PTH-053 Endocuff assisted colonoscopy significantly improve ADR comparing to cap assisted colonoscopy: a randomised study (detect)
Introduction Biliary anastomotic strictures (AS) occur in 5%-15% of liver transplant (LT) recipients and cause graft dysfunction and morbidity. The main alternative to surgical reconstruction is stenting at endoscopic retrograde cholangiopancreatography (ERCP), using plastic polyethylene or fully-covered self-expanding metal stents (fcSEMS). We retrospectively reviewed outcomes after ERCP for biliary AS, aiming to assess rates of success and complications. Methods Records for all patients
... all patients undergoing ERCP post LT between 2013-16 were reviewed. AS were classified as early or late (<3 or!3 mths post LT) and cases of diffuse cholangiopathy excluded. Data collected included graft characteristics, timing/nature of ERCPs and complications. Stricture resolution was determined from graft function, imaging and ERCP findings. Results In total 252 ERCPs were performed (median 4/ patient, range 2-10) in 62 patients, 72.6% male, age at LT 54 years (range 20-71). 48 grafts (77.4%) were donations after brain death, 13 (21.0%) after cardiac death and 1 live donor. At first endoscopy 53 (85.4%) had a native papilla. Median time from LT was 28 days (4-75) in early AS (n=29, 46.7%, 9 presenting with bile leak) vs 11.5 mths (3.4-251) in late AS (n=33, 53.2%). Biliary stents were placed in 172 ERCPs (63.4% plastic vs 36.6% fcSEMS) and AS dilated in 68 (27.0%; 60 in conjunction with stenting). Stricture resolution was achieved endoscopically in 47/55 patients with complete outcome data (85.5%). Plastic stents were placed at index ERCP in 23/26 of early AS, in whom sequential plastic 'upstenting' was ultimately successful in 9 (39.1%) and 12 (52.2%) proceeded to fcSEMS (stricture remodelled in all). Of late AS, 9/29 were managed with fcSEMS (88.8% successfully), 8 plastic 'upstenting' (75% success), 8 fcSEMS after initial plastic stent (all successful) and 2 resolved with dilatation only. The overall rate of post-ERCP pancreatitis (PEP) was 7.1% (none severe by Cotton criteria) and was higher after fcSEMS (15.9%) than plastic stenting (5.5%, p=0.024), despite similar use of NSAID prophylaxis. Compared with plastic stents, fcSEMS were more likely to migrate (36.5% vs 12.8%, p<0.001) and embed (6.3% vs 0%, p=0.008) but stent occlusion was numerically lower (0% vs 4.6%, p=0.084). Of 8 endoscopic failures (14.5%), 3 (5.5%) required percutaneous stenting and 2 (3.6%) biliary reconstruction, one after duodenal perforation by a migrated plastic stent. Conclusions Endoscopic management is effective in treating 85% of biliary AS. fcSEMS appear superior to sequential plastic 'upstenting' but are associated with higher rates of PEP and migration.