title: Clinical outcome of progressive stenting in patients with anastomotic strictures after orthotopic liver transplantation.
abstract: OBJECTIVE
  Anastomotic strictures are an important cause of morbidity after orthotopic liver transplantation (OLT). Endoscopic treatment is the primary treatment modality for biliary complications after OLT. The outcome and complications of a progressive stenting protocol are largely unknown.
  
  
  METHODS
  A longitudinal cohort study of OLTs was conducted. Only patients with late strictures were included. Treatment success was defined as cholangiographic stricture resolution and liver enzymes returning to normal with follow-up of at least 12 months.
  
  
  RESULTS
  Between May 2000 and June 2009, 375 OLTs were performed. A duct-to-duct anastomosis was created in 304 cases (81 %). In 63 patients (21 %; 95 % confidence interval [CI] 16.5 % - 25.6 %) an anastomotic stricture developed and progressive stenting was started in 35. During treatment two patients died of a non-treatment-related cause and two patients underwent a second OLT during stent therapy. Therefore 31 patients were available for analysis (male : female 21:10; median age 61 years, range 28 - 75 years). Progressive stenting required a median number of 5 endoscopic retrograde cholangiopancreatography (ERCP) procedures (range 4 - 11). A median maximum of 4 stents (range 2 - 8) were inserted. A total of 21 patients (67.7 %; 95 %CI 50.1 % - 81.4 %) developed a treatment-related complication. In 33 out of a total of 155 ERCPs (21.3 %) a complication occurred: cholangitis (n = 12), transient cholestasis (n = 11), post-ERCP pancreatitis (n = 7), and treatment-related pain (n = 3). The median follow-up time after stent removal was 28 months (range 12 - 92). Treatment was successful in 25 patients (80.6 %; 95 %CI 63.7 % - 90.8 %).
  
  
  CONCLUSIONS
  Progressive stenting for anastomotic strictures after OLT is demanding and burdensome, necessitating a median of 5 ERCP procedures with complications occurring in one out of five procedures. Its success rate however is high (81 %), avoiding surgery in the large majority of patients.
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands. j.poley@erasmusmc.nl
authors.forename: J W
authors.initials: JW
authors.lastname: Poley
authors.forename: M N
authors.initials: MN
authors.lastname: Lekkerkerker
authors.forename: H J
authors.initials: HJ
authors.lastname: Metselaar
authors.forename: E J
authors.initials: EJ
authors.lastname: Kuipers
authors.forename: M J
authors.initials: MJ
authors.lastname: Bruno
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D001653:Bile Ducts, Intrahepatic / Q000601:surgery; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002780:Cholestasis, Intrahepatic / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000628:therapy*; D011446:Prospective Studies; D015607:Stents; D016896:Treatment Outcome