Tratamento endoscópico na estenose da anastomose biliar no
						pós-transplante hepático: revisão sistemática e meta-análise

NACIF, Lucas Souto; BERNARDO, Wanderley Marques; BERNARDO, Luca; ANDRAUS, Wellington; TORRES, Lucas; CHAIB, Eleazar; D'ALBUQUERQUE, Luiz Carneiro; MALUF-FILHO, Fauze

doi:10.1590/S0004-28032014000300014

Contexto

A estenose biliar figura como uma das complicações mais frequentes pós-transplante hepático. São classificadas em anastomóticas e não anastomóticas, sendo estas últimas geralmente isquêmicas. Dentre as várias opções de tratamento, destacam-se a dilatação balonada, a colocação de próteses plásticas e a colocação de próteses metálicas autoexpansíveis, que podem ser realizadas tanto por via endoscópica, como por via percutânea. Não há consenso quanto ao melhor tratamento para a estenose da anastomose biliar.

Objetivos

O objetivo deste estudo foi realizar revisão sistemática da literatura sobre o resultado do tratamento endoscópico da estenose da anastomose biliar após transplante hepático.

Métodos

Revisão sistemática da literatura foi realizada sobre o tratamento da estenose da anastomose biliar pós transplante hepático, através do acesso aos bancos de dados pesquisados eletronicamente: Medline - PubMed, EMBASE, Scielo- Lilacs, Cochrane de janeiro de 1966 a abril de 2013.

Resultados

Não foi encontrado estudo clinico controlado e randomizado. A maioria dos estudos são comparativos retrospectivos ou prospectivos. Um estudo (86 pacientes) avaliou o acesso endoscópico e percutâneo. As taxas de sucesso clínico sustentados foram semelhantes, mas a duração do tratamento foi maior no grupo de acesso percutâneo. Dois estudos (56 pacientes) compararam a dilatação por balão com dilatação por balão e múltiplas próteses plásticas. Não houve diferenças em relação as taxas de sucesso e de complicações clínicas sustentadas.

Conclusões

A dilatação com balão é tão eficaz quanto a dilatação associada à colocação de múltiplas próteses plásticas para a resolução da estenose da anastomose biliar. Estudos randomizados bem desenhados ainda são necessários para comparar a simples dilatação balonada e a colocação de próteses plásticas.

Transplante de fígado; Constrição; Revisão; Metanálise; Endoscopia gastrointestinal

[1] Correspondence: Fauze Maluf Filho Divisão de Transplante Hepático e Gastrointestinal. Departamento de Gastroenterologia. Faculdade de Medicina, Universidade de São Paulo. CEP 05403-900, São Paulo, SP, Brasil.E-mail: fauze.maluf@terra.com.br

