Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)

BackgroundThe optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established.ObjectiveTo review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution.DesignRetrospective study.SettingTertiary-care center.PatientsEighty-three patients with a diagnosis of ABS.InterventionsERCP with balloon dilation and maximal stenting.Main Outcome MeasurementsStricture resolution, stricture recurrence, and complication rates.ResultsOf 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP.LimitationsRetrospective study, single endoscopist.ConclusionsOur maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment.