Can a B1 (Benign stricture grade 1) anastomotic stricture be treated with stenting?

From the Guidelines

Yes, a B1 anastomotic stricture can be stented, with endoscopic sphincterotomy, balloon dilatation, and plastic stent placement having a reported success rate of approximately 75%. Stenting is a viable treatment option for biliary anastomotic strictures that occur after liver transplantation, particularly at the site of the bile duct-to-bile duct (B1) anastomosis. The procedure typically involves endoscopic retrograde cholangiopancreatography (ERCP) with placement of either plastic stents or self-expandable metal stents (SEMS) 1. For initial management, multiple plastic stents are often preferred, with stent exchange every 3-4 months for a total treatment duration of 12-24 months. Alternatively, fully covered SEMS may be used for 3-6 months.

Some key points to consider when stenting a B1 anastomotic stricture include:

• The choice between stenting and balloon dilation should be left to the endoscopist’s discretion, as suggested by the European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline 1.
• Polymeric temporary stents (aka plastic stents) remain the mainstay of endoscopic therapy when stenting is desired, although SEMS can be used as an alternative 1.
• Potential complications of stenting include cholangitis, stent migration, and stent occlusion, so patients require close follow-up.
• If endoscopic stenting fails, percutaneous approaches or surgical revision may be necessary.

It's worth noting that the European multicenter randomized DILSTENT trial comparing single-balloon dilatation vs. short-term stenting was prematurely stopped due to a significantly higher serious adverse event rate in the stent group 1. However, the most recent and highest quality study suggests that stenting is a viable treatment option for B1 anastomotic strictures, with a success rate of approximately 75% 1.

From the Research

Stenting for B1 Anastomotic Stricture

• Stenting can be a viable option for treating B1 anastomotic strictures, as seen in various studies 2, 3, 4.
• The use of fully-covered metal stents (FCSEMS) has been shown to be effective in resolving strictures, with a stricture resolution rate of 85.0% at three months of stent placement 2.
• Another study compared percutaneous temporary covered stent placement with balloon dilatation and found that stent placement provided longer patency and shorter PTBD indwelling time compared with balloon dilatation 3.
• However, the effectiveness of stenting can vary depending on the type of stent used and the specific patient population, as seen in a study where plastic multistenting was found to be the preferred first-line treatment for biliary anastomotic strictures, while fully covered self-expandable metal stenting was used as a rescue option 4.

Types of Stents and Their Effectiveness

• Fully-covered metal stents (FCSEMS) have been shown to be effective in resolving strictures, with a stricture resolution rate of 85.0% at three months of stent placement 2.
• Plastic multistenting has been found to be the preferred first-line treatment for biliary anastomotic strictures, with a radiological success rate of 88% 4.
• Self-expandable metal stenting has been used as a rescue option for biliary anastomotic strictures, with a radiological success rate of 88% 4.
• Single stenting has been found to have sub-optimal results and should be abandoned 4.

Complications and Limitations

• Stent migration can occur, as seen in a study where stent migration occurred in 10 patients (47%) 5.
• Stent perforation can also occur, as seen in a study where patients with metallic stents had a significantly higher incidence of postprocedure strictures 6.
• The effectiveness of stenting can vary depending on the type of stent used and the specific patient population, as seen in a study where the overall stricture resolution rate was 95.0% 2.