Response

Gastrointestinal Endoscopy, vol. 98, pp. 464–466

Abstract

We would like to express our gratitude for the letter to the editor by Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar related to our article “Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation”2Sissingh N.J. de Vries B.A. Inderson A. et al.Intraductal fully covered self-expandable metal stent versus multiple plastic stents for treating biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 97: 704-712.e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar published in the April issue. We appreciate their feedback and would like to provide a response. Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar stated that not every stent migration in the treatment of anastomotic strictures after liver transplantation should be considered an adverse event, a point with which we fully agree. In fact, this is precisely why we provided details about the specific context in which stent migration was detected (ie, elective vs nonelective ERCP) and the occurrence of adverse events such as cholangitis and progressive cholestatic liver enzymes. Inasmuch as Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar raised the suggestion to distinguish between migrations that occurred before stricture resolution and at the time of stricture resolution, we went back to the data. After the exclusion of stent migrations that occurred at the time of stricture resolution, 3 out of 8 cases in the intraductal fully covered self-expandable metal stent (ID-FCSEMS) group (n = 3 patients, 7%) versus 18 out of 21 cases in the multiple plastic stent (MPS) group (n = 13 patients, 36%) remained. The majority of patients in the MPS group required additional treatment after stent migration because the stricture was still present. This implies that the majority of stent migrations in the MPS group were clinically relevant and contributed to a suboptimal treatment and persistence of the stricture. For ID-FCSEMS, one could argue the opposite, inasmuch as only a minority of the stent migrations occurred before stricture resolution. It is possible that in ID-FCSEMS, migration can be seen as a result of successful stricture resolution. These differences in clinically relevant migration, however, only confirm the benefit of ID-FCSEMS over MPS. We agree with Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar that a cost-effectiveness analysis is an important issue. Costs were previously evaluated in 3 randomized trials evaluating anastomotic strictures after liver transplantation to compare (intraductal or transpapillary) FCSEMS and MPS.3Kaffes A. Griffin S. Vaughan R. et al.A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation.Therap Adv Gastroenterol. 2014; 7: 64-71Crossref PubMed Scopus (106) Google Scholar, 4Martins F.P. De Paulo G.A. Contini M.L.C. et al.Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial.Gastrointest Endosc. 2018; 87: 131.e1-131.e13Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 5Cantù P. Santi G. Rosa R. et al.Cost analysis of a long-term randomized controlled study in biliary duct-to-duct anastomotic stricture after liver transplantation.Transpl Int. 2021; 34: 825-834Crossref PubMed Scopus (6) Google Scholar Although 2 of 3 studies observed reduced procedural costs favoring (ID-)FCSEMS,3Kaffes A. Griffin S. Vaughan R. et al.A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation.Therap Adv Gastroenterol. 2014; 7: 64-71Crossref PubMed Scopus (106) Google Scholar,4Martins F.P. De Paulo G.A. Contini M.L.C. et al.Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial.Gastrointest Endosc. 2018; 87: 131.e1-131.e13Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar none of these studies performed a cost-effectiveness analysis.6Tringali A. Tarantino I. Barresi L. et al.Multiple plastic versus fully covered metal stents for managing post-liver transplantation anastomotic biliary strictures: a meta-analysis of randomized controlled trials.Ann Gastroenterol. 2019; 32: 407-415PubMed Google Scholar Owing to the retrospective nature of our study, we were unable to evaluate the costs of all intramural health care use, and we therefore thought that an accurate cost comparison between ID-FCSEMS and MPS was not possible. Nonetheless, previous studies have shown that stent costs are only a minor cost driver compared with the total health care costs, including hospital stay and the need for reinterventions, in patients with distal malignant biliary obstruction,7Walter D. van Boeckel P.G. Groenen M.J. et al.Cost efficacy of metal stents for palliation of extrahepatic bile duct obstruction in a randomized controlled trial.Gastroenterology. 2015; 149: 130-138Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar biliary strictures related to chronic pancreatitis,8Behm B.W. Brock A. Clarke B.W. et al.Cost analysis of temporarily placed covered self expandable metallic stents versus plastic stents in biliary strictures related to chronic pancreatitis [abstract].Gastrointest Endosc. 2007; 65: AB211Abstract Full Text Full Text PDF Google Scholar and infected necrotizing pancreatitis.9Boxhoorn L. Verdonk R.C. Besselink M.G. et al.Comparison of lumen-apposing metal stents versus double-pigtail plastic stents for infected necrotising pancreatitis.Gut. 2023; 72: 66-72Crossref PubMed Scopus (15) Google Scholar On the basis of this information, it is reasonable to speculate that the reduced number of ERCPs and admission days observed in our study compensate, or even outweigh, the price of an ID-FCSEMS. Moreover, and perhaps more importantly, such outcomes may contribute to a reduction in carbon emissions. However, we agree with Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar that future trials with an extensive health economic analysis should be performed to confirm whether ID-FCSEMS placement is truly cost effective over MPS. Concerning the comments on the statistical analysis, we performed a log-rank test for both time to stricture resolution (P = .004) and time to stricture recurrence (P = .455). Again, we appreciate the interest of Chen et al1Chen S. Zhai Y. Li M. Considerations on intraductal fully covered self-expandable metal stent in treatment of biliary anastomotic strictures after liver transplantation.Gastrointest Endosc. 2023; 98: 464Abstract Full Text Full Text PDF Scopus (1) Google Scholar in our study. In the future, well-designed randomized controlled trials should be performed to validate the findings of our study. Dr Inderson has received research support from Prion Medical (Taewoong supplier) for a nonrelated project and has acted as consultant for Cook Medical and Olympus. Dr van Hooft has received research support from Cook Medical and has acted as consultant for Cook Medical, Boston Scientific, Olympus, Medtronic, and Abbvie. All other authors disclosed no financial relationships. Drs Sissingh and de Vries contributed equally to this article.

Authors 6

1. Noor J. Sissingh Aachen Department of Gastroenterology and Hepatology

   Leiden University Medical Center

   Affiliation as printed

   Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands

2. Boudewijn A. de Vries

   University Medical Center Groningen

   Affiliation as printed

   Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands

3. Akin Inderson Aachen Department of Gastroenterology and Hepatology

   Leiden University Medical Center

   Affiliation as printed

   Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands

4. Bart van Hoek Aachen Department of Gastroenterology and Hepatology

   Leiden University Medical Center

   Affiliation as printed

   Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands

5. Frans van der Heide

   University Medical Center Groningen

   Affiliation as printed

   Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands

6. Jeanin Elise van Hooft Aachen Department of Gastroenterology and Hepatology

   Leiden University Medical Center

   Affiliation as printed

   Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands