Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients

Less is more: The use of single biodegradable stenting to treat biliary anastomotic strictures in pediatric liver transplantation

This study reports our experience of using biodegradable biliary stents (BBSs) for anastomotic biliary strictures (ABSs) in pediatric patients undergoing liver transplants. It involves the analysis of a retrospective data collection from January 2014 to January 2023, including all pediatric recipients of liver transplants in our center treated for ABSs with BBSs. In phase 1 (2014-2019), there was an initial percutaneous transhepatic cholangiography with anastomotic dilatation followed 2 weeks after a second percutaneous transhepatic cholangiography with BBS insertion. In phase 2 (2019-2023), the BBS was placed shortly after ABS dilatation, requiring only 1 percutaneous transhepatic cholangiography. All patients were followed up with routine tests and ultrasound. Forty-six ABSs were diagnosed in 43 pediatric recipients of liver transplants with a median of 6.7 months after liver transplantation (0.1-246.8 mo). Eight out of 46 ABSs (17.4%) treated with BBSs relapsed (median recurrence time: 6.5 mo; 1.6-17.0 mo). Four resolved with further BBS placement; only 4 needed surgical revision (8.7%) after a median follow-up time of 43.9 months (0.3-106.3). There were no differences in ABS recurrence rate, time between stent placement and recurrence, or the presence of cholangitis based on whether the BBS was deployed in 1 or 2 steps. Patients with end-to-end anastomosis had a higher ABS recurrence (OR 10.8; 1.4-81.3, p = 0.008) than those with bilioenteric anastomosis. The use of biodegradable stents could be a good option for treating ABSs in pediatric patients undergoing liver transplants, with our series showing a success rate of over 90% and an average follow-up of 43.9 months.

Treatment Strategies for Bile Leak Following Pediatric Liver Transplantation

There are no standard management protocols for the treatment of bile leak (BL) after liver transplantation. The objective of this study is to describe treatment options for BL after pediatric LT.

METHODS

Retrospective analysis (January 2010-March 2023).

VARIABLES STUDIED

preoperative data, status at diagnosis, and postoperative outcome. Four groups: observation (n = 9), percutaneous transhepatic cholangiography (PTC, n = 38), ERCP (2), and surgery (n = 27).

RESULTS

Nine hundred and thirty-one pediatric liver transplantation (859 LDLT and 72 DDT); 78 (8.3%) patients had BL, all in LDLT. The median (IQR) peritoneal bilirubin (PB) level and fluid-to-serum bilirubin ratio (FSBR) at diagnosis was 14.40 mg/dL (8.5-29), and 10.7 (4.1-23.7). Patients who required surgery for treatment underwent the procedure earlier, at a median of 14 days (IQR: 7-19) versus 22 days for PTC (IQR: 15-27, p = 0.002). PB and FSBR were significantly lower in the observation group. In 11 cases, conservative management had resolution of the BL in an average time of 35 days, and 38 patients underwent PTC in a median time of 22 days (15-27). Twenty-seven (34.6%) patients were reoperated as initial treatment for BL in a median time of 17 days (1-108 days); 25 (33%) patients evolved with biliary stricture, 5 (18.5%) after surgery, and 20 (52.6%) after PTC (p = 0.01).

CONCLUSION

Patients with BL who were observed presented significantly lower levels of PB and FSBR versus those who underwent PTC or surgery. Patients treated with PTC presented higher rates of biliary stricture during the follow-up.

Long-term outcome of combined radiologic and surgical strategy for the management of biliary complications after pediatric liver transplantation

OBJECTIVES

We aimed to analyze the risk factors for management failure of BC after pediatric liver transplantation (pLT) by retrospectively analyzing primary pLT performed between 1997 and 2018 (n = 620 patients).

RESULTS

In all, 117/620 patients (19%) developed BC. The median (range) follow-up was 9 (1.4-21) years. Patient survival at 1, 5 and 10 years was 88.9%, 85.7%, 84.4% and liver graft survival was 82.4%, 77.4%, and 74.3% respectively. Graft not patient survival was impaired by BC (p = 0.01). Multivariate analysis identified the number of dilatation courses > 2 (p = 0.008), prolonged cold ischemia time (p = 0.004), anastomosed multiple biliary ducts (p = 0.019) and hepatic artery thrombosis (p = 0.01) as factors associated with impaired graft survival. The number of dilatation courses > 2 (p < 0.001) and intrahepatic vs anastomotic stricture (p = 0.014) were associated with management failure. Thus, repeated (> 2) radiologic dilatation courses are associated with impaired graft survival and management failure. Overall, graft but not patient survival was impaired by BC.

