Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures

Background: Over the past decade, ERCP has become the preferred method of treatment for biliary strictures in patients after orthotopic liver transplantation (OLT). Although data strongly support ERCP for treating anastomotic strictures, the little information available for the role of ERCP in the treatment of nonanastomotic strictures (NAS) has been unpromising. Objective: We investigated the efficacy and safety of using balloon dilation and multiple biliary stents to treat NAS. Design: A retrospective study. Setting: A tertiary-care medical center. Patients: Fifteen patients who were diagnosed with post-OLT NAS between January 2003 and June 2007. Interventions: ERCP with balloon dilation and multiple stenting. Main Outcome Measurements: Resolution, complication, and recurrence rates. Results: Eleven of the 15 patients completed endoscopic treatment, of whom 9 had cholangiographic improvement, biochemical normalization, and cholestatic symptom relief (treatment success), and 1 required retransplantation (treatment failure). None of the 9 successfully treated patients experienced NAS recurrence in a mean follow-up of 17 months. Of the remaining 4 patients, 1 died of nonbiliary causes and 3 were still undergoing treatment with stents in place, of whom 2 have near-normalized total serum bilirubin and were cholestatic symptom free. Limitations: A retrospective study, small sample size, single endoscopist. Conclusions: Endoscopic treatment of NAS with balloon dilation and multiple stents appears to be safe and effective, and it may reduce the need for retransplantation because of NAS. Larger studies are still required to confirm its utility as a mainstay for treating NAS and to determine what factors are associated with endoscopic treatment success.