Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study

Background and study aims: Biliary strictures are a major cause of morbidity following liver transplantation. In the present prospective comparative trial, we evaluated balloon dilation vs. balloon dilation plus stenting with regard to technical and clinical efficacy as well as complications.

Patients and methods: A total of 32 patients with symptomatic biliary strictures after liver transplantation were assigned to balloon dilation (n = 17) or balloon dilation plus plastic stent placement (n = 15). The main outcome parameter was sustained clinical success defined as an interval of at least 3 months without further endoscopic intervention. Additional outcome parameters were assisted clinical success and treatment failure, as well as procedure-related complications.

Results: The initial technical success and primary clinical success rates in the dilation group were both 100 %; in the stent group, the corresponding rates were 100 % and 93 % (n. s.). The sustained clinical success was 71 % vs. 73 %, respectively (n. s.). The time interval to reach sustained clinical success was 6.1 and 5.1 months, respectively (n. s.). No significant differences were found in assisted clinical success or in treatment failure. Complications were observed in 4.3 % in the dilation group and 13.6 % in the stent group (P < 0.05). Independent of the treatment group, a sustained clinical success in anastomotic strictures was achieved in 100 %, whereas the success rate of strictures of the donor hepatic duct was 50 % and of strictures involving the hilum, only 14 % (P < 0.05).

Conclusions: In patients with biliary strictures after liver transplantation, endoscopic balloon dilation alone was as effective as dilation plus stent placement. Stent placement was associated with a significantly higher complication rate. Endoscopic treatment of strictures of the biliary anastomosis is highly effective, whereas attempts to treat more complex strictures are less promising.

References

• 1 Scanga A E, Kowdley K V. Management of biliary complications following orthotopic liver transplantation.  Curr Gastroenterol Rep. 2007;  9 31-38
• 2 Tsujino T, Isayama H, Sugawara Y. et al . Endoscopic management of biliary complications after adult living donor liver transplantation.  Am J Gastroenterol. 2006;  101 2230-2236
• 3 Hampe T, Dogan A, Encke J. et al . Biliary complications after liver transplantation.  Clin Transplant. 2006;  20 Suppl 17 93-96
• 4 Pasha S F, Harrison M E, Das A. et al . Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy.  Gastrointest Endosc. 2007;  66 44-51
• 5 Graziadei I W, Schwaighofer H, Koch R. et al . Long-term outcome of endoscopic treatment of biliary strictures after liver transplantation.  Liver Transpl. 2006;  12 718-725
• 6 Pascher A, Neuhaus P. Bile duct complications after liver transplantation.  Transpl Int. 2005;  18 627-642
• 7 Zoepf T, Maldonado-Lopez E J, Hilgard P. et al . Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantation.  Liver Transpl. 2006;  12 88-94
• 8 Stiehl A. Primary sclerosing cholangitis: the role of endoscopic therapy.  Semin Liver Dis. 2006;  26 62-68
• 9 Rost D, Kulaksiz H, Stiehl A. et al . Treatment of primary sclerosing cholangitis.  Curr Treat Options Gastroenterol. 2007;  10 111-119
• 10 Kaya M, Petersen B T, Angulo P. et al . Balloon dilatation compared to stenting of dominant strictures in primary sclerosing cholangitis.  Am J Gastroenterol. 2001;  96 1059-1066
• 11 Koneru B, Sterling M J, Bahramipour P F. Bile duct strictures after liver transplantation: a changing landscape of the Achilles’ heel.  Liver Transpl. 2006;  12 702-704
• 12 Verdonk R C, Buis C I, Porte R J. et al . Anastomotic biliary strictures after liver transplantation: causes and consequences.  Liver Transpl. 2006;  12 726-735
• 13 Thuluvath P J, Pfau P R, Kimmey M B. et al . Biliary complications after liver transplantation: the role of endoscopy.  Endoscopy. 2005;  37 857-863
• 14 Rerknimitr R, Sherman S, Fogel E L. et al . Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy.  Gastrointest Endosc. 2002;  55 224-231
• 15 Pfau P R, Kochman M L, Lewis J D. et al . Endoscopic management of postoperative biliary complications in orthotopic liver transplantation.  Gastrointest Endosc. 2000;  52 55-63
• 16 Rossi A F, Grosso C, Zanasi G. et al . Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation.  Endoscopy. 1998;  30 360-366
• 17 Rizk R S, McVicar J P, Emond M J. et al . Endoscopic management of biliary strictures in liver transplant recipients: effect on patient and graft survival.  Gastrointest Endosc. 1998;  47 128-135
• 18 Costamagna G, Pandolfi M, Mutignani M. et al . Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents.  Gastrointest Endosc. 2001;  54 162-168
• 19 Shah J N, Ahmad N A, Shetty K. et al . Endoscopic management of biliary complications after adult living donor liver transplantation.  Am J Gastroenterol. 2004;  99 1291-1295
• 20 Holt A P, Thorburn D, Mirza D. et al . A prospective study of standardized nonsurgical therapy in the management of biliary anastomotic strictures complicating liver transplantation.  Transplantation. 2007;  84 857-863
• 21 Schwartz D A, Petersen B T, Poterucha J J. et al . Endoscopic therapy of anastomotic bile duct strictures occuring after liver transplantation.  Gastrointest Endosc. 2000;  51 169-174
• 22 Alazmi W M, Fogel E L, Watkins J L. et al . Recurrence rate of anastomotic biliary strictures in patients who have had previous successful endoscopic therapy for anastomotic narrowing after orthotopic liver transplantation.  Endoscopy. 2006;  38 571-574