Biliary Leak after Pediatric Liver Transplantation Treated by Percutaneous Transhepatic Biliary Drainage-A Case Series

BACKGROUND

Biliary leaks are a severe complication after pediatric liver transplantation (pLT), and successful management is challenging.

OBJECTIVES

The aim of this case series was to assess the outcome of percutaneous transhepatic biliary drainage (PTBD) in children with bile leaks following pLT. The necessity of additional percutaneous bilioma drainage and laboratory changes during therapy and follow-up was documented.

MATERIAL AND METHODS

All children who underwent PTBD for biliary leak following pLT were included in this consecutive retrospective single-center study and analyzed regarding site of leak, management of additional bilioma, treatment response, and patient and transplant survival. The courses of inflammation, cholestasis parameters, and liver enzymes were retrospectively reviewed.

RESULTS

Ten children underwent PTBD treatment for biliary leak after pLT. Seven patients presented with leakage at the hepaticojejunostomy, two with leakage at the choledocho-choledochostomy and one with a bile leak because of an overlooked segmental bile duct. In terms of the mean, the PTBD treatment started 40.3 ± 31.7 days after pLT. The mean duration of PTBD treatment was 109.7 ± 103.6 days. Additional percutaneous bilioma drainage was required in eight cases. Bile leak treatment was successful in all cases, and no complications occurred. The patient and transplant survival rate was 100%. CRP serum level, leukocyte count, gamma-glutamyl transferase (GGT), and total and direct bilirubin level decreased significantly during treatment with a very strong effect size. Additionally, the gamma-glutamyl transferase level showed a statistically significant reduction during follow-up.

CONCLUSIONS

PTBD is a very successful strategy for bile leak therapy after pLT.

A case of hepaticojejunal anastomotic obstruction after a living-donor liver transplantation and recanalization using a high-frequency knife under the rendezvous technique

A 65-year-old woman underwent living-donor liver transplantation (left-lobe graft: GWRW ratio, 0.54) for cirrhosis caused by autoimmune hepatitis. At 68 years, she was diagnosed with obstructive cholangitis due to stricture during a hepaticojejunostomy following impaired liver function. Endoscopic balloon dilation of anastomosis and placement of a plastic stent resulted in improved liver function. However, at 72 years, the patient experienced a flare-up of liver damage. The plastic stent had fallen out, and although endoscopic stenotic dilation was attempted, the anastomotic site was obstructed completely. Therefore, recanalization of the hepaticojejunostomy was attempted using a rendezvous technique. A percutaneous transhepatic biliary drainage tube was inserted through the B3 bile duct, and the complete obstructed anastomosis was confirmed by percutaneous transhepatic and transjejunal approaches. The anastomosis was reopened by excising the scarred tissues from the jejunal side using a 1.5-mm high-frequency knife. A 14-Fr. catheter for the internal fistula tube was percutaneously placed at the opened anastomosis to achieve anastomotic site recanalization. The patient's liver damage improved after the re-internalization, and no symptom recurrence such as obstructive cholangitis developed for 1 year. There are few reports of recanalization of the hepaticojejunostomy with a high-frequency knife. Herein, we report the case with a literature review.

Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study

Donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), and living-donation (LD) are the three possible options for liver transplantation (LT), each with unique benefits and complication rates. We aimed to compare DCD-, DBD-, and LD-LT-specific graft survival and biliary complications (BC). We collected data on 138 DCD-, 3,027 DBD- and 318 LD-LTs adult recipients from a single center and analyzed patient/graft survival. BC (leak and anastomotic/non-anastomotic stricture (AS/NAS)) were analyzed in a subset of 414 patients. One-/five-year graft survival were 88.6%/70.0% for DCD-LT, 92.6%/79.9% for DBD-LT, and, 91.7%/82.9% for LD-LT. DCD-LTs had a 1.7-/1.3-fold adjusted risk of losing their graft compared to DBD-LT and LD-LT, respectively (p < 0.010/0.403). Bile leaks were present in 10.1% (DCD-LTs), 7.2% (DBD-LTs), and 36.2% (LD-LTs) (ORs, DBD/LD vs. DCD: 0.7/4.2, p = 0.402/<0.001). AS developed in 28.3% DCD-LTs, 18.1% DBD-LTs, and 43.5% LD-LTs (ORs, DBD/LD vs. DCD: 0.5/1.8, p = 0.018/0.006). NAS was present in 15.2% DCD-LTs, 1.4% DBDs-LT, and 4.3% LD-LTs (ORs, DBD/LD vs. DCD: 0.1/0.3, p = 0.001/0.005). LTs w/o BC had better liver graft survival compared to any other groups with BC. DCD-LT and LD-LT had excellent graft survival despite significantly higher BC rates compared to DBD-LT. DCD-LT represents a valid alternative whose importance should increase further with machine/perfusion systems.

Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age

BACKGROUND/PURPOSE

The incidence of hepatic artery thrombosis (HAT) in recipients is high after pediatric LT using young donors. In this study we investigated the management and outcome of HAT after whole-LT using donors less than one year of age. And evaluate the safety of pediatric donors, and increase the utilization of pediatric donors overall.

METHODS

We retrospectively analyzed the clinical data encompassing children who underwent whole-liver transplantation in our department from January 2014 to December 2019. Recipients receiving a liver from a donor ≥1 month and ≤12 months were included, and a total of 110 patients were included in this study.

RESULTS

The results showed an incidence for HAT of 20% and the median time to HAT diagnosis was 3.0 (2.0, 5.3) days post-operation. Anticoagulant therapy was used for 19 cases and 94.7% of them achieved hepatic artery recanalization or collateral formation. The median time of recanalization was 12 (5, 15) days. Bile leakage and biliary strictures occurring in the HAT group were higher than in the non HAT group (13.6% vs. 1.1% and 31.8% vs. 3.4%). There were no significant differences in the survival rates of recipients or grafts among the two groups (P = 0.474, P = 0.208, respectively).

CONCLUSION

We confirmed that the incidence of HAT in LT recipients use donors less than 1 year is high, but recanalization can be performed using anticoagulant therapy. Although biliary complications increased significantly after HAT, the survival rates of patients and grafts were satisfactory.

LEVEL OF EVIDENCE

Level III.

Research Priorities in Percutaneous Image and Endoscopy Guided Interventions for Biliary and Gallbladder Diseases: Proceedings from the Society of Interventional Radiology Foundation Multidisciplinary Research Consensus Panel

Recent technological advancements including the introduction of disposable endoscopes have enhanced the role of interventional radiology (IR) in the management of biliary/gallbladder diseases. There are unanswered questions in this growing field. The Society of Interventional Radiology Foundation convened a virtual Research Consensus Panel consisting of a multidisciplinary group of experts, to develop a prioritized research agenda regarding percutaneous image and endoscopy guided procedures for biliary and gallbladder diseases. The panelists discussed current data, opportunities for IR and future efforts to maximize IR's ability and scope. A recurring theme throughout the discussions was to find ways to reduce the total duration of percutaneous drains and to improve the patients' quality of life. Following the presentations and discussions, research priorities were ranked based on their clinical relevance and impact. The research ideas ranked top three were as follows: 1- Percutaneous multimodality management of benign anastomotic biliary strictures (Laser vs endobiliary ablation vs cholangioplasty vs drain upsize protocol alone); 2- Ablation of intraductal cholangiocarcinoma with and without stenting; and 3- Cholecystoscopy/choledochoscopy and lithotripsy in non-surgical patients with calculous cholecystitis. Collaborative retrospective and prospective research studies are essential to answer these questions and to improve the management protocols for patients with biliary/gallbladder diseases.

Biliary complications in pediatric liver transplantation: findings of percutaneous transhepatic cholangiography in a large single-center cohort

BACKGROUND

Although biliary complications after orthotopic liver transplantation represent a common source of morbidity and mortality, decreasing graft survival, consensus is lacking on their management in the pediatric population.

OBJECTIVE

The aim of this study was to present the prevalence of such biliary complications and their interventional radiologic management with representative images.

MATERIALS AND METHODS

This retrospective study reports our experience with percutaneous transhepatic cholangiography in the management of biliary complications after orthotopic liver transplantation in pediatric patients. This study enrolled all pediatric patients (<18 years old) who underwent percutaneous transhepatic cholangiography for the management of biliary complications after orthotopic liver transplantation at a tertiary care center between January 2010 and December 2020. Diagnosis of biliary complications and indication to perform percutaneous transhepatic cholangiography were based on clinical, laboratory or radiologic data.