Study	Population	Intervention	Comparison	Outcome
Chang JH et al.⁽¹1. Chang JH, Lee IS, Chun HJ, Choi JY, Yoon SK, Kim DG, et al. Comparative study of rendezvous techniques in post-liver transplant biliary stricture. World J Gastroenterol. 2012;18:5957-64.⁾ 2012	Patients with a biliary stricture after living donor LT	Rendezvous technique - percutaneous transhepatic biliary drainage catheters for inside stents	Guidewire group vs KMP catheter	Rendezvous technique use KMP catheter was a fast and safe
Zoepf T et al.⁽¹⁸18. Zoepf T, Maldonado de Dechêne EJ, Dechêne A, Malágo M, Beckebaum S, Paul A, et al. Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation. Gastrointest Endosc. 2012;76:556-63.⁾ 2012	Adult patients underwent LT (ischemic-type biliary lesions)	Endoscopic intervention	BD vs combination implantation of a BD+EP	BD+EP was successful in 5 of 16 (31%) and BD alone in 30 of 32 patients (91%; P = 0.0027)
Tarantino I et al.⁽¹⁵15. Tarantino I, Mangiavillano B, Di Mitri R, Barresi L, Mocciaro F, Granata A, et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy. 2012;44:923-7.⁾ 2012	Benign biliary stricture	Fully covered self-expandable metal stents	After endoscopic therapy vs no previous endoscopic treatment	Effective for refractory benign biliary strictures
Giampalma E et al.⁽³3. Giampalma E, Renzulli M, Mosconi C, Ercolani G, Pinna AD, Golfieri R. Outcome of post-liver transplant ischemic and nonischemic biliary stenoses treated with percutaneous interventions: the Bologna experience. Liver Transpl. 2012;18:177-87.⁾ 2012	Post-LT biliary stricture (BSs)	Percutaneous treatmentBilioplasty and were refractory to bilioplasty, metallic stents	Ischemic and nonischemic biliary stenoses	Ischemic stricture needs closer follow up
Li QY et al.⁽¹¹11. Li QY, Qin YS, Ling Q, Yang FC, Zheng SS. No therapeutic ERCP in anastomotic stricture without intrahepatic biliary dilation after liver transplantation. Hepatogastroenterology. 2011;58:1127-31.⁾ 2011	AS after LT	ERCP	Intrahepatic biliary dilation vs AS without intrahepatic biliary dilation	ERCP is not effective in AS without intrahepatic biliary dilation after LT
Kim J et al.⁽⁶6. Kim J, Ko GY, Sung KB, Gwon DI, Lee SG, Kim KM, et al. Percutaneously placed covered retrievable stents for the treatment of biliary anastomotic strictures following living donor liver transplantation. Liver Transpl. 2010;16:1410-20.⁾2010	Biliary anastomotic strictures following LDLT	Percutaneous treatment	Covered retrievable stent placement vs drainage catheter placement for treating biliary anastomotic strictures	Covered retrievable stents has an acceptable clinical success rate with shorter treatment duration
Tabibian JH et al.⁽¹⁴14. Tabibian JH, Asham EH, Han S, Saab S, Tong MJ, Goldstein L, et al. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc. 2010;71:505-12.⁾ 2010	Post LT anastomotic biliary strictures	ERCP	ERCP with balloon dilation and maximal stenting	Maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence
Gomez CM et al.⁽⁴4. Gómez CM, Dumonceau JM, Marcolongo M, de Santibañes E, Ciardullo M, Pekolj J, et al. Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation. Transplantation. 2009;88:1280-5.⁾ 2009	Biliary complications after DDLT and to adult LDLT	ERCP	30 LDLT vs 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction	Biliary complications were more frequent after LDLT compared with DDLT
Kobayashi T et al.⁽⁷7. Kobayashi N, Kubota K, Shimamura T, Watanabe S, Kato S, Suzuki K, et al. Complications of the treatment of endoscopic biliary strictures developing after liver transplantation. J Hepatobiliary Pancreat Sci. 2011;18:202-10.⁾ 2009	Biliary strictures after adult living donor liver transplant	Endoscopic retrograde cholangiography	Endoscopic approach for endoscopic dilatation and/or stent placement	Endoscopic treatment after OLT was a significant risk factor for post-ERCP pancreatitis
Kulaksiz H et al.⁽⁹9. Kulaksiz H, Weiss KH, Gotthardt D, Adler G, Stremmel W, Schaible A, et al. Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study. Endoscopy. 2008;40:746-51.⁾ 2008	Post-LT biliary strictures	Endoscopic treatment of strictures	Balloon dilation vs balloon dilation plus stenting	Endoscopic balloon dilation alone was as effective as dilation plus stent placement
Lee SH et al.⁽¹⁰10. Lee SH, Ryu JK, Woo SM, Park JK, Yoo JW, Kim YT, et al. Optimal interventional treatment and long-term outcomes for biliary stricture after liver transplantation. Clin Transplant. 2008;22:484-93.⁾ 2008	Biliary strictures after LT	ECP and PCP	ECP and PCP for anastomotic stricture vs non-anastomotic stricture	Endoscopic access should be the preferred first approach in patients with biliary stricture after LT
Pasha SF et al.⁽¹²12. Pasha SF, Harrison ME, Das A, Nguyen CC, Vargas HE, Balan V, et al. Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc. 2007;66:44-51.⁾ 2007	ABS after deceased donor LT	Endoscopic treatment	Combined technique of BD and maximal stent placement	Combined therapy was successful
Zoepf T et al.⁽¹⁷17. Zoepf T, Maldonado-Lopez EJ, Hilgard P, Malago M, Broelsch CE, Treichel U, et al. Balloon dilatation vs. balloon dilatation plus bile duct endoprostheses for treatment of anastomotic biliary strictures after liver transplantation. Liver Transpl. 2006;12:88-94.⁾ 2006	ABS after-LT	Endoscopic treatment	BD or combined BD+EP	Combination of BD followed by an increasing number and diameter of endoprostheses

