Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation

Biliary strictures post pediatric liver transplantation-incidence and risk factors in a single tertiary referral transplant center

BACKGROUND

Biliary strictures are a significant cause of morbidity and graft loss in pediatric liver transplant recipients. Risk factors for the development of biliary strictures are not fully established. We aimed to evaluate the incidence of biliary strictures and treatment modalities outcomes and to identify potential risk factors for occurrence.

METHODS

Pediatric patients who underwent liver transplantation in the single tertiary pediatric liver transplant center in Israel were evaluated. We compared demographics, presentation, laboratory results, imaging, treatment, and outcomes between patients with and without biliary stricture. Multivariate regression analyses were used to identify risk factors for biliary strictures.

RESULTS

Among 121 pediatric liver transplant patients, 65 (53.7%) were males; the median age at the time of liver transplantation was 43 (3-215) months. Fifteen patients (12.4%) had biliary strictures following transplantation. One (7%) patient with biliary stricture was treated via endoscopic retrograde cholangiopancreatography, and 12 patients (80%) underwent interventions via a percutaneous transhepatic approach. Nine of the 12 patients were treated successfully, requiring one or multiple procedures, while the remaining had surgery or laser therapy. Risk factors for the development of biliary strictures were biliary leak, acute cellular rejection, and the presence of two biliary anastomoses.

CONCLUSIONS

In our cohort, the presence of two biliary anastomoses and post-transplant complications including acute cellular rejection and early biliary leaks were associated with biliary strictures in pediatric liver transplantation recipients. Percutaneous transhepatic interventions result in good outcomes in most patients.

Safety of Periprocedural Antithrombotics during Pediatric Transplant Liver Biopsies

The purpose of this study was to compare the adverse event (AE) rates of percutaneous pediatric transplant liver biopsies in patients receiving periprocedural antithrombotic agents with those in patients not receiving them. A 19-year retrospective single-center study of ultrasound-guided transplant liver biopsies was conducted. Patients who received aspirin for <5 days (n = 51) or heparin <4 hours (n = 15) before biopsy were separately grouped. AEs were reported using the Society of Interventional Radiology classification. In 276 biopsy samples from patients with a mean age of 6.75 years ± 5.80, the overall AE (P = .72) and moderate AE (P = .78) rates for control and antithrombotic groups were not significantly different. No severe AEs or deaths occurred. In conclusion, aspirin continuation during percutaneous pediatric transplant liver biopsies may be safe, but more studies are necessary to confirm the safety of periprocedural heparin.

Endoscopic Ultrasound-guided Hepaticogastrostomy in a Seven-year-old Girl

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage procedure in adult cases with difficult biliary access. However, there have been no reports on this procedure being used in pediatric cases. We successfully performed EUS-HGS in a pediatric case with a surgically altered anatomy. A standard convex-type echoendoscope and standard devices were used, and there were no device-related complications. The benefit of EUS-HGS for pediatric patients was avoidance of a percutaneous tube, which is difficult to maintain in active children. The accumulation of further cases and performance of a prospective study are warranted to standardize and expand the experience with this procedure.

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.

Factors affecting anxiety, depression, and self-care ability in patients who have undergone liver transplantation

BACKGROUND

Depression, anxiety, and altered self-care ability are among the most important factors affecting the quality of life of liver transplant recipients. Depending on the severity of the underlying liver disease, signs and symptoms of anxiety and depression may become more pronounced.

AIM

To evaluate the factors affecting depression, anxiety and self-care abilities of liver transplant recipients.

METHODS

Recipients who are ≥ 18 years and who underwent liver transplantation at Inonu University Liver Transplantation Institute were included in this descriptive and cross-sectional study. Sample size analysis showed that the minimum number of recipients should be 301 (confidence level = 95%, confidence interval = 2.5, population = 1382). Three hundred and twenty recipients were interviewed and 316 recipients that have answered the questionnaires accurately were analyzed. The dependent variables were the Beck Depression Scale, State-Trait Anxiety Scale (Form I and II), and Self-Care Agency Scale. The independent variables of the study were sociodemographic characteristics, biliary complications, hepatocellular carcinoma, recommending liver transplantation to other patients, and the interval of out-patient clinic visits.

RESULTS

Self-care ability scores were lower (P = 0.002) and anxiety scores were higher (P = 0.004) in recipients with biliary complications. On the other hand, in recipients with hepatocellular carcinoma, self-care scores were lower (P = 0.006) while depression (P = 0.003) and anxiety scores (P = 0.009) were higher. Liver transplantation recipients with a monthly income < 3000 Turkish liras had higher depression (P < 0.001) and anxiety (P = 0.003) scores. The recipients who stated that they would not recommend liver transplantation to others had lower self-care scores (P = 0.002), higher depression (P < 0.001), higher state anxiety (P = 0.02), and trait anxiety (P < 0.001) scores.

CONCLUSION

Presence of biliary complications and hepatocellular carcinoma, low income level, and an obligation for monthly visits to the outpatient clinic are factors that are found to affect self-care capability, depression, and anxiety.

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.

Role of Interventional Radiology in Children with Biliary and Gallbladder Diseases

Biliary and gallbladder diseases in infants and children often present unique diagnostic and therapeutic challenges that require a fundamental understanding of notable biliary diseases and anatomical variations. Surgical and endoscopic approaches that are often the gold standard in adult biliary treatment may be technically challenging and are associated with a high morbidity that may warrant a multidisciplinary treatment approach. This article will provide a comprehensive overview of the biliary conditions where interventional radiology can play a vital role in the diagnosis, management, and treatment. Differences in approach or technique between children and adults will be highlighted.

Establishing local diagnostic reference levels for pediatric percutaneous transhepatic cholangiography interventions and optimizing the routine practice

BACKGROUND

Liver-transplanted, immunosuppressed pediatric patients undergoing repeated percutaneous transhepatic cholangiography (PTC) require optimized exposure to ionizing radiation.

OBJECTIVE

To establish local diagnostic reference levels (DRL) for pediatric PTC and investigate the routine use of X-ray equipment.

MATERIALS AND METHODS

The study retrospectively analyzed data collected between October 2016 and June 2018 from a single center performing PTC. We collected exposure parameters including kerma area product (P_KA), air kerma at patient entrance reference point (K_a,r) and fluoroscopy time via a dose archiving and communication system. Local diagnostic reference levels were derived as the 50th percentile of the distributions while considering published recommended weight groups. We investigated exposure variability with procedure complexity and with technical parameters recovered from the radiation dose structured report.

RESULTS

The analysis included 162 PTC procedures performed in 64 children: 58% male, average age 6 years (range 39 days to 16 years) and weight 24 kg (range 3-60 kg). Local DRLs for weight groups 0-5 kg, 5-15 kg, 15-30 kg, 30-50 kg and 50-80 kg were, respectively, 6 cGy.cm², 22 cGy.cm², 68 cGy.cm², 107 cGy.cm² and 179 cGy.cm² in P_KA. Local DRLs per weight group were also established for intermediate and complex procedures. Radiation dose structured report analysis highlighted good local practice with efficient collimation, low fluoroscopy pulse rate, no magnification and limited use of radiographic acquisitions. Meanwhile, table and detector positioning and tube projection could still be optimized. P_KA correlated significantly with the number of acquisitions and tube-to-table distance.

CONCLUSION

We established local DRLs for children undergoing PTC.

Treatment of obstructive jaundice caused by hepatic artery pseudoaneurysm after liver transplantation: A case report

RATIONALE

Despite vast improvements in technique, several complications still challenge surgeons and medical practitioners alike, including biliary and vascular complications, acute and chronic rejection, and disease recurrence.

PATIENT CONCERNS

A 59-year-old man was admitted to hospital on July, 2016. He had hepatitis B cirrhosis related recurrent hepatocellular carcinoma and underwent living donor liver transplantation in our hospital.

DIAGNOSIS

At the time of admission, the patient's spirit, diet, sleep, normal urine and stool, and weight did not change significantly. The test indicators are as follows: total bilirubin: 100.1 μmol/L, direct bilirubin: 65.0 μmol/L. Emergency CT in the hospital after admission showed that hepatic artery pseudoaneurysm formation after liver transplantation was observed.

INTERVENTIONS

This patient underwent minimal invasive endovascular treatment. The demographic, clinical, and laboratory data were collected and reviewed. He was treated successfully by endovascular stent grafting and thrombolytic treatment.

OUTCOMES

The blood concentration of tacrolimus (FK506) was 6.3 ng/mL total bilirubin 19.6 μmol/L before discharge. The changing of total bilirubin and direct bilirubin were investigated (Fig. 1). The patient recovered well and was discharged 2 weeks later. The patient is doing well and regularly followed up.

LESSONS

Coil embolization of aneurysmal sac or placement of a stent graft is a minimally invasive alternative to surgery and definitively excludes a bleeding hepatic artery pseudoaneurysm. This technique can be considered as an effective treatment option for hepatic artery pseudoaneurysm instead of a difficult surgical repair.