RESULTS

Among the 301 orthotopic liver transplantations, 78 (26%) developed biliary complications that were managed by interventional radiology: these included 52 (17.3%) biliary strictures, 19 (6.3%) bile leaks, 5 (1.7%) biliary stones, 1 (0.3%) iatrogenic biliary obstruction and 1 (0.3%) vanishing syndrome. The median time interval between orthotopic liver transplantation and the diagnosis of biliary complications was 6.0 years (interquartile range [IQR] 8.2 years). Percutaneous transhepatic cholangiography and biliary duct catheterization were successful in all cases, with low rates of complications that were variable among subgroups.

CONCLUSION

A wide spectrum of biliary complications can occur after pediatric orthotopic liver transplantation. In this large single-center experience, we highlight the value of percutaneous transhepatic cholangiography in their diagnosis and management. Percutaneous treatments in pediatric patients are safe and effective, providing resolution or serving as a bridge to surgery, including re-transplantation.

Hepatolithiasis After Living Donor Liver Transplantation in Pediatric Patients: Mechanism, Diagnosis, Treatment, and Prognosis

There is little information about the outcomes of pediatric patients with hepatolithiasis after living donor liver transplantation (LDLT). We retrospectively reviewed hepatolithiasis after pediatric LDLT. Between May 2001 and December 2020, 310 pediatric patients underwent LDLT with hepaticojejunostomy. Treatment for 57 patients (18%) with post-transplant biliary strictures included interventions through double-balloon enteroscopy (DBE) in 100 times, percutaneous transhepatic biliary drainage (PTBD) in 43, surgical re-anastomosis in 4, and repeat liver transplantation in 3. The median age and interval at treatment were 12.3 years old and 2.4 years after LDLT, respectively. At the time of treatments, 23 patients (7%) had developed hepatolithiasis of whom 12 (52%) were diagnosed by computed tomography before treatment. Treatment for hepatolithiasis included intervention through DBE performed 34 times and PTBD 6, including lithotripsy by catheter 23 times, removal of plastic stent in 8, natural exclusion after balloon dilatation in 7, and impossibility of removal in 2. The incidence of recurrent hepatolithiasis was 30%. The 15-years graft survival rates in patients with and without hepatolithiasis were 91% and 89%, respectively (p = 0.860). Although hepatolithiasis after pediatric LDLT can be treated using interventions through DBE or PTBD and its long-term prognosis is good, the recurrence rate is somewhat high.

Management of Biliary Stricture in Pediatric Liver Transplantation Patients: Long-Term Outcomes

Postoperative biliary complications have been reported to occur in 10% to 33% of pediatric liver transplantation (LT) recipients. Percutaneous intervention has become the primary treatment method for these complications; however, the efficacy and outcomes of these patients have not been well studied. Institutional pediatric LT from 1998 to 2019 were retrospectively reviewed to determine the patients referred for percutaneous treatment of post-LT biliary strictures. Clinical parameters, percutaneous transhepatic cholangiograms (PTCs), biliary catheter placement, cholangioplasty, and long-term outcomes were analyzed. Of the 396 consecutive pediatric LT recipients during our study period, 50 (12.6%) were diagnosed with biliary strictures on PTC. LT biliary reconstructions were Roux-en-Y hepaticojejunostomy in 28 patients (56%), choledochojejunostomy in 11 patients (22%), and choledochocholedochostomy in 11 patients (22%). Median age at LT was 23.2 months (interquartile range [IQR], 10.9-90.6), and 14 patients (28%) developed hepatic artery thrombosis. A total of 44 patients (88%) were treated with internal/external biliary catheters, of whom 38 (76%) underwent balloon cholangioplasty. By 12 months, 84% of patients had complete stricture resolution and catheter removal. Median total duration of catheter drainage was 152 days (IQR, 76-308). A total of 8 patients required additional surgery (biliary reconstruction or repeat LT [re-LT]) or died with a drainage catheter in place from complications unrelated to PTC intervention. Among the 6 patients (12%) treated with unilateral external biliary drainage catheters, 2 had catheters removed for inadequate drainage but then had spontaneous biliary obstruction resolution, 1 underwent duct reconstruction, and 3 required long-term catheterization. Biliary strictures following pediatric LT can be successfully treated with internal/external biliary drainage catheters and cholangioplasty if the stricture can be crossed. However, patients with isolated strictured ducts may require long-term external catheter drainage until re-LT or percutaneous obliteration of isolated ducts.

Influence of early biliary complications on survival rates after pediatric liver transplantation-A positive outlook

BACKGROUND

Early biliary complications (EBC) constitute a burden after pediatric liver transplantation frequently requiring immediate therapy. We aimed to assess the impact of EBC on short- and long-term patient and graft survival as well as post-transplant morbidity.

