Abstract: Objective:To explore the application value of plastic biliary stent and fully covered selfexpandable metallic stent (FCSEMS) in endoscopic retrograde cholangio pancreatography (ERCP) for treatment of benign biliary stricture after liver transplantation.
Methods:The retrospective crosssectional study was conducted. The clinical data of 54 patients with benign biliary stricture after liver transplantation undergoing ERCP treatment who were admitted to the First Affiliated Hospital of Xi′an Jiaotong University between January 2010 and August 2016 were collected. Among 54 patients, 44 had simple anastomotic stricture and 10 had nonanastomotic stricture. All the patients underwent stent implantation by ERCP. Patients with stricture within 1 month postoperatively initially selected single plastic stent or endoscopic nasobiliary drainage (ENBD), and then changed into multiple plastic stents at the second stent replacement. Patients with stricture after 1 month postoperatively selected multiple plastic stents, multiple plastic stents after balloon dilation or FCSEMS. Observation indicators: ERCP situations, stent implantation, time of stent indwelling, postoperative complications, stent dislocation, treatment outcome and followup situations. Patients were followed up by outpatient examination and telephone interview up to November 2016. Clinical symptoms of patients were observed within 1 month postoperatively and liver function and abdominal ultrasound were retested. Liver function and remission degree of biliary stricture were monitored regularly once every 3 months. Measurement data were described as average (range).
Results:All the patients underwent successful ERCP, of which 53 completed the process of ERCP and 1 rejected treatment due to economic problems. All the 54 patients received 140 times ERCPs with an average of 2.59 times per person, 21 times ENBDs, 11 times FCSEMSs and 108 times plastic stent implantations (including 35 times single stent implantations, 46 times double stents implantations, 23 times 3stents implantations and 4 times 4stents implantations). All the 54 patients were followed up for 3-143 months, with an average time of 73 months. Of 44 with anastomotic stricture, 34 received plastic stent implantation and 98 times ERCPs, with an average number of stent implantation of 2 (range, 1-4) and an average time of stent indwelling of 10.7 months (range, 9.0- 13.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 4 persons every time, 7 persons every time, 10 persons every time and 3 persons every time, respectively; 26 patients were cured and 5 were improved, with an effective rate of 91.2% (31/34); 3 patients with noneffective treatment continued to undergo ERCP and 3 patients had recurrence of anastomotic stricture. Among 10 patients with initial FCSEMS implantation, 12 times ERCPs were performed, with an average time of stent indwelling of 7.6 months (range, 6.0-12.0 months); postoperative biliary infection, hyperamylasemia and stent dislocation were detected in 1 person every time, 1 person every time and 1 person every time, respectively; 8 patients were cured, with an effective rate of 8/10; of 2 patients with persistent stricture, 1 patient received contrast examination after stent removal, showing a comparative stricture in level 1 branch of intrahepatic duct and considering combined ischaemia, and then underwent the second implantation using multiple plastic stents; the other patient had elevated level of jaundice at 3 months after stents removal and received ERCP, showing anastomotic inflammatory polyp, and then underwent FCSEMS implantation again. Ten patients with nonanastomotic stricture received plastic stent implantation and 30 times ERCPs, with an average number of stent implantation of 3 (range, 2-4) and an average time of stent indwelling of 11.3 months (range, 10.0-14.0 months); the postoperative acute pancreatitis, biliary infection, hyperamylasemia and adverse stent implantation or dislocation were detected in 2 persons every time, 5 persons every time, 2 persons every time and 1 person every time, respectively; 3 patients were cured and 3 were improved, with an effective rate of 6/10; of 4 patients with noneffective treatment, 2 died of gradually deteriorating liver function and 2 underwent the second liver transplantation.
Conclusions:Stent implantation in ERCP is safe and effective for treatment of benign biliary stricture after liver transplantation, single plastic stent should be used in the early period (within 1 month) and multiple plastic stents should be used in the later period. Although FCSEMS has a higher displacement rate, it should be recommended due to a better clinical effect, lower incidence of complications and simple operation. For patients with nonanastomotic stricture, plastic stent should be used for extrahepatic biliary stricture, with a good clinical effect, and there is worse effect in stent implantation through ERCP for multiple intrahepatic biliary strictures.