Over the period investigated, 761 patients were transplanted. Sixty-two of these patients had a Kaffes stent inserted for post-transplant anastomotic stricture, mean age of 53 (SD 11.9, range 13-72) years; 1 patient had a living-related donor right lobe graft; of the remainder 68% were DBD (donation after brain death) grafts. The mean CIT (cold ischaemic time) was 8.4 hours (±2.4) for the DBD group and 8.9 (±2.5) for the DCD (donation after circulatory death) group (Table 1). The aetiologies for liver disease are shown in Table 2. 13 (21%) patients had previous plastic stenting and 1 patient had had the traditional type of longer-length FCSEMS (WallflexTM, Boston Scientific) without stricture resolution. 2 patients had had previous stenting for post anastomotic biliary leaks. The median time between the transplant and Kaffes insertion was 10 months (IQR 34). 16 (26%) patients required stenting for stricturing within 3 months of transplantation. 38 patients had balloon dilatations of strictures prior to stent insertion. 29 had a sphincterotomy at the time of stent insertion, whilst another patient had had a previous sphincterotomy.
Immediate stricture resolution (Figure 2)
To date, 56 patients have had their Kaffes stent removed, of whom 54 (96%) had immediate stricture resolution at the time of stent removal. There was no relationship between stent size, balloon dilatations (N=33, P=1.00) and/or sphincterotomies (N=26, P=1.00) and stricture resolution. Of the 2 patients in whom the Kaffes stent had failed to resolve stricturing, 1 went onto have stricture resolution with a plastic stent insertion, whilst the other had a traditional longer-type of FCSEMS inserted, both without successful stricture resolution.
Of the 54 patients in whom there was immediate stricture resolution, 1 died of frailty a year after transplant and another was re-transplanted due to chronic rejection, both having no relationship to their initial anastomotic stricture; these patients were excluded from the overall analysis.
Long-term stricture resolution
Overall, 42/52 (81%) patients went onto have long-term stricture resolution with no recurrence (mean follow-up period was 548 days (SD 256, range 13-1097 days). Of the 10 patients who had recurrence (mean time to recurrence was 224 days (SD 200, range 37-575 days), 1 patient became jaundiced 3 months after stent removal, but instead of further stenting, a sphincterotomy was enough to improve drainage. 9 had asymptomatic recurrence on imaging (5 with cholestatic LFTs), of whom 5 had a further Kaffes placed, 1 had the traditional FCSEMS placement, another improved with sphincterotomy. Only 1 patient required biliary reconstruction as the wire failed to pass through the stricture at their ERCP.
Improvement in symptoms
Forty-six patients were asymptomatic with an anastomotic stricture on imaging (37 with cholestatic LFTs). 16 patients were symptomatic (6 jaundiced, 4 pruritic, 6 cholangitic). Of these, symptoms resolved in 13 (3 clinically jaundiced, 4 pruritic, 6 cholangitic). Of the 3 patients who also continued to be jaundiced after stent insertion, 2 had their stent removed within 4 weeks of insertion, the 3rd after 86 days; all 3 were found to have stricture resolution. Two of these patients were found to have papillary stenosis and improved after sphincterotomy; the other patient required re-transplantation due to chronic rejection. Overall, there was a significant improvement in LFTs when comparing LFTs before stent insertion and after removal in those 54 patients for whom their stricture had resolved (see Table 3).
Overall, 9 (15%) of the 62 patients had a complication: 3 patients developed pancreatitis after the Kaffes stent insertion, 4 developed cholangitis, 1 after insertion and 3 following stent removal, 1 patient had a wire-guided perforation of the bile duct without complication, 1 had the retrieval wires uncoil. There was no associated mortality.
Of the stents that were removed at the time of writing, all were removed successfully (mean of 114 days (SD 70), range 3-345 days), although as above, 1 stent needed 2 attempts because the removal wires uncoiled. Stent removal for a patient 345 days after insertion was delayed due to pregnancy; the stent was removed easily without complications.