Management and outcomes of biliary strictures following pediatric liver transplantation: A single-center...

Biliary strictures (BS) remain a common and serious complication after pediatric liver transplantation (pLT), potentially leading to recurrent cholangitis and graft failure. Prompt diagnosis and appropriate management are essential to improve outcomes.

This retrospective, single-center study included 1454 pediatric liver transplants performed between January 2013 and December 2021. BS were classified as anastomotic strictures (AS), non-anastomotic strictures (NAS), or intraoperative technical misadventure (ITM). Cases involving both AS and NAS were classified under the BOTH group. A standardized percutaneous transhepatic cholangiography drainage (PTCD)-based protocol was applied: mild strictures were treated with PTCD alone, whereas severe strictures required balloon dilatation (BD) with external drainage. Surgical revision was performed when guidewire passage failed. Outcomes included stricture resolution, recurrence, and graft survival.

BS occurred in 120 patients, with AS accounting for 63.3%, NAS & BOTH for 31.7%, and ITM for 5.0%. The overall incidence of BS declined significantly from 12.38% (2013-2016) to 7.07% (2017-2021). PTCD ± BD achieved an 85.7% resolution rate in AS, while surgical reanastomosis was successful in all refractory cases. NAS & BOTH were associated with significantly lower graft survival and showed limited response to both minimally invasive and surgical treatments.

Minimally invasive approaches, particularly PTCD ± BD, combined with timely surgical intervention, is effective for AS after pLT. However, NAS & BOTH remain challenging and are associated with inferior graft outcomes, underscoring the need for improved early detection and the development of novel therapeutic strategies.