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

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; I2=35%). Stricture recurrence, migration rates and adverse events were also comparable (OR 1.71, 95%CI 0.87-3.38; I2=55%, OR 0.73, 95%CI 0.32-1.68; I2=56%, and OR 1.47, 95%CI 0.89-2.43; I2=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; I2=0%), and complication rates were higher after FC-SEMS compared to MPS (OR 1.76, 95%CI 1.06-2.93; I2=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, self-expandable metal stents, intraductal, fully covered, plastic stents

Ann Gastroenterol 2024; 37 (4): 485-492