Early ERCP After Biliary Stenting of Anastomotic Biliary Stricture in Orthotopic Liver Transplant (OLT)

Introduction: Biliary anastomotic stricture is the most common complication of orthotopic liver transplantation (OLT) occurring in about 20% of cases. Endoscopic stent placement across the stricture is the first-line treatment strategy. The aim of this study is to report the incidence of early unplanned ERCP following biliary stenting of anastomotic biliary strictures and investigate any potential predictors. Methods: This is a retrospective study of post OLT patients who underwent ERCP over a 3-year period between 2018-2020. Out of 178 post OLT patients who underwent ERCP, 108 were excluded because of only one ERCP performed and repeat ERCP was not indicated or because ERCP was performed for indications other than anastomotic biliary strictures. Data was collected including type and number of stents used, duration of stenting and reason for early ERCP when performed. Results: A total of 70 patients were included in the study. The average recommended follow up duration after first ERCP during the studied period was 2.2 ± 0.6 months for plastic stents (PS) vs 3.8 ± 1.1 months for fully covered self-expanding metal stents (FCSEMS). Actual follow up duration was 2.2 ± 2.1 months for PS and 3.7 ± 1.4 months for FCSEMS (p < 0.01). Repeat ERCP was performed urgently earlier than the recommended follow-up time by an average of 1.4 ± 1.2 months in 11 (15.7%) patients secondary to suspected cholangitis or worsening liver tests from stent obstruction. There was no difference between PS and FCSEMS with respect to the need to urgently perform ERCP; 8 (15.1%) vs 3 (17.6%) (p=0.8). Using multiple plastic stents instead of a single plastic stent didn’t prevent early ERCP (17.4% vs 13.3%, p = 0.7). Reducing the recommended ERCP follow-up by 1 month could have prevented 4 (36.4%) unplanned early ERCP procedures. Conclusion: Early unplanned ERCP because of worsening liver tests or suspected cholangitis is not uncommon. Stent number and size don’t seem to play a role in preventing unplanned ERCP but reducing ERCP follow up a duration by 1 month for stent removal/exchange may.