Objectives To investigate long-term outcomes of combined endoscopic-percutaneous methods for endoscopically unmanageable anastomotic biliary strictures in living donor liver recipients. Materials and methods This retrospective single-center study included 144 patients referred for biliary stricture between November 2017 and May 2023. Eighty-eight patients (leak = 8, non-anastomotic stricture = 3, treatment refused = 12, successful ERCP = 65) were excluded. Patients initially underwent percutaneous biliary drainage. Patients for whom percutaneous intervention was successful in traversing stricture were followed up with fully-covered self-expandable metallic stents and/or plastic catheter stents. However, in case of failure, magnetic compression anastomosis (MCA) was performed. Results A total of 56 patients (mean age, 59 years ±11; 35 men) comprised the study group. Percutaneous intervention was successful in traversing the stricture in 26/56 patients. Among the remaining 30 patients, 26 were eligible for MCA, which was performed successfully in 24 patients (92%). The mean duration from magnet placement to internalization was 7.71 ± 2.77 days (95% CI: 6.54–8.88). Altogether, in 47 patients (24 of whom underwent MCA), percutaneous drains were removed following biliary stenting. The mean follow-up was 1082.5 ± 668.2 days (95% CI: 907.49–1257.51). In 19 patients (40%), recurrent stricture was evident at ERCP during a median follow-up of 90 (IQR: 60–210) days following stent removal. The recurrent stricture rate following MCA (n = 6/24) was significantly lower compared to patients in whom MCA was not performed (n = 13/23; p = 0.026). Overall, stent type had no significant effect on patency (p = 0.189). Conclusion Percutaneous biliary procedures are essential for endoscopically unmanageable post-transplant anastomotic biliary strictures. MCA seems to provide higher patency rates even in patients with total biliary occlusion. Key Points <Emphasis Type="BoldItalic">Question</Emphasis> What steps can be taken when endoscopy fails in the treatment of post-transplant anastomotic biliary strictures? <Emphasis Type="BoldItalic">Findings</Emphasis> Percutaneous biliary access and magnetic compression anastomosis can be applied to increase graft survival in the setting of endoscopically unmanageable post-transplant biliary strictures. <Emphasis Type="BoldItalic">Clinical relevance</Emphasis> Impassable biliary obstructions are unfortunate complications and not uncommon in liver transplant recipients. Magnetic compression anastomosis is an alternative minimally invasive method of treatment for complete biliary occlusions. Graphical Abstract

Combined endoscopic-percutaneous approach for magnetic compression anastomosis in post-transplant anastomotic biliary strictures

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2025年4月27日

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Emre Ünal,
Ümran Esen,
Aycan Uysal,
Türkmen Turan Çiftçi,
Devrim Akinci,
Erkan Parlak

摘要

Objectives

To investigate long-term outcomes of combined endoscopic-percutaneous methods for endoscopically unmanageable anastomotic biliary strictures in living donor liver recipients.

Materials and methods

This retrospective single-center study included 144 patients referred for biliary stricture between November 2017 and May 2023. Eighty-eight patients (leak = 8, non-anastomotic stricture = 3, treatment refused = 12, successful ERCP = 65) were excluded. Patients initially underwent percutaneous biliary drainage. Patients for whom percutaneous intervention was successful in traversing stricture were followed up with fully-covered self-expandable metallic stents and/or plastic catheter stents. However, in case of failure, magnetic compression anastomosis (MCA) was performed.

Results

A total of 56 patients (mean age, 59 years ±11; 35 men) comprised the study group. Percutaneous intervention was successful in traversing the stricture in 26/56 patients. Among the remaining 30 patients, 26 were eligible for MCA, which was performed successfully in 24 patients (92%). The mean duration from magnet placement to internalization was 7.71 ± 2.77 days (95% CI: 6.54–8.88). Altogether, in 47 patients (24 of whom underwent MCA), percutaneous drains were removed following biliary stenting. The mean follow-up was 1082.5 ± 668.2 days (95% CI: 907.49–1257.51). In 19 patients (40%), recurrent stricture was evident at ERCP during a median follow-up of 90 (IQR: 60–210) days following stent removal. The recurrent stricture rate following MCA (n = 6/24) was significantly lower compared to patients in whom MCA was not performed (n = 13/23; p = 0.026). Overall, stent type had no significant effect on patency (p = 0.189).

Conclusion

Percutaneous biliary procedures are essential for endoscopically unmanageable post-transplant anastomotic biliary strictures. MCA seems to provide higher patency rates even in patients with total biliary occlusion.

Key Points

Question What steps can be taken when endoscopy fails in the treatment of post-transplant anastomotic biliary strictures?

Findings Percutaneous biliary access and magnetic compression anastomosis can be applied to increase graft survival in the setting of endoscopically unmanageable post-transplant biliary strictures.

Clinical relevance Impassable biliary obstructions are unfortunate complications and not uncommon in liver transplant recipients. Magnetic compression anastomosis is an alternative minimally invasive method of treatment for complete biliary occlusions.

Graphical Abstract