METHODS

We analyzed 121 pediatric liver transplantations performed between 1984 and 2019 at the Medical University of Innsbruck for the occurrence of early (<90 days) biliary complications and investigated the influence of EBC on patient and graft survival.

RESULTS

Early biliary complications occurred in 30 (24.8%) out of the 121 pediatric liver transplant recipients. Patient survival at 15 years (89.2% vs. 84.2%, p = .65) and all-cause (82.5% vs. 74.0%) and death-censored graft survival (82.5% vs. 75.1%, p = .71) at 10 years were similar between the EBC and the non-EBC group. The EBC group had a significantly longer ICU (25 vs. 16 days, p < .001) and initial hospital stay (64 vs. 42 days, p = .002). Livers of patients with EBC were characterized by multiple bile ducts (33.3% vs. 13.2%, p = .027), and patients with EBC had a higher risk to develop late biliary complications (OR 2.821 [95% CI 1.049-7.587], p = .044) and bowel obstruction/perforation (OR 4.388 [95% CI 1.503-12.812], p = .007).

CONCLUSION

Early biliary complications after pediatric liver transplantation is frequent. The occurrence of EBC significantly increased post-transplant morbidity without affecting mortality. Multiple bile ducts were the only risk factor for the development of EBC in our cohort.

Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience

BACKGROUND

To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children.

METHODS

Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak.

RESULTS

Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02).

CONCLUSIONS

Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.

Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long-term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO-compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow-up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long-term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

Pediatric biliary disorders: Multimodality imaging evaluation with clinicopathologic correlation

The spectrum of pathologies affecting the biliary tree in the pediatric population varies depending on the age of presentation. While in utero insults can result in an array of anatomic variants and congenital anomalies in newborns, diverse acquired biliary pathologies are observed in older children. These acquired pathologies display different presentations and consequences than adults. Multimodality imaging assessment of the pediatric biliary system is requisite to establishing an appropriate management plan. Awareness of the imaging features of the various biliary pathologies and conveying clinically actionable information is essential to facilitate appropriate patient management. In this paper, we will illustrate the anatomy and embryology of the pediatric biliary system. Then, we will provide an overview of the imaging modalities used to assess the biliary system. Finally, we will review the unique features of the pediatric biliary pathologies, complemented by histopathologic correlation and discussions of clinical management.

Subclinical biliary strictures as a cause of long-term allograft dysfunction in children who underwent liver transplantation

We aimed to evaluate the role of liver biopsy to predict subclinical biliary strictures (BS) and assess the impact of BS on long-term allograft dysfunction following liver transplantation in children (LT). We reviewed all liver biopsies performed from 2012-2018. Percutaneous transhepatic cholangiography (PTC) was performed in patients presenting cholangiolar proliferation on cytokeratin-7 stained sections. We performed 271 biopsies in 161 children (86% with a left lateral segment); 44/161 (27%) presented with diffuse or multifocal cholangiolar proliferation. Among them, a tight BS was confirmed in 38/44 (86%, 24% of total) and it was managed by balloon dilatation. Cholangiolar proliferation showed a positive predictive value (PPV) for BS of 86.4%. Levels of alkaline phosphatase >325 IU/L predicted BS (P = .007). Dilatation of intrahepatic bile ducts on ultrasound was found only in 44% of patients with BS. Following a median follow-up of 9.2 years, only 15/38 (39%) patients resolved the BS. In conclusion subclinical BS is very common and probably underdiagnosed in these patients. Histological evidence of cholangiolar proliferation detectable by cytokeratin-7 immunostain should be preferred to liver function tests and ultrasound to suspect BS. BS in this setting should be regarded as a main cause of long-term allograft dysfunction.

Treatment of biliodigestive anastomotic strictures after transplantation of left lateral segment of the liver

