Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric 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.

Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter Collaborative

OBJECTIVES

We aimed to determine which characteristics and management approaches were associated with postoperative invasive mechanical ventilation (IMV) and with a prolonged course of IMV in children post liver transplant as well as describing the utilization of critical care resources.

DESIGN

Retrospective, multicenter, cohort study of children who underwent an isolated liver transplantation between January 2017 and December 2018.

SETTING

Twelve U.S., pediatric, liver transplant centers.

PATIENTS

Three hundred thirty children post liver transplant admitted to the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six patients died in our cohort. The median length of PICU stay was 4.5 days (interquartile range [IQR], 2.9-8.2 d). Most patients were initially monitored with arterial catheters (96%), central venous pressures (95%), and liver ultrasound (93%). Anticoagulation (80%), blood product administration (52.4%), and vasoactive agents (23.0%) were commonly used therapies in the first 7 days. In multivariable logistic regression analysis, age (adjusted odds ratio [aOR] 0.9 [0.86-0.95]), open fascia (aOR 7.0 [95% CI, 2.6-18.9]), large center size (aOR 4.3 [95% CI 2.2-8.3]), and higher Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores (aOR 1.04 [95% CI, 1.01-1.06]) were associated with postoperative IMV. In multivariable logistic regression analysis, postoperative day 0 peak inspiratory pressure (PIP) (aOR 1.2 [95% CI, 1.1-1.3]), large center size (aOR 2.9 [95% CI, 1.6-5.4]), and age (aOR 0.89 [95% CI, 0.85-0.95]) were associated with length of IMV greater than 24 hours. Length of IMV greater than 24 hours was associated with bleeding complications ( p = 0.03), infections ( p = 0.03), graft loss ( p = 0.02), and reoperation ( p = 0.03).

CONCLUSIONS

Younger age, preoperative hospitalization, large center size, and open fascia are associated with use of IMV, and younger age, large center size, and postoperative day 0 PIP are associated with prolonged IMV on multivariable analysis. Longer IMV is associated with negative outcomes, making it an important clinical marker.

Liver transplantation in pediatric patients under 15 kg; duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses

Back ground. Liver transplantation is an effective treatment for acute or chronic liver failure and metabolic liver disease, which is associated with good quality of life in over 80 percent of recipients. We aimed to evaluate outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in pediatric liver transplant recipients below 15-kg.

Methods. In this single-center retrospective study, all children less than 15 kg that have undergone liver transplantation at Nemazee Hospital Organ Transplant Center affiliated with Shiraz University of Medical Sciences from 2009 till 2019, were enrolled. Over a 10-yr period, 181 liver transplants were performed in patients with two techniques including duct-to-duct (Group 1) vs. Roux-en-Y hepaticojejunostomy biliary anastomoses (Group 2). All data was collected from patients’ medical records, operative notes, and post-transplant follow up notes. Data was analyzed by SPSS software V21.

Results. Overall, 94 patients had duct to duct anastomosis (group 1) and 87 cases had Roux-en-Y hepaticojejunostomy (group 2). The mean age of the patients was 2.46 ± 1.5. The most common underlying diseases was biliary atresia (32%). The most prevalent complication after the surgery was infection in both groups. cardiopulmonary problems were significantly higher in group 2 (24.1% vs 4.3%) (p < 0.001). The rate of infection was significantly higher in group 2, as well.

Conclusion. Our study showed a relatively high rate of post-operative infection which was the most among patients who had undergone Roux-en-Y hepaticojejunostomy. Except from biliary complications which were mostly observed in DD group, other complications were more common among Roux-en-Y group.

Complications in pediatric hepatobiliary surgery

This review highlights the complications and their risk factors encountered in pediatric hepatobiliary surgery, specifically in the context of pediatric hepatic resection, excision of choledochal cyst, and the Kasai hepatoportoenterostomy procedure for biliary atresia as well as other procedures potentially affecting the biliary tree. With the understanding that these are relatively rare procedures, case reports and small case series are included in addition to larger series when available. The review focuses on publications in English over the past 15 years. Complications included both surgery-specific pathology, such as biliary stricture after excision of choledochal cyst, and disease-specific entities, such as malnutrition in biliary atresia. This review may be useful when considering a particular procedure or in the discussion thereof with a patient and family. Additionally, it illuminates the need for additional work with larger patient databases to refine and expand our knowledge of these complications and precipitating risk factors.

Results of pediatric liver transplant: a single-center experience

OBJECTIVES

Liver transplant is an established curative therapy for children with chronic end-stage liver disease or acute liver failure. In this study, we aimed to evaluate pediatric liver transplant in terms of outcomes, complications, and long-term followup results.

MATERIALS AND METHODS

Pediatric patients who had liver transplant in our institution were included. We retrospectively evaluated demographic features including body weight, Child-Pugh score, etiology of liver disease, graft source, perioperative outcomes, perioperative complications, postoperative complications, and long-term results. Outcomes of treatment of complications and revision transplant were evaluated.

RESULTS

Between September 2001 and December 2013, there were 188 pediatric liver transplants performed in our institution. Most grafts (90.9%) were obtained from living-related donors. There were 13 patients (6.9%) who had an intervention because of a hemorrhage postoperatively. Biliary leakage was observed in 33 patients (17.5%) and biliary stricture during follow-up was observed in 32 patients (17%). Thrombosis rates in the hepatic artery and portal vein were 12.3% and 0.5%. Revision transplant was performed in 11 patients (5.8%); reason for revision transplant was rejection in 50% patients. The remaining children were alive with good graft functioning after treatment of complications and revision transplant. The overall 5- and 10-year survival rates were 82.3% and 78.9%.

CONCLUSIONS

The overall outcomes of pediatric liver transplant at our center are very promising. With improved care of younger children and the combined efforts of the parents and medical team, the number of the children receiving transplants will increase in the future.