Background and Aims

Anastomotic biliary strictures (ABSs) are one of the most frequent adverse events that occur after orthotopic liver transplantation (OLT). Multiple plastic stents (MPS) have been validated for this indication. More recently, fully covered self-expandable metallic stents (FCSEMSs) have been used with positive outcomes, but also have a higher rate of migration, which may limit success. Our primary objective was to compare stent migration rates observed with standard FCSEMSs (Std-FCSEMSs) and so-called anti-migration FCSEMSs (Am-FCSEMSs), which are newly designed with reversed proximal side flaps. Secondary objectives were to compare rates of stricture resolution and procedure-related morbidity.

Methods

We conducted a retrospective analysis of a subset of patients (FCSEMSs for post-OLT ABS) from 2 prospectively maintained databases of (1) OLT patients, and (2) ERCP and stent placement. Between January 2009 and January 2016, consecutive patients presenting with ABS after OLT referred to Cochin Hospital (Paris, France) for ERCP and receiving a FCSEMS were included. Exclusion criteria were any other cause of biliary stricture (ie, malignant stricture, ischemic origin), and biliary fistulae.

Results

One hundred twenty-five FCSEMSs (57 Am-FCSEMSs, 52 type 1 Std-FCSEMSs, and 16 type 2 Std-FCSEMSs) were used in 75 patients for ABS after OLT, with a planned stent placement period of 6 months in all patients. Patient characteristics and rates of previous endoscopic treatment or timing of ABS occurrence after OLT were not different between the groups. The rate of FCSEMS complete migration was 16% (20/125), consisting of 1.7% (1/57) for Am-FCSEMSs and 28% (19/68) for type 1 and 2 Std-FCSEMSs (P < .0001). All attempted stent removals (100% of patients) were successful. First follow-up ERCP after each FCSEMS highlighted a stricture resolution rate of 78.4% (98/125), including 93% (53/57) for Am-FCSEMSs and 66.2% (45/68) for type 1 and 2 Std-FCSEMSs (P < .001). After a median follow-up of 28 months after stent removal (range, 12-66 months), stricture recurrence was observed in 12.3% (range, 11%-17%) of patients treated with Am-FCSEMSs against 55.9% (range, 54%-56%) of those receiving Std-FCSEMSs (P < .0001).

Conclusions

In patients with ABS after OLT, the use of Am-FCSEMSs significantly decreased the risk of stent migration, improved stricture resolution at the time of stent removal, and reduced the rate of stricture recurrence during follow-up. Endoscopic removal success and procedure-related morbidity were similar for both standard and anti-migration stents.

中文翻译：

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完全覆盖的金属支架在肝移植术后吻合胆管狭窄中的抗迁移特征的临床疗效：常规支架和抗迁移支架的比较

背景和目标

吻合胆道狭窄（ABS）是原位肝移植（OLT）后发生的最常见的不良事件之一。多个塑料支架（MPS）已针对这种适应症进行了验证。最近，已经使用了完全覆盖的自膨胀金属支架（FCSEMS），取得了积极的成果，但迁移率更高，这可能会限制成功。我们的主要目的是比较标准FCSEMSs（Std-FCSEMSs）和所谓的抗迁移FCSEMSs（Am-FCSEMSs）观察到的支架迁移率，这些都是新设计的，具有反向的近侧侧翼。次要目标是比较狭窄解决率和与手术相关的发病率。

方法

我们对2个前瞻性维护的（1）OLT患者以及（2）ERCP和支架置入的数据库进行了患者亚组（OLTS后ABS的FCSEMS）的回顾性分析。在2009年1月至2016年1月期间，纳入了OLT后转诊到法国巴黎的Cochin医院接受ERCP并接受FCSEMS治疗的连续ABS患者。排除标准是任何其他引起胆道狭窄的原因（即恶性狭窄，缺血性起源）和胆道瘘。

结果

在75例OLT后ABS患者中使用了125个FCSEMS（57 Am-FCSEMS，52个1型Std-FCSEMS和16个2型Std-FCSEMS），计划所有患者的支架放置期为6个月。两组之间的患者特征和先前内镜治疗的比率或OLT后发生ABS的时间没有差异。FCSEMS完全迁移的比率为16％（20/125），其中Am-FCSEMS为1.7％（1/57），1型和2型Std-FCSEMS为28％（19/68）（P  <.0001） 。所有尝试去除支架的患者（100％的患者）均成功。每次FCSEMS之后的首次随访ERCP强调狭窄分辨率为78.4％（98/125），其中Am-FCSEMS为93％（53/57），1型和2型Std-FCSEMS为66.2％（45/68）。 （P <.001）。在支架移除后28个月（范围12-66个月）的中位随访后，在接受Am-FCSEMS治疗的患者中，狭窄复发率分别为12.3％（范围11％-17％）和55.9％（范围54％-56％）接受Std-FCSEMS的患者（P  <.0001）。

结论

在OLT后ABS患者中，使用Am-FCSEMS显着降低了支架迁移的风险，提高了支架拆除时的狭窄分辨率，并降低了随访期间的狭窄复发率。对于标准支架和抗迁移支架，内窥镜摘除成功率和与手术相关的发病率相似。