Many studies have shown that biliary complications after transplantation of the left lateral segment (LLS) of the liver reduce graft and recipient survival. Thus, timely correction of biliary complications, and strictures in particular, improves long-term outcomes in transplantation. Objective: to analyze our own experience in correcting biliary strictures in LLS graft transplantation. Materials and methods. From February 2014 to April 2020, 425 LLS grafts were transplanted in children. 19 (4.5%) patients were diagnosed with biliary strictures at different times after transplantation (from 0.2 to 97 months). Results. Biliary strictures were more often formed a year after transplantation (17.8 ± 23.9 months). In 14 out of the 19 patients, internal-external biliary drainage was successfully performed with phased replacement of the catheter with one that was larger in diameter (from 8.5 Fr to 14 Fr). The catheters were removed in 8 patients after completion of the treatment cycle. Restenosis was not observed during follow-up (13 ± 8.7 months) after the internal-external biliary drainage catheter had been removed. In 5 cases, antegrade passage of a guide wire through the stricture was unsuccessful. As a result, biliary reconstruction was performed in 4 (21.1%) patients and retransplantation was required in 1 (5.3%) patient. Conclusion. An antegrade minimally invasive approach can successfully eliminate biliary strictures in most children after liver LLS graft transplantation. The proposed technique is effective and safe.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

Successful percutaneous treatment of biliary stenosis after living donor liver transplantation in a child

We report the case of a 16-year-old boy with primary sclerosing cholangitis associated with inflammatory bowel disease who was initially treated and controlled pharmacologically. He underwent living donor liver transplantation (LDLT) after he developed progressive biliary tract abnormalities and portal hypertension accompanied by recurrent bile duct infections. Two months following LDLT, the hepaticojejunostomy anastomosis became occluded and it was treated surgically. Few weeks later, an increase in drain production persisted without focus; therefore, further diagnostic tests were conducted which proved the recurrence of biliary cast. Under sonographic guidance, external drainage of bile was carried out by percutaneous transhepatic cholangiography and drainage. In total, our patient underwent 5 interventions under general anesthesia and clinically, our patient's general condition improved, and he gained weight. Minimally invasive procedures such as percutaneous transhepatic cholangiography and drainage and balloon dilation are safe and effective, but may require several attempts before being successful.

Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation

Background

Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS.

Material/Methods

Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD).

Results

Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007.

Conclusions

Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.

Endoscopic treatment in biliary strictures after pediatric liver transplantation

BACKGROUND AND AIM

The aim of the study was to assess efficacy and safety of endoscopic treatment in BS after pediatric LTx.

METHODS

We retrospectively reviewed data of patients with DDA who developed BS and underwent ERCP.

RESULTS

Of 189 transplanted patients with DDA, strictures developed in 30 (16%). In this subgroup, the median age at LTx was 14.7 (1.5-17.6) and follow-up period was 3.9 (1.3-11.3). ABS were in 76% and NABS in combination with ABS in 24% of patients. Overall, 95 ERCP sessions (3.0 per patient) were performed with successful outcome in 22 (73%) cases. Duration of treatment was 9.1 (1.8-24.1) months. Five patients underwent surgical revision and three patients retransplantation (10%). Risk factors of endoscopy failure were HCV or HBV infection, prolonged CIT and treatment before 2007. The most common complications after ERCP were cholangitis (8.2%) and pancreatitis (4.2%). There were worse overall prognosis and higher risk of post-ERCP complications in NABS.

CONCLUSIONS

ERCP is safe and effective in the majority of patients with post-transplant duct-to-duct BS, and it is currently recommended as the first-line treatment.

Endoscopic retrograde cholangio-pancreatography in the management of biliary complications after paediatric liver transplantation - a retrospective study

The published paediatric experience with endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnosis and management of biliary complications following liver transplantation (LT) is limited. We describe our experience with ERCP in the management of children following LT who presented with biliary complications, over a 20-year period (1995-2014). The retrospectively reviewed data are summarized descriptively. Of 94 children (47 boys) who received 102 liver transplants at our centre, seven children (five boys, two girls) underwent ERCP after liver transplantation. In total, 25 ERCP procedures were carried out in these patients. The median age at liver transplantation was 10.7 (3.9-16.2) years. The median interval between LT and the first ERCP was 28 days (12 days-6.8 years). All patients were on standard calcineurin-inhibitor-based immunosuppression regimens. Six of the seven patients underwent ERCP on more than one occasion [median number of ERCP sessions per patient- 4, (1-6)]. Seventeen procedures were carried out under conscious sedation, remaining eight under general anaesthesia. Sedation was achieved employing a standard regimen (Midazolam 5 mg with Pethidine 50 mg) and occasionally Fentanyl. ERCP is an effective and safe intervention from both diagnostic and therapeutic point of view, in the management of post-LT biliary complications in children.

The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation

OBJECTIVE

To evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation.

MATERIALS AND METHODS

This was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures.

RESULTS

In the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2-4), and the average interval between them was 2.9 months (range, 0.8-9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1-12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3-26.7 months).

CONCLUSION

The percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.

