Resultados a longo prazo e fatores preditivos de recorrência de estenose anastomótica pós-transplante hepático da terapia endoscópica com próteses metálicas e plásticas
Data
2024-07-04
Autores
Pinheiro, Larissa Wermelinger 
Orientadores
Libera Junior, Ermelindo Della
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Estenoses da via biliar podem representar até 40% dos eventos adversos biliares após transplante hepático, e estenoses da anastomose biliar correspondem à maioria das complicações na via biliar. A terapia endoscópica é o tratamento de primeira linha que pode ser realizada por meio da dilatação da estenose e colocação de próteses plásticas ou metálica, com sucesso entre 70% e 100%. Objetivos: Primário - Comparar a terapia endoscópica com próteses plásticas em relação à prótese metálica, no tratamento da estenose biliar anastomótica pós-transplante de fígado. Secundários - 1. avaliar a eficácia das próteses metálicas com e sem sistema antimigração; 2. comparar a taxa de migração entre elas; 3. identificar possíveis fatores preditivos para recorrência de estenose nestes pacientes. Pacientes e Métodos: estudo coorte retrospectivo, onde foram incluídos 161 pacientes. Foram analisados os resultados do tratamento endoscópico nos pacientes com estenose biliar anastomótica pós-transplante hepático tratados com próteses metálicas ou próteses plásticas e acompanhados no Hospital Israelita Albert Einstein - São Paulo, durante o período de abril de 2012 a agosto de 2022. Os pacientes foram estratificados em 3 grupos conforme a terapia: próteses plásticas, prótese metálica ou grupo híbrido. Resultados primários: resolução da estenose e recorrência da estenose biliar. Resultado secundário: avaliação de possíveis fatores preditores de recorrência da estenose biliar. Resultados: resolução geral da estenose foi 151/161 pacientes (93,7%). A resolução ocorreu em 83/84 pacientes (99%) no grupo prótese metálica, 18/20 (90%) no grupo próteses plásticas e 50/57 (88%) no grupo híbrido (P = 0,013). Falha da terapia ocorreu em 10/161 (6,2%). A recorrência da estenose ocorreu em 22/161 (14%) pacientes. A análise de Kaplan-Meier mostrou diferença no tempo livre de recorrência entre os grupos (P = 0,015), porém não houve diferença entre os grupos de prótese metálica e plástica (P = 0,201). A diferença foi encontrada no grupo híbrido, com menor tempo livre de recorrência da estenose. Na análise entre os grupos de próteses metálicas com e sem sistema antimigração a resolução ocorreu em 96% no grupo sem e 88% no grupo com sistema antimigração (P = 0,150). A recorrência foi de 14% e 8%, nas próteses sem e com sistema antimigração respectivamente (P = 0,741). A migração das próteses metálicas foi de 46% para a prótese sem sistema antimigração e 4% para a prótese com sistema antimigração (OR: 20,4; IC 95%: 2,697 – 154, 541; P< 0,001). Análise multivariada identificou número de colangiopancreatografia retrógrada endoscópica (taxa de risco: 1,4; IC 95%: 1,194 – 1,619; P < 0,001) e complicações (taxa de risco: 2,8; IC 95%: 1,008 – 7,724; P = 0,048) como preditores de recorrência da estenose. Conclusão: Próteses metálica e plástica foram eficazes e comparáveis em relação à resolução e recorrência de estenose biliar anastomótica pós-transplante hepático. Próteses metálicas com e sem sistema antimigração foram comparáveis em termos de resolução e recorrência para a terapia da estenose biliar anastomótica. A prótese com sistema antimigração apresentou menos migração. O número de colangiopancreatografia retrógrada endoscópica e complicações foram preditores de recorrência da estenose.
