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Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation

Piotr Czubkowski¹, Malgorzata Markiewicz-Kijewska², Kazimierz Janiszewski³

¹Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland.

Annals of Transplantation

|December 12, 2018

Insights

Percutaneous transhepatic biliary drainage (PTBD) is an effective first-line treatment for pediatric biliary strictures after liver transplantation. While multiple interventions may be needed, PTBD offers a low complication rate and good outcomes.

Area of Science:

Hepatobiliary Surgery
Pediatric Gastroenterology
Transplantation Medicine

Background:

Biliary strictures (BS) are a common complication following pediatric liver transplantation (LTx), significantly impacting patient morbidity.
Hepatico-jejunal anastomosis (HJA) is the predominant reconstruction method in pediatric LTx, often leading to BS.
Percutaneous transhepatic biliary drainage (PTBD) is explored as a treatment modality for BS.

Purpose of the Study:

To evaluate the efficacy and safety of percutaneous transhepatic treatment for biliary strictures (BS) in pediatric liver transplant recipients.
To analyze the outcomes of PTBD in patients with hepatico-jejunal anastomosis (HJA) related BS.
To compare PTBD outcomes with surgical intervention for refractory BS.

Main Methods:

Retrospective review of pediatric LTx patients who developed BS after HJA between 1998 and 2014.
Analysis of data from patients undergoing percutaneous transhepatic biliary drainage (PTBD) for BS.
Comparison of success rates, complications, and outcomes between PTBD and subsequent surgical interventions.

Main Results:

Out of 400 patients with HJA, 35 developed BS (27 anastomotic, 8 multilevel).
Percutaneous transhepatic biliary drainage (PTBD) achieved successful outcomes in 20 out of 35 patients (57%), with an average of 2.5 sessions per patient.
Surgery was successful in 11 out of 15 patients who failed PTBD, leading to overall good outcomes in 88.5% of cases. Cholangitis was the most common complication (5.4%).

Conclusions:

Percutaneous treatment of biliary strictures (BS) is effective and safe, recommended as a primary approach in pediatric liver transplant patients.
While many patients require multiple interventions, PTBD demonstrates a low overall complication rate.
Surgical intervention remains crucial for selected cases, particularly when PTBD proves unsuccessful.

Read full analysis

Abstract:

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 AND 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.

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