Intrahepatic cholangiojejunostomy for complex biliary stenosis after pediatric living-donor liver transplantation

The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.

Percutaneous management of benign biliary disorders in children

PURPOSE

The goal of this study was to analyze the outcomes of percutaneous transhepatic management of benign biliary disorders in pediatric patients.

MATERIALS AND METHODS

This study included 11 pediatric patients who underwent percutaneous transhepatic biliary interventional procedures between September 2007 and December 2016. There were 3 males and 8 females with a mean age of 9.6±5.4 (SD)years (range: 2-17years). Technical details, complications and outcome of the procedures were evaluated.

RESULTS

The underlying pathologies were bile duct stones (n=2), bile leakage (n=4), choledochal cyst (n=3) and benign biliary stricture (n=2). The therapeutic interventional procedures were as follows; percutaneous stone removal in patients with bile duct stones, external biliary drainage in patients with choledochal cyst, bile diversion by internal-external percutaneous biliary drainage (IE-PBD) in patients with bile leakage, plastic stent placement, IE-PBD with balloon dilatation in patients with benign biliary stricture. The procedures were successful in all patients technically and clinically. One patient experienced intermittent fever.

CONCLUSION

Percutaneous transhepatic biliary interventional procedure is an effective and safe approach for the treatment of pediatric patients with bile duct stones, bile leakage, symptomatic choledochal cyst and benign biliary stricture when endoscopic procedure is unavailable or fails.

Pediatric Liver Transplantation: An Update for the Pediatrician

Pediatric liver transplantation is a state-of-the-art treatment for children with end-stage liver disease. Over the past few decades, the advent of new surgical techniques using split liver grafts and living donors has drastically increased the organ availability for pediatric patients, while advances in immunosuppression have improved overall outcomes. The pediatrician is a key player in the multidisciplinary team that cares for these children starting with the timely referral of children who require liver transplantation to the active participation in optimizing the child's overall health before and after transplantation. [Pediatr Ann. 2016;45(12):e439-e445.].

Living donor liver transplantation in Brazil-current state

Currently in Brazil, living donor liver transplantation (LDLT) represents 8.5% of liver transplantation (LT), being the majority pediatric one. Up to now, according to Brazilian Organ Transplantation Association (ABTO) annual report, 2,086 procedures have been done nationwide, most of them in southeast and south regions. Based on national centers reports, biliary complication is the most common recipient postoperative complication (14.5-20.6%), followed by hepatic artery thrombosis (3.1-10.7%) and portal vein thrombosis (2.3-9.1%). Patient and graft overall 5-y survival correspond to 76% and 74%, respectively. Regarding the donor, morbidity rate ranges from 12.4% to 28.3%, with a national mortality rate of 0.14%. In conclusion, Brazilian LDLT programs enhance international experience that this is a feasible and safe procedure, as well as an excellent alternative strategy to overcome organs shortage.

[The results of biliary reconstructions after liver fragments transplantation]

AIM

To analyze the results of repeated reconstructions of choleresis after living related liver fragments transplantation.

MATERIAL AND METHODS

The study included 268 recipients (145 women and 123 men) aged 5 months - 61 years (mean age 16,11 ± 14,62 years) who underwent liver fragments transplantation in the department of liver transplantation of cad. B.V. Petrovskiy Russian Research Surgery Center from 1997 to 2012. Biliary reconstructions were performed at different terms after transplantation in 37 patients (13.81%). Complications followed repeated reconstructions, the initial conditions for biliary anastomosis formation during transplantation, the results of biliary reconstructions after transplantation were analyzed.

RESULTS

In most cases despite the prevailing complications there is a combination of various biliary complications requiring biliary reconstruction. It was found that live rfragment used for transplantation, type of primary reconstruction of choler sis, number of bile ducts orifices of graft and biliary anastomoses do not demonstrate statistically significant effect on the incidence of post-transplant biliary reconstructions (p>0.05). Poor prognosis in patients with biliary complications required biliary reconstructionsis determined by the development of graft dysfunction. Early reconstruction before development of liver transplant dysfunction is necessary condition of successful treatment. In the case of graft dysfunction liver retransplantation is unique method of treatment.

