Efficacy of different stent types in post-liver-transplant anastomotic biliary strictures: a systematic review and meta-analysis

Apostolis Papaefthymiou; Daryl Ramai; Marcello Maida; Georgios Tziatzios; Antonio Facciorusso; Konstantinos Triantafyllou; Marianna Arvanitakis; Gavin Johnson; Simon Phillpotts; George Webster; Paraskevas Gkolfakis

doi:10.20524/aog.2024.0886

Efficacy of different stent types in post-liver-transplant anastomotic biliary strictures: a systematic review and meta-analysis

Ann Gastroenterol. 2024 Jul-Aug;37(4):485-492. doi: 10.20524/aog.2024.0886. Epub 2024 Jun 14.

Affiliations

¹ Pancreatobiliary Unit, University College London Hospitals, London, United Kingdom (Apostolis Papaefthymiou, Gavin Johnson, Simon Phillpotts, George Webster).
² Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT, USA (Daryl Ramai).
³ Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy (Marcello Maida).
⁴ Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital of Nea Ionia, Athens, Greece (Georgios Tziatzios, Paraskevas Gkolfakis).
⁵ Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Italy (Antonio Facciorusso).
⁶ Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutics, Medical School, National and Kapodistrian University of Athens, Greece (Konstantinos Triantafyllou).
⁷ Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, ULB, Brussels, Belgium (Marianna Arvanitakis, Paraskevas Gkolfakis).

Abstract

Background: Stent selection in the endoscopic management of post-liver-transplant anastomotic biliary strictures remains controversial. This systematic review and meta-analysis aimed to evaluate the potential differences between available stents.

Methods: MEDLINE, Cochrane, and Scopus databases were searched until April 2023 for comparative studies evaluating stricture management using multiple plastic stents (MPS) and self-expandable metal stents (SEMS), including fully-covered (FC)- and intraductal (ID)-SEMS. The primary outcome was stricture resolution, while secondary outcomes included stricture recurrence, stent migration and adverse events. Meta-analyses were based on a random-effects model and the results were reported as odds ratios (OR) with 95% confidence intervals (CI). Subgroup analyses by type of metal stent and a cost-effectiveness analysis were also performed.

Results: Nine studies (687 patients) were finally included. Considering stricture resolution, SEMS and MPS did not differ significantly (OR 0.99, 95%CI 0.48-2.01; I ²=35%). Stricture recurrence, migration rates and adverse events were also comparable (OR 1.71, 95%CI 0.87-3.38; I ²=55%, OR 0.73, 95%CI 0.32-1.68; I ²=56%, and OR 1.47, 95%CI 0.89-2.43; I ²=24%, respectively). In the subgroup analysis, stricture resolution and recurrence rates did not differ for ID-SEMS vs. MPS or FC-SEMS vs. MPS. Migration rates were lower for ID-SEMS compared to MPS (OR 0.28, 95%CI 0.11-0.70; I ²=0%), and complication rates were higher after FC-SEMS compared to MPS (OR 1.76, 95%CI 1.06-2.93; I ²=0%). Finally, ID-SEMS were the most cost-effective approach, with the lowest incremental cost-effectiveness ratio: 3447.6 £/QALY.

Conclusion: Stent type did not affect stricture resolution and recurrence; however, ID-SEMS placement was the most cost-effective approach compared to the alternatives.

Keywords: Post-liver-transplant biliary strictures; fully covered; intraductal; plastic stents; self-expandable metal stents.