Lee SH ₍ _{¹⁰10. Lee SH, Ryu JK, Woo SM, Park JK, Yoo JW, Kim YT, et al. Optimal interventional treatment and long-term outcomes for biliary stricture after liver transplantation. Clin Transplant. 2008;22:484-93.} ₎ 2008
P: Biliary strictures after liver transplantation
I: Endoscopic cholangioplasty (ECP) BD + Stent
C: Percuteneous cholangioplasty (PCP) Balloon dilation + Cateter + Stent
O: Success
	ECP (%)	PCP (%)	P
Success	15/25 (60)	36/61 (59)	0.93
Failure	10/25	25/61	0.83
Complications	6/25 (24)	14/61 (23)	0.92
Patency (days)	159 ± 24	195 ± 21	0.31

Zoepf T ⁽ ¹⁸18. Zoepf T, Maldonado de Dechêne EJ, Dechêne A, Malágo M, Beckebaum S, Paul A, et al. Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation. Gastrointest Endosc. 2012;76:556-63. ⁾ 2006
P: Post Liver Transplant Anastomotic Stricture (PTAS)
I: BD
C: BD+EP
O: Normalization of Cholestasis
	BD (%)	BD + EP (%)	P
Initial success	8/9 (89)	13/15 (87)	NA
Initial failure	1/9 (11)	2/15 (13)	NA
Recurrence	5/8 (62.5)	4/13 (31)	NA
Complications	4/18 (22)	9/60 (15)	NA
Cholangitis	3/18	3/60	NA
Pancreatitis	0/18	5/60	NA
Mean duration of the treatment	45 d/ 1.5 m	120 d/ 4 m	NA
Kulaksiz H⁽⁹9. Kulaksiz H, Weiss KH, Gotthardt D, Adler G, Stremmel W, Schaible A, et al. Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study. Endoscopy. 2008;40:746-51.⁾2008 Prospective comparative study
P: Symptomatic biliary strictures after liver transplantation (Anastomotic and Non-anastomotic BS)
I: BD
C: BD + EP
O: Dilation success (3 months without further endoscopic intervention)
	BD (%)	BD + EP (%)	P
Initial Success (anastomotic and non-anastomotic strictures)	12/17 (70.6)	11/15 (73.3)	n.s.
Anastomotic stricture	10	9	NA
Success/Recurrence	10/1	9/2	NA
Non-anastomotic stricture	4	2	NA
Success/Recurrence	2/1	-	NA
Initial Failure	5/17 (29.4)	4/15 (26.7)	NA
Recurrence	2/17	2/15	NA
Complications	4/94 (4.3)	12/87 (13.6)	<0.05
Cholangitis	2/94	4/87	NA
Pancreatitis	1/94	2/87	NA
Mean duration of the treament	183 ± 111	153 ± 57	n.s.

Tarantino I ⁽ ¹⁵15. Tarantino I, Mangiavillano B, Di Mitri R, Barresi L, Mocciaro F, Granata A, et al. Fully covered self-expandable metallic stents in benign biliary strictures: a multicenter study on efficacy and safety. Endoscopy. 2012;44:923-7. ⁾ 2012
P: Liver Trasplantation Complications
I: SEMS after endoscopic therapy failure
C: Self-expandable metallic stents
O: Success, Recurrence/ SEMS migration, Duration
	SEMS after failure (%)	SEMS 1st line(%)	P
Success	28/39 (71.8)	8/15 (53.3)	NA*
Failure	11/39	7/15	NA
Recurrence	4/28 (14.3)	2/8 (25)	NA
Migration	13/39 (33.3)	7/15 (46.7)	NA
Follow up period (days)	663 ± 300	432 ± 66	NA
*NA - not available

Kim J(6) 2010
P: Biliary anastomotic strictures following LDLT
I: BD + Drainage catheter placement
C: Covered retrievable stent placement after PTBD
O: Success, Recurrence / Migration, Duration
	Plastic stent	SEMS	P
Success	37/39	14/20	0.005
Failure	2/39	6/20	NA*
Complications	6/39	12/20	0.011
Recurrence	4/37	1/14	n.s.
Treatment duration (days)	278 ± 115	197 ± 89	0.018