Biliary complications after pediatric liver transplantation: Risk factors, diagnosis and management

The expanded indications of partial grafts in pediatric liver transplantation have reduced waiting list mortality. However, a higher morbidity is observed, including an increased rate of biliary complications (BCs). Factors such as the type of graft, the preservation methods applied, the donor characteristics, the type of biliary reconstruction, and the number of bile ducts in the liver graft influences the occurrence of these complications. Bile leaks and strictures comprise the majority of post-transplant BCs. Biliary strictures require a high grade of suspicion, and because most children have a bileo-enteric anastomosis, its diagnosis and management rely on percutaneous hepatic cholangiography and percutaneous biliary interventions (PBI). The success rates with PBI range from 70% to 90%. Surgery is reserved for patients who have failed PBI. BCs in children after liver transplantation have a prolonged treatment and are associated with a longer length of stay and higher hospital costs. However, with early diagnosis and aggressive treatment, patient and graft survival are not significantly compromised.

Biliary complications in pediatric liver transplantation: Incidence and management over a decade

This study analyzed how features of a liver graft and the technique of biliary reconstruction interact to affect biliary complications in pediatric liver transplantation. A retrospective analysis was performed of data collected from 2001 to 2011 in a single high-volume North American pediatric transplant center. The study cohort comprised 173 pediatric recipients, 75 living donor (LD) and 98 deceased donor (DD) recipients. The median follow-up was 70 months. Twenty-nine (16.7%) patients suffered a biliary complication. The majority of leaks (9/12, 75.0%) and the majority of strictures (18/22, 81.8%) were anastomotic. There was no difference in the rate of biliary complications associated with DD (18.4%) and LD (14.7%) grafts (P = 0.55). Roux-en-Y (RY) reconstruction was associated with a significantly lower rate of biliary complications compared to duct-to-duct reconstruction (13.3% versus 28.2%, respectively; P = 0.048). RY anastomosis was the only significant factor protecting from biliary complications in our population (hazard ratio, 0.30; 95% confidence interval, 0.1-0.85). The leaks were managed primarily by relaparotomy (10/12, 83.3%), and the majority of strictures were managed by percutaneous biliary intervention (14/22, 63.6%). Patients suffering biliary complications had inferior graft survival (P = 0.04) at 1, 5, and 10 years compared to patients without biliary complications. Our analysis demonstrates a lower incidence of biliary complications with RY biliary reconstruction, and patients with biliary complications have decreased graft survival.

Roux-en-Y hepatico-jejunostomy for a left segmental graft: Do not twist the loop, stick it!

Biliary complications remain a major challenge for long-term success after LT, as it is, as a rule, the most common technical - early and late - complication that occurs, and because these complications contribute to a significant number of late graft losses and retransplantations. In the pediatric age group, both biliary atresia, as the patient's condition, and the use of a left liver graft, obtained by a liver division technique, make it necessary for the use of a Roux-en-Y jejunal loop for the biliary reconstruction in the majority of cases. A slight modification of the technique is presented, consisting of a straight positioning along the cut surface (rather than the conventional position that results in a harpoon shape). A favorable outcome in terms of a technical complication and graft survival was observed. This way of doing this is an interesting variation and adds to the surgical armamentarium.

Endoscopic treatment of pediatric post-transplant biliary complications is safe and effective

BACKGROUND AND AIM

Biliary complications (BC) after liver transplantation (LT) are associated with significant morbidity and mortality. Incidence of BC after pediatric LT is more than 10%. In adults, treatment by endoscopic retrograde cholangiopancreaticography (ERCP) is successful. As data in pediatric patients are limited, endoscopic treatment of BC in a pediatric cohort in a German transplant center was analyzed.

METHODS

LT recipients <18 years of age who were endoscopically treated for BC at University Hospital Essen were retrospectively analyzed. Characteristics of LT, endoscopic treatment measures, clinical and endoscopic presentation of BC, and outcomes after endoscopic treatment were evaluated.

RESULTS

Seventeen patients (median age 12 years) with clinical signs of BC were treated endoscopically using ERCP. Eleven patients had received a full-size liver, and six a left-sided living-donor transplant graft. In 12 patients, the bile ducts were accessible via Vater's papilla and five patients had a bilioenteric anastomosis. Biliary sphincterotomy was done in 13 patients. Eleven patients presented with stricture of the biliary anastomosis (AST), either isolated (nine) or in combination with biliary cast syndrome (BCS) or biliary leakage (one patient each). Ischemia-type biliary lesions (ITBL) were found in two patients. Five patients suffered from BCS, either as isolated pathology (two) or in combination with AST, bile leak or ITBL. In one patient, biliary access via the major papilla was not obtainable.

CONCLUSIONS

BC in pediatric LT were treated safely and successfully in pediatric patients when the biliary tract was accessible. The most common complications were AST, BCS and ITBL.