Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review

Background: Anastomotic biliary strictures (ABSs) are common after liver transplantation, especially with living donors. The strategy of balloon dilation and multiple plastic stents (MPSs) is effective in treating ABSs, but requires multiple ERCPs with the associated risks, cost, and patient burden. Covered self-expandable metal stents (SEMSs) have been increasingly used in this setting. However, it is not clear whether there are definite advantages of using SEMSs over MPSs.

Objective: To compare the efficacy and safety of MPSs and SEMSs in ABS after orthotopic liver transplantation (OLT) and living donor liver transplantation (LDLT).

Design: Systematic review by searching MEDLINE and EMBASE databases.

Patients: OLT and LDLT patients.

Interventions: MPSs versus SEMSs.

Main outcome measurements: Stricture resolution and adverse event rates.

Results: Eight studies (446 patients) using MPSs in OLT, 3 studies (120 patients) using MPSs in LDLT, and 10 studies (200 patients) using SEMSs fulfilled the inclusion and exclusion criteria. The stricture resolution rates were highest (94%-100%) when MPS duration was 12 months or longer. The stricture resolution rates with SEMSs in OLT patients were also high when stent duration was 3 months or longer (80%-95%) compared with a duration less than 3 months (53%-88%). Although the overall adverse event rates were low, the overall SEMS migration rate was significant at 16%.

Limitations: No randomized, controlled trials were identified; only small case series using either MPSs or SEMSs were included.

Conclusions: Although SEMSs appeared to be a promising option in the endoscopic management of ABSs after liver transplantation, current evidence does not suggest a clear advantage of SEMS use over MPSs for this indication.