Aims
Biliary anastomotic strictures (BAS) are the most common biliary complication following orthotopic liver transplantation (OLT) with duct-to-duct anastomosis, occurring in up to 25% of cases [1]. Endoscopic plastic multistenting (EPM), with [2] or without [3] previous stent exchange, is the first-line treatment for post-OLT BAS [4].While most patients respond favorably, a significant proportion fail EPM and require percutaneous transhepatic biliary drainage (PTBD) or surgical revision [5]. This study aims to determine the incidence of BAS in a high-volume transplant center, the effectiveness and safety of EPM without stent exchange and of PTBD in ERCP-failure patients.
Methods
This retrospective single-center cohort study included all adult patients who developed BAS after OLT and completed a 6-months biochemical and radiological follow-up after completion of the EPM or PTBD treatment protocol.Clinical, biochemical, radiological, and procedural data were systematically collected.The EPM group included patients who completed ERCP treatment protocol as previously described by Tarantino et al., i.e. ERCP scheduled every 3 months, up to 1 year, with endoscopic dilation plus sequential plastic stents across the narrowing without removing the previous stents. The PTBD group included any ERCP failure patients receiving a 2-step PTBD with metal stenting to be removed 4-6 later via ERCP.The primary endpoint was the clinical success defined by biochemical and radiological resolution at six months follow-up. EPM or PTBD with a clear radiological success in patients with biochemical alterations secondary to chronic rejection or hepatocarcinoma recurrence were classified clinically successful on a case-by-case basis with a multidisciplinary judgment.
Results
Between January 2017 and April 2024, 43 BAS were identified among 348 OLT, corresponding to an overall incidence of 12.4%.
Among these, 33 entered the EPM group and 10 the PTBD group.Baseline characteristics were comparable in the EPM and the PTBD group: median age at first ERCP 58.9 years (52.6–63.6) vs 59.1 years (57.2–62.8), male sex 79% vs 60%, Kehr T-tube placement 48% vs 30%, respectively.
Pre-procedural imaging identified a clear BAS in 73% of cases within the EPM group and in all PTBD cases (p=0.089); consistently, upstream biliary dilatation was slightly more frequent in the PTBD cohort (100% vs 67%, p=0.043). Biliary stones or sludge were found in 15% vs 10% (p=1.00). Median follow-up following EPM and PTBD was 21.6 and 34.6 months (p=0.24).
In the EPM group, the biochemical, radiological and clinical success at 6-months follow-up was achieved in 93.5%, 96.0%, and 90.9% respectively. Only one late BAS recurrence (3.0%) occurred 4.2 months after a successful EPM and was conservatively treated with additional ERCP plus balloon dilation. Adverse events included stent migration in 8 patients (24%), cholangitis in 9 (27%), fever in 10 (30%), and transient abdominal pain in 7 (21%).
In the PTBD group, biochemical, radiological and clinical success at 6-month follow-up were achieved in 20.0%, 30.0% and 30.0% of patients, respectively, all markedly inferior to the ERCP group (p<0.01). BAS recurrence occurred in 2/10 PTBD patients (20.0%) compared with 1/33 in the ERCP cohort (3.0%). In the PTBD group, 3 patients (30%) ultimately required re-transplant and 2 (20%) underwent hepaticojejunostomy because of persistent or recurrent biliary complications.
Conclusions
In this eight-year experience, the incidence of BAS after OLT was 12.4%, consistent with international benchmarks. EPM has excellent effectiveness and long-term outcomes, with >90% clinical success and sporadic late recurrence. PTBD was a rescue treatment to prevent surgical anastomotic revision or re-transplant successful only in a proportion of patients with failed EPM, reflecting the higher intrinsic complexity of ERCP-refractory post-OLT BAS. These findings confirm the strategy of sequential EPM without stent exchange as a robust first-line therapy and highlight the importance of early identification of ERCP-failure to optimize therapeutic sequencing in post-OLT biliary complications.