Percutaneous interventional management of biliary complications after pediatric liver transplantation: A 16-year single-institution experience

American Society for Gastrointestinal Endoscopy guideline on management of post-liver transplant biliary strictures: methodology and review of evidence

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for strategies to manage biliary strictures in liver transplant recipients. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the role of ERCP versus percutaneous transhepatic biliary drainage and covered self-expandable metal stents (cSEMSs) versus multiple plastic stents for therapy of strictures, use of MRCP for diagnosing post-transplant biliary strictures, and administration of antibiotics versus no antibiotics during ERCP. In patients with post-transplant biliary strictures, we suggest ERCP as the initial intervention and cSEMSs as the preferred stent. In patients with unclear diagnosis or intermediate probability of a stricture, we suggest MRCP as the diagnostic modality. We suggest that antibiotics should be administered during ERCP when biliary drainage cannot be assured.

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.

North American Biliary Stricture Management Strategies in Children After Liver Transplantation: A Multicenter Analysis From the Society of Pediatric Liver Transplantation (SPLIT) Registry

Biliary strictures affect 4%-12% of pediatric liver transplantations. Biliary strictures can contribute to graft loss if left untreated; however, there remains no consensus on the best course of treatment. Study objectives included analyses of outcomes associated with biliary stricture management strategies via percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or surgery. We identified pediatric liver transplantation recipients (2011-2016) with biliary strictures from the Society of Pediatric Liver Transplantation (SPLIT) registry and retrieved imaging, procedural, and operative reports from individual centers. Subanalyses were performed to specifically evaluate PTC and ERCP for "optimal biliary outcome" (OBO), defined as graft survival with stricture resolution and without recurrence or surgery. A total of 113 children with a median follow-up of 3.9 years had strictures diagnosed 100 days (interquartile range, 30-290) after liver transplantation; 81% were isolated anastomotic strictures. Stricture resolution was achieved in 92% within 101 days, more frequently with isolated anastomotic strictures (96%). 20% of strictures recurred, more commonly in association with hepatic artery thrombosis (32%). Patient and graft survival at 1 and 3 years were 99% and 98% and 94% and 92%, respectively. In a subgroup analysis of 79 patients with extrahepatic strictures managed by PTC/ERCP, 59% achieved OBO following a median of 4 PTC, and 75% following a median of 3 ERCP (P < 0.001). Among patients with OBO, those with ERCP had longer time intervals between successive procedures (41, 47, 54, 62, 71 days) than for PTC (27, 31, 36, 41, 48 days; P < 0.001). Allograft salvage was successful across all interventions. Stricture resolution was achieved in 92%, with 20% risk of recurrence. Resolution without recurrence was highest in patients with isolated anastomotic strictures and without hepatic artery thrombosis.

Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques

In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction.

Novel technique for recanalization of severe hepaticojejunal obstruction using a transseptal needle in a pediatric liver transplant recipient

BACKGROUND

Endoscopic and PTB interventions are common nonsurgical interventions for biliary anastomotic strictures that occur after liver transplantation. When these nonsurgical interventions fail, surgical re-anastomosis is considered; however, this is quite invasive and can cause additional injury that may lead to graft loss. We report a case in which conventional nonsurgical interventions failed, but a new method that involve the use of a transseptal needle-a device to create a transseptal left-heart access during cardiac catheter interventions-was successfully used in recanalization of the hepaticojejunal anastomotic obstruction.

CASE

A 21-year-old man, who had received living-donor liver transplantation for biliary atresia at the age of 23 months presented with recurrent cholangitis and liver dysfunction due to a biliary anastomotic stricture of the hepaticojejunostomy. Therapeutic interventions for biliary stricture, including the PTB approach, double-balloon enteroscopic approach, and rendezvous approach failed. We then performed needle puncture of the anastomotic obstruction using a transseptal needle and succeeded in recanalizing the complete anastomotic obstruction. To perform the procedures safely, we evaluated the organ and needle positions using biplane fluoroscopy and placed a balloon in the afferent jejunal limb as a target for puncture. The 12 Fr catheter via the biliary route was removed 7 months after the procedure, without using a catheter, there was no recurrent stricture or cholangitis for 26 months.

CONCLUSION

Using a transseptal needle to manage hepaticojejunal anastomotic obstruction can reduce the number of patients who need surgical re-anastomosis.

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.

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.