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Management of Biliary Stricture in Pediatric Liver Transplantation Patients: Long-Term Outcomes
Kimberly L Yan1, Antoinette S Gomes1,2, Phillip A Monteleone2
1School of MedicineDavid Geffen School of Medicine at UCLA, University of California, Los AngelesLos AngelesCA.
Insights
Percutaneous intervention effectively treats biliary strictures after pediatric liver transplantation (LT). Most patients achieve resolution with catheters and balloon angioplasty, but some may need long-term drainage or further surgery.
Area of Science:
- Hepatology
- Pediatric Surgery
- Interventional Radiology
Background:
- Postoperative biliary complications affect 10-33% of pediatric liver transplant (LT) recipients.
- Percutaneous intervention is the primary treatment, but outcomes require further study.
Purpose of the Study:
- To evaluate the efficacy and outcomes of percutaneous treatment for post-LT biliary strictures in pediatric patients.
- To analyze clinical parameters, interventions, and long-term results.
Main Methods:
- Retrospective review of 396 pediatric LT recipients (1998-2019).
- Analysis of 50 patients with biliary strictures diagnosed by percutaneous transhepatic cholangiogram (PTC).
- Evaluation of internal/external biliary catheters and balloon cholangioplasty.
Main Results:
- 84% of patients achieved stricture resolution and catheter removal within 12 months.
- Median catheter drainage duration was 152 days.
- 8 patients required additional surgery or died; 6 patients treated with unilateral drainage had varied outcomes.
Conclusions:
- Percutaneous treatment with biliary drainage catheters and cholangioplasty is successful for pediatric post-LT biliary strictures if the stricture is accessible.
- Isolated strictures may necessitate long-term external drainage or re-transplantation.
Abstract:
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.
