliary stricture | 24/33 | 6/17 |
4.89 (1.39 - 17.16) |
| Early post-LT infection | 13/33 | 7/17 |
0.93 (0.28 - 3.06) |
| Early post-LT CMV infection | 6/33 | 1/17 |
3.56 (0.39 - 32.27) |
Conclusions
Patients with early BS have a higher risk of recurrence after FC-SEMS for six months and may benefit from early follow-up. Recurrence of BS in the context of LT is a pathology that needs further studies to establish treatment strategies. For instance, in patients with early BS, to implant a second FC-SEMS after the withdrawal of the first in six months.