Comparison of Plastic, Fully Covered Metal, and Intraductal Metal Stents for Biliary Anastomotic Strictures After Living Donor Liver Transplantation: A Single-Center Experience.

Background: Benign biliary anastomotic strictures (BAS) remain among the most frequent complications after living donor liver transplantation (LDLT). Although multiple plastic stents (MPS) have traditionally been considered the standard endoscopic treatment, fully covered self-expandable metal stents (FCSEMS) and intraductal fully covered self-expandable metal stents (ID-FCSEMS) have emerged as alternative strategies. This study aimed to compare the efficacy and safety of MPS, FCSEMS, and ID-FCSEMS in the management of post-transplant biliary anastomotic strictures. Methods: This retrospective single-center cohort study included consecutive adult patients who developed benign biliary anastomotic strictures after LDLT and underwent ERCP-based treatment between January 2020 and January 2025. Patients were categorized according to the initial stent strategy: MPS (n = 32), FCSEMS (n = 30), and ID-FCSEMS (n = 25). Primary outcome was overall treatment success. Secondary outcomes included recurrence, number of ERCP sessions, treatment duration, post-procedural hospitalization, stent migration, and procedure-related adverse events. Results: A total of 87 patients were included. Clinical success was achieved in 81.3% of patients treated with MPS, 83.3% treated with FCSEMS, and 92.0% treated with ID-FCSEMS (p = 0.501). Recurrence rates were 18.8%, 10.0%, and 12.0%, respectively (p = 0.579). Patients treated with metal stents required significantly fewer ERCP sessions than those treated with MPS (median 5 vs. 2 vs. 2; p < 0.001). Median treatment duration was significantly shorter in the FCSEMS and ID-FCSEMS groups compared with the MPS group (12 vs. 10 vs. 9 months; p < 0.001). Post-procedural hospitalization was also reduced with metal stents (7 vs. 4 vs. 3 days; p < 0.001). Adverse event rates, including cholangitis, pancreatitis, bleeding, perforation, and mortality, were comparable among groups. Stent migration occurred in 21.9% of MPS patients, 23.3% of FCSEMS patients, and 12.0% of ID-FCSEMS patients (p = 0.525). On multivariable analysis, MELD score was the only independent predictor of treatment success (adjusted OR 0.90, 95% CI 0.83-0.98; p = 0.012). Conclusions: MPS, FCSEMS, and ID-FCSEMS achieved comparable rates of stricture resolution, recurrence, and adverse events in the treatment of biliary anastomotic strictures after LDLT. However, FCSEMS and ID-FCSEMS significantly reduced the number of ERCP procedures, treatment duration, and hospitalization compared with conventional plastic stenting. Among the evaluated strategies, ID-FCSEMS demonstrated the highest numerical success rate and lowest migration rate, suggesting a potential procedural advantage while maintaining comparable safety and efficacy.