Background: Bile duct strictures can represent up to 40% of adverse biliary events after liver transplantation, and biliary anastomosis strictures account for most bile duct complications. Endoscopic therapy is the first line treatment and can be performed by stricture dilation and plastic or metal stents placement, with success rates between 70% and 100%. Aims: Primary To compare endoscopic therapy with plastic stents versus metal stent in the treatment of post liver transplant anastomotic biliary strictures. Secondary 1. to compare effectiveness of metal stents with and without an antimigration system; 2. to compare migration rate between them; 3. to identify possible predictive factors for strictures recurrence. Patients and Methods: This is a retrospective cohort study, with 161 patients. Endoscopic treatment results were analyzed in patients with anastomotic biliary stricture after liver transplantation treated with metal or plastics stents and followed up at Hospital Israelita Albert Einstein São Paulo, between April 2012 to August 2022. Patients were stratified into 3 groups according to therapy: plastics stents, metal stent or hybrid group. Primary outcome was resolution and recurrence of biliary stricture. Secondary outcome was assessment of possible predictors of recurrence for biliary stricture. Results: overall stricture resolution was 151/161 patients (93.7%). Resolution occurred in 83/84 patients (99%) in the metal stent group, 18/20 (90%) in the plastics stents group and 50/57 (88%) in the hybrid group (P = 0.013). Therapy failure occurred in 10/161 (6.2%). Stricture recurrence occurred in 22/161 (14%) patients. The KaplanMeier analysis showed a difference in recurrencefree time among the groups (P = 0.015), but there was no difference between metal and plastic stents groups (P = 0.201). The difference was found in the hybrid group, with a shorter time free from stricture recurrence. In the analysis between the groups of metal stent with and without antimigration system; resolution occurred in 96% in the group without and 88% in the group with anti migration system (P = 0.150). Recurrence was 14% and 8%, for stents without and with antimigration system respectively (P = 0.741). Migration of metal stents was 46% for stents without an antimigration system versus 4% for those with an antimigration system (OR: 20.4; 95% CI: 2.697 – 154.541; P< 0.001). Multivariate analysis identified number of endoscopic retrograde cholangiopancreatography (hazard ratio: 1.4; 95% CI: 1.194 – 1.619; P < 0.001) and complications (hazard ratio: 2.8; 95% CI: 1.008 – 7.724; P = 0.048) as predictors of stricture recurrence. Conclusion: Metal and plastic stents were effective and comparable in relation to resolution and recurrence of post liver transplant anastomotic biliary stricture. Metal stent with and without antimigration system were comparable in terms of anastomotic biliary stricture resolution and recurrence. The stent with antimigration system showed less migration. The number of endoscopic retrograde cholangiopancreatography and complications were predictors of stricture recurrence.
Background: Bile duct strictures can represent up to 40% of adverse biliary events after liver transplantation, and biliary anastomosis strictures account for most bile duct complications. Endoscopic therapy is the first line treatment and can be performed by stricture dilation and plastic or metal stents placement, with success rates between 70% and 100%. Aims: Primary To compare endoscopic therapy with plastic stents versus metal stent in the treatment of post liver transplant anastomotic biliary strictures. Secondary 1. to compare effectiveness of metal stents with and without an antimigration system; 2. to compare migration rate between them; 3. to identify possible predictive factors for strictures recurrence. Patients and Methods: This is a retrospective cohort study, with 161 patients. Endoscopic treatment results were analyzed in patients with anastomotic biliary stricture after liver transplantation treated with metal or plastics stents and followed up at Hospital Israelita Albert Einstein São Paulo, between April 2012 to August 2022. Patients were stratified into 3 groups according to therapy: plastics stents, metal stent or hybrid group. Primary outcome was resolution and recurrence of biliary stricture. Secondary outcome was assessment of possible predictors of recurrence for biliary stricture. Results: overall stricture resolution was 151/161 patients (93.7%). Resolution occurred in 83/84 patients (99%) in the metal stent group, 18/20 (90%) in the plastics stents group and 50/57 (88%) in the hybrid group (P = 0.013). Therapy failure occurred in 10/161 (6.2%). Stricture recurrence occurred in 22/161 (14%) patients. The KaplanMeier analysis showed a difference in recurrencefree time among the groups (P = 0.015), but there was no difference between metal and plastic stents groups (P = 0.201). The difference was found in the hybrid group, with a shorter time free from stricture recurrence. In the analysis between the groups of metal stent with and without antimigration system; resolution occurred in 96% in the group without and 88% in the group with anti migration system (P = 0.150). Recurrence was 14% and 8%, for stents without and with antimigration system respectively (P = 0.741). Migration of metal stents was 46% for stents without an antimigration system versus 4% for those with an antimigration system (OR: 20.4; 95% CI: 2.697 – 154.541; P< 0.001). Multivariate analysis identified number of endoscopic retrograde cholangiopancreatography (hazard ratio: 1.4; 95% CI: 1.194 – 1.619; P < 0.001) and complications (hazard ratio: 2.8; 95% CI: 1.008 – 7.724; P = 0.048) as predictors of stricture recurrence. Conclusion: Metal and plastic stents were effective and comparable in relation to resolution and recurrence of post liver transplant anastomotic biliary stricture. Metal stent with and without antimigration system were comparable in terms of anastomotic biliary stricture resolution and recurrence. The stent with antimigration system showed less migration. The number of endoscopic retrograde cholangiopancreatography and complications were predictors of stricture recurrence.
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Citação
PINHEIRO, Larissa Wermelinge. Resultados a longo prazo e fatores preditivos de recorrência de estenose anastomótica póstransplante hepático da terapia endoscópica com próteses metálicas e plásticas. 2024. 92 f. Dissertação (Mestrado em Gastroenterologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2024.