Gastroenterology Department, Hôpital Cochin, Paris-Descartes University, Paris, France.
Digestive Surgery Department, Hôpital Pitié-Salpêtrière, Pierre et Marie Curie University, Paris, France.
Gastrointest Endosc. 2018 Oct;88(4):655-664. doi: 10.1016/j.gie.2018.06.035. Epub 2018 Jul 10.
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.
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.
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).
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.
吻合口胆道狭窄（ABS）是肝移植（OLT）后最常见的不良事件之一。已经验证了多种塑料支架（MPS）用于该适应症。最近，全覆膜自膨式金属支架（FCSEMS）已用于治疗，取得了积极的效果，但也存在较高的迁移率，这可能会限制其成功。我们的主要目的是比较标准 FCSEMS（Std-FCSEMS）和所谓的抗迁移 FCSEMS（Am-FCSEMS）的支架迁移率，后者是新设计的，具有反向近端瓣。次要目的是比较狭窄缓解率和与程序相关的发病率。
我们对来自两个前瞻性维护的数据库（1）OLT 患者和（2）ERCP 和支架放置的患者子集（接受 FCSEMS 治疗的 ABS 患者）进行了回顾性分析。2009 年 1 月至 2016 年 1 月期间，OLT 后出现 ABS 并转诊至 Cochin 医院（法国巴黎）进行 ERCP 并接受 FCSEMS 的连续患者被纳入研究。排除标准为任何其他原因引起的胆道狭窄（即恶性狭窄、缺血性起源）和胆瘘。
125 例 FCSEMS（57 例 Am-FCSEMS、52 例 1 型 Std-FCSEMS 和 16 例 2 型 Std-FCSEMS）用于 75 例 OLT 后 ABS 的患者，所有患者计划支架置入期均为 6 个月。两组患者的特征和先前内镜治疗的发生率或 ABS 发生的时间在统计学上无差异。FCSEMS 完全迁移的发生率为 16%（20/125），Am-FCSEMS 为 1.7%（1/57），1 型和 2 型 Std-FCSEMS 为 28%（19/68）（P<.0001）。所有尝试的支架取出（100%的患者）均成功。每个 FCSEMS 后首次随访的 ERCP 显示狭窄缓解率为 78.4%（98/125），Am-FCSEMS 为 93%（53/57），1 型和 2 型 Std-FCSEMS 为 66.2%（45/68）（P<.001）。支架取出后中位随访 28 个月（范围 12-66 个月），Am-FCSEMS 治疗组狭窄复发率为 12.3%（范围 11%-17%），而 Std-FCSEMS 治疗组为 55.9%（范围 54%-56%）（P<.0001）。
OLT 后 ABS 患者使用 Am-FCSEMS 可显著降低支架迁移风险，提高支架取出时的狭窄缓解率，并降低随访期间的狭窄复发率。标准和抗迁移支架的内镜取出成功率和与程序相关的发病率相似。
