Biliary strictures in pediatric liver transplant recipients - Early diagnosis and treatment results in excellent graft outcomes

Department of Surgery, School of Medicine, Washington University in St. Louis, St Louis, MO 63110, USA.
Pediatric Transplantation (Impact Factor: 1.44). 12/2009; 14(3):358-63. DOI: 10.1111/j.1399-3046.2009.01246.x
Source: PubMed


Biliary complications in pediatric LT are important causes of morbidity and graft loss. We examined our recent pediatric LT experience to determine the outcome of post-LT biliary complications and their relationship to graft type. All initially isolated LTs performed at our institution between January 1, 2000 and August 20, 2007 were reviewed. Recipient data, donor type, graft survival, and biliary complications data were examined. Of 66 LTs, 32 patients received whole organ grafts, and 34 received partial grafts; 11 split, seven reduced size, and 16 live donors. Seventy-seven percent of patients had biliary reconstruction using a RYH. Overall, 17 (26%) developed biliary complications, and 15 were diagnosed within six months post-LT. Live donor and split allografts had more biliary complications than reduced size or whole allografts (50% and 36% vs. 0% and 16%, respectively). Seventy-one percent responded to percutaneous or endoscopic treatment. Five failed initial non-operative management and required reoperation (one retransplantation). These data suggest that biliary strictures occur most frequently in live donor and split allografts and that non-operative therapy is highly successful. Partial grafts are essential in pediatric LT, and a high clinical suspicion for biliary complications combined with aggressive and early diagnosis and therapy rarely results in graft loss.

Download full-text


Available from: Jeffrey A Lowell,
15 Reads
  • Source
    • "TABLE 2 . Pediatric Living Related Liver Transplant Recipients With BSs Subjected to PTC Recipients ( n ) LDLT ( n ) BS [ n ( % ) ] PTC Sessions [ n ( % ) ] Drainage Time ( Months ) Success Rate ( % ) Follow - Up ( Months ) Anderson et al . 18 ( 2010 ) 66 16 17 ( 26 ) NA 6 - 9 * 71 NA Sunku et al . 36 ( 2006 ) — 11 35 1 ( 66 ) § 3 34 54 ( 4 . 8 - 75 . 6 ) † Chok et al . 11 ( 2012 ) 78 78 13 ( 16 . 7 ) NA NA NA 79 . 5 Kling et al . 2 ( 2004 ) 47 47 8 ( 17 ) 11 ( 2 - 45 ) † 8 . 5 ( 2 - 58 ) † 100 56 6 37 ‡ Moreira et al . 15 ( 2010 ) — 16 35 1 ( 65 . 7 ) § 10 - 44 * 61 66 * The data a"
    [Show abstract] [Hide abstract]
    ABSTRACT: The incidence of biliary complications (BC) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population is limited and treatment protocols vary. Our aim is to describe the clinical scenario and treatment approaches in BC after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT were performed. BC developed in 71 patients (14.5%). Biliary strictures (BS) developed in 45 (9.2%) patients and bile leaks (BL) in 33 (6.7%). Diagnosis of BL was clinical in all cases and 69.6% of patients underwent surgery. Of the BS cases, nearly half had clinical features or suggestive US findings. Liver biopsy suggested BS in 51.7%. Percutaneous transhepatic cholangiography (PTC) was performed in 95.5% of the BS patients. Success-rate was of 77% (mean of 3.9 ± 1.98 percutaneous biliary interventions (PBI) and median drainage time of 8 months). In conclusion, BL patients can be managed with conservative therapy, even though most of the patients are ultimately treated with surgery. Diagnosing BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of the cases. A higher number of PBI and a longer permanence of the drainage catheter may be required to achieve better results with this technique. Liver Transpl , 2014. © 2014 AASLD.
    Liver Transplantation 08/2014; 20(8). DOI:10.1002/lt.23896 · 4.24 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To review the literature on graft type in pediatric liver transplantation, with a specific focus on publications since 2010. Due to the limited availability of whole livers for transplantation, the majority of pediatric patients will receive a technical variant graft (live donor, reduced, split). