Fully-Covered Self-Expandable Metal Stents Are More Efficacious Than Plastic Stents As First-Line Therapy in Treating Extrahepatic Benign Biliary Strictures Following Liver Transplantation: ACG/AstraZeneca Fellow Award

Purpose: Benign biliary strictures (BBS) can occur following orthotopic liver transplantation (OLT). Fully-covered self-expanding metal stents (FC-SEMS) offer an alternative to repeated ERCP with upsizing of plastic stents. Our aim was to compare the efficacy of FC-SEMS to plastic biliary stents as first-line treatment of extrahepatic BBS following OLT. Methods: Consecutive patients who underwent OLT from 7/08 to 10/11 were included, and medical records were retrospectively reviewed. BBS was defined by abnormal LFTs (total bilirubin or alkaline phosphatase >2x ULN) with ERCP that revealed narrowing of the extrahepatic bile duct. Stricture resolution was defined as normalization of labs and imaging. Multiple plastic stents (7, 8.5, or 10 Fr) were placed after balloon dilation of the BBS. Single FC-SEMS (8 or 10 mm diameters) were used. Informed consent was obtained prior to ERCPs. Results: 238 consecutive patients (mean age: 54 years, range: 19-72 years) who underwent OLT were included. 43 patients (18.1%, 22 men, mean age: 56 years) had an extrahepatic BBS. 39 patients (90.7%, 22 men) received biliary stents (Figure 1). Stricture resolution was achieved in 10/14 patients with FC-SEMS (71.4%, median time: 94 days) and in 8/25 patients with plastic stents (32%, median time: 142 days). Use of FC-SEMS as initial therapy for BBS was associated with a six-fold increased odds of stricture resolution on age- and gender-adjusted multivariate analysis (OR 6.4, p=0.019). Patients who received FC-SEMS required a mean of 0.6 stent exchanges/patient prior to stricture resolution as compared to a mean of 1.3 in those who received plastic stents (adjusted OR favoring metal stents was 2.7, p<0.02). Post-ERCP pancreatitis occurred in 2 patients with plastic stents and in 1 patient with a FC-SEMS.Figure: [1865] Figure 1. Distribution and outcomes of covered metal stents vs. sequential upsizing of plastic stents for the treatment of biliary strictures after liver transplantation.Conclusion: FC-SEMS as initial therapy was more efficacious than sequential upsizing of plastic biliary stents for the resolution of extrahepatic BBS in patients after OLT. A prospective randomized study is indicated to validate these findings.