1. Post transplantation strictures: which
stent type and optimal staging?
Mario Traina
1

2. Post transplantation strictures
Background
Biliary complications represent a serious source of
morbidity after OLT (Orthotopic Liver Transplantation) and
LRLT (Living Related Liver Transplantation)
The rate of biliary complications in transplant recipients
ranging from 8% to 35% in the published series
The most common biliary complication is the
anastomotic stricture, which is followed by biliary
leakage, although patients often develop more than one
complication
2

3. Post transplantation strictures
Predictors of biliary complications by multivariate
analysis
• Take-back surgery after liver transplantation was identified
as strongly predictive of the development of a biliary
problem.
• Patients who received a DCD (Donation after Cardiac Death) graft
had a 4.5-fold increased risk of the development of a biliary
complication.
• Patients with PSC (primary sclerosing clolangitis) had a 2.8-fold
increase in the risk of the development of biliary problems.
3

4. Post transplantation strictures
Standard Treatment
The standard endoscopic treatment consists in performing
ERCP, with sphincterotomy plus stent placement for
biliary leaks, or progressive pneumatic dilatation with
stents placement for biliary stenosis alone
Results :
The endoscopic treatment of biliary complications reaches
a success rate of about 70-80% after orthotopic liver
transplantation and 60% after living-related liver
transplantation.
4

5. Post transplantation strictures
Predictors of endoscopic treatment outcomes
•Patients who had grafts from DCD and in whom biliary
complications developed were less likely to respond to
endoscopic therapy.
•Patients who received a living donor liver transplant were
less likely to respond to endoscopic therapy.
•Finally, transplant recipients who had undergone take-back
surgery for nonbiliary indications, particularly bleeding, had
less favorable endoscopic results for the management of
biliary problems.
5

6. Multivariate analysis
demostrated that
treatment success was
directly related to the
number of stent used
6

7. Post transplantation strictures
Which stent type
The rationale for using
covered metallic stent was to
improve the durability of
patency, because the plastic
stents have limited patency
rate and become occluded
within 3 to 6 months, so that
frequent replacement and an
increasing number of stents
are required.
7

8. Post transplantation strictures
SEMS (self-expanding metal stents)
• Uncovered
• Partially covered
• Fully covered: Silicon, Permalume®, PTFE
(Polytetrafluoroethylene), Gore-tex,
• Steel, Nitinol, Platinol™
• Conforming to anatomy
Antimigration properties
• Flared type
• Anchoring fins
• Anchoring flaps
• Bumpy
8

9. Post transplantation strictures
Covered SEMS
9

10. Post transplantation strictures
Treatment with SEMS
•Traina M, Tarantino I, Barresi L, et al. Efficacy and safety of fully covered
selfexpandable metallic stents in biliary complications after liver
transplantation: a preliminary study. Liver Transpl 2009; 15:1493–1498.
•Tee HP, James MW, Kaffes AJ. Placement of removable metal biliary stent
in postorthotopic liver transplantation anastomotic stricture. World J
Gastroenterol 2010; 16:3597–3600.
•Garcıa-Pajares F, Sanchez-Antolın G, Pelayo SL, et al. Covered metal
stents for the treatment of biliary complications after orthotopic liver
transplantation. Transplant Proc 2010; 42:2966–2969.
•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.
10

11. Post transplantation strictures
11

12. Post transplantation strictures
12

13. Post transplantation strictures
13

14. Post transplantation strictures
14

15. Post transplantation strictures
15

16. Post transplantation strictures
Now that fully CSEMS are available, partially
CSEMS should not be used due to imbedding
of the uncovered portion, which has the
potential for causing stent-induced strictures
and to make stent removal difficult or
impossible.
Todd H. Baron
16

17. Post transplantation strictures
• Our preliminary data showed that in patients who do not respond to
standard endoscopic treatment, the placement of a fully covered
metal stent could be considered a valid alternative to surgery.
• These results were limited in generalizability by a short follow-up
time (a mean of 10 months) and a small patient’s cohort.
With the present study we aim to implement our previous
experience with longer follow-up period and higher
number of treated patients, analyzing the efficacy of
SEMS both as first-line approach and in patients in whom
plastic stents failed in resolving the biliary complication
17

18. Post transplantation strictures
AIMS of the study
To evaluate the clinical success in a large cohort of
patients treated with SEMS, after failure of
conventional endoscopic treatment*, and with a long
follow up.
To evaluate the clinical success of SEMS placement
as first procedure in a subgroup of consecutive
treated patients.
*Failure of endoscopic treatment was defined as: 1) evidence of continuous
bile leakage despite endoscopic stent placement; 2) persistence of stenosis
after one year despite multiple dilatation and stent placement
18

19. Post transplantation strictures
Study design
• Prospective observational study
Population of patients with
biliary complications
after liver transplantation
(OLT and LRLT)
After failure of
conventional First diagnosis
endoscopic treatment
19

20. Post transplantation strictures
Materials and Methods
From January 2008 to August 2010, all failures of
endoscopic conventional therapy, were treated with
SEMS placement according with our previous series.
From January to August 2010, we also tried to treat all
new cases without any previous endoscopic
treatments, with SEMS placement as first approach.
20

21. Post transplantation strictures
Results
54
consecutive patients
were treated with SEMS
for biliary stenosis and/or
leak after liver transplantation
and were included in the study
39
after failure of 15
conventional as first approach
treatment
21

22. Post transplantation strictures
Patients Characteristic
GROUP 1 (39) GROUP 2 (15)
MALE/FEMALE N 25/14 10/5
MEAN AGE 60.1 ± 8.9 59.1 ± 6.6
LIVER DONORS
•Cadaveric 33 (84.6%) 15 (100%)
• Living 6 (15.4%) -
BILIARY
ANASTOMOSIS
•Duct-to-duct 35 (89.7) 15 (100)
•Multiple anastomosis 4 (10.3) -
COMPLICATIONS
• Stenosis 32 (82) 15 (100)
• Stenosis plus leak 6 (15.4) -
• Leak 1 (2.6) - 22

23. Post transplantation strictures
Results
GROUP 1 (39) GROUP 2 (15)
SOLUTION N (%) 28/39 (71.8) 8/15 (53.3)
MEAN FOLLOW-UP 16.6±9 months 10.4±4.5 months
RECURRENCE n (%) 4/28 (14.3) 2/8 (25)
TIME OF RECURRENCE 8.5 months (3-24) 1 and 13 months
SEMS MIGRATION n (%) 13/39 (33.3) 7/15 (46.7)
23

24. Post transplantation strictures
Anchoring Fins
Removal may be problematic because of
these multiple anchoring fins, which can
cause ulceration and bleeding from the
mucosa as the SEMS is extracted.
24

25. Post transplantation strictures
Anchoring Flap e Flared end
25

26. Post transplantation strictures
Bumpy
•
26

27. Post transplantation strictures
Bumpy
27

28. Post transplantation strictures
Bumpy
28

29. Post transplantation strictures
Conclusions
• ERCP with conventional treatment is a safe first-line
approach for post-OLT biliary complications.
• In patients in whom the standard approach fails
temporary SEMS placement is able to solve biliary
complication and may eliminate the need for surgery in
almost ¾ of cases.
• SEMS placement is not useful and not recommended as
first line approach soon after the diagnosis of biliary
complications
• Partially CSEMS should not be used due to imbedding of
the uncovered portion
• The ideal stent: fully covered, flared, conforming to
anatomy, with a safe antimigration system
29