Objectives. Endoscopic management of bile leak after orthotopic liver transplant (OLT) is widely accepted. Preliminary studies demonstrated encouraging results for covered self-expandable metal stents (CSEMS) in complex bile leaks. Methods. Thirty-one patients with post-OLT bile leaks underwent endoscopic temporary placement of CSEMS (3 partially CSEMS , 18 fully CSEMS with fins and 10 fully CSEMS with flare ends) between December 2003 and December 2010. Long-term clinical success and safety were evaluated. Results. Median stent indwelling and follow-up were 89 and 1,353 days for PCSEMS, 102 and 849 for FCSEMS with fins and 98 and 203 for FCSEMS with flare ends. Clinical success was achieved in 100%, 77.8%, and 70%, respectively. Postplacement complications: cholangitis (1) and proximal migration (1), both in the FCSEMS with fins. Postremoval complications were biliary strictures requiring drainage: PCSEMS (1), FCSEMS with fins (6) and with flare ends (1). There was no significant differences in the FCSEMS groups regarding clinical success, age, gender, leak location, previous treatment, stent indwelling, and complications. Conclusion. Temporary placement of CSEMS is effective to treat post-OLT biliary leaks. However, a high number of post removal biliary strictures occurred especially in the FCSEMS with fins. CSEMS cannot be recommended in this patient population. 1. Introduction Biliary complications are frequent after orthotopic liver transplantation (OLT), affecting 5 to 15% of patients after deceased OLT and 28 to 32% after right-lobe living donor OLT [1–4]. Post-OLT bile leaks are reported in 10 to 15% of patients and are usually an early complication and represent a high morbidity condition for the patient [5]. Endoscopic treatment is well recognized as first-line therapy in the management of post-OLT biliary leaks or stricture [1, 4, 6, 7]. Endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy and/or transpapillary plastic stent placement is typically offered as standard treatment [8–10]. Successful endoscopic therapy for postsurgical bile leaks has been reported in 88 to 97% of cases and up to 83.9% in those secondary to OLT [11]. Covered self-expandable metallic stents (CSEMSs) have been increasingly used to treat benign biliary conditions and have been shown promising results for both biliary strictures and leakages [7, 12–14]. Their larger diameter, long-term patency, and proven removability have turned them into an appealing option to assess refractory and/or complex bile leaks [7, 13–15]. Although few studies have already
References
[1]
E. D. Williams and P. V. Draganov, “Endoscopic management of biliary strictures after liver transplantation,” World Journal of Gastroenterology, vol. 15, no. 30, pp. 3725–3733, 2009.
[2]
A. Amador, R. Charco, J. Marti et al., “One thousand liver transplants: the hospital clinic experience,” Transplantation Proceedings, vol. 37, no. 9, pp. 3916–3918, 2005.
[3]
R. Rerknimitr, S. Sherman, E. L. Fogel et al., “Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy,” Gastrointestinal Endoscopy, vol. 55, no. 2, pp. 224–231, 2002.
[4]
J. H. Tabibian, E. H. Asham, L. Goldstein et al., “Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures,” Gastrointestinal Endoscopy, vol. 69, no. 7, pp. 1236–1243, 2009.
[5]
J. N. Shah, N. A. Ahmad, K. Shetty et al., “Endoscopic management of biliary complications after adult living donor liver transplantation,” American Journal of Gastroenterology, vol. 99, no. 7, pp. 1291–1295, 2004.
[6]
J. W. Ostroff, “Management of biliary complications in the liver transplant patient,” Gastroenterology and Hepatology, vol. 6, no. 4, pp. 264–272, 2010.
[7]
M. Traina, I. Tarantino, L. Barresi et al., “Efficacy and safety of fully covered self-expandable metallic stents in biliary complications after liver transplantation: a preliminary study,” Liver Transplantation, vol. 15, no. 11, pp. 1493–1498, 2009.
[8]
G. S. Sandha, M. J. Bourke, G. B. Haber, and P. P. Kortan, “Endoscopic therapy for bile leak based on a new classification: results in 207 patients,” Gastrointestinal Endoscopy, vol. 60, no. 4, pp. 567–574, 2004.
[9]
A. J. Kaffes, L. Hourigan, N. de Luca, K. Byth, S. J. Williams, and M. J. Bourke, “Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak,” Gastrointestinal Endoscopy, vol. 61, no. 2, pp. 269–275, 2005.
[10]
M. E. Ryan, J. E. Geenen, G. A. Lehman et al., “Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review,” Gastrointestinal Endoscopy, vol. 47, no. 3, pp. 261–266, 1998.
[11]
P. R. Pfau, M. L. Kochman, J. D. Lewis et al., “Endoscopic management of postoperative biliary complications in orthotopic liver transplantation,” Gastrointestinal Endoscopy, vol. 52, no. 1, pp. 55–63, 2000.
[12]
M. Kahaleh, B. Behm, B. W. Clarke et al., “Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video),” Gastrointestinal Endoscopy, vol. 67, no. 3, pp. 446–454, 2008.
[13]
M. Kahaleh, V. Sundaram, S. L. Condron et al., “Temporary placement of covered self-expandable metallic stents in patients with biliary leak: midterm evaluation of a pilot study,” Gastrointestinal Endoscopy, vol. 66, no. 1, pp. 52–59, 2007.
[14]
A. Y. Wang, K. Ellen, C. L. Berg, T. M. Schmitt, and M. Kahaleh, “Fully covered self-expandable metallic stents in the management of complex biliary leaks: preliminary data—a case series 1,” Endoscopy, vol. 41, no. 9, pp. 781–786, 2009.
[15]
T. H. Baron and J. J. Poterucha, “Insertion and removal of covered expandable metal stents for closure of complex biliary leaks,” Clinical Gastroenterology and Hepatology, vol. 4, no. 3, pp. 381–386, 2006.
[16]
M. Kahaleh, J. Tokar, T. Le, and P. Yeaton, “Removal of self-expandable metallic Wallstents,” Gastrointestinal Endoscopy, vol. 60, no. 4, pp. 640–644, 2004.
[17]
H. Ho, A. Mahajan, S. Gosain et al., “Management of complications associated with partially covered biliary metal stents,” Digestive Diseases and Sciences, vol. 55, no. 2, pp. 516–522, 2010.
[18]
I. Tarantino, L. Barresi, I. Petridis, R. Volpes, M. Traina, and B. Gridelli, “Endoscopic treatment of biliary complications after liver transplantation,” World Journal of Gastroenterology, vol. 14, no. 26, pp. 4185–4189, 2008.
[19]
L. M. Marin-Gomez, S. Sobrino-Rodriguez, J. M. Alamo-Martinez et al., “Use of fully covered self-expandable stent in biliary complications after liver transplantation: a case series,” Transplantation Proceedings, vol. 42, no. 8, pp. 2975–2977, 2010.
[20]
F. Garcia-Pajares, G. Sanchez-Antolin, S. L. Pelayo, et al., “Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation,” Transplantation Proceedings, vol. 42, no. 8, pp. 2966–2969, 2010.
[21]
H. Isayama, Y. Nakai, Y. Toyokawa et al., “Measurement of radial and axial forces of biliary self-expandable metallic stents,” Gastrointestinal Endoscopy, vol. 70, no. 1, pp. 37–44, 2009.
[22]
U. Chaput, O. Scatton, P. Bichard et al., “Temporary placement of partially covered self-expandable metal stents for anastomotic biliary strictures after liver transplantation: a prospective, multicenter study,” Gastrointestinal Endoscopy, vol. 72, no. 6, pp. 1167–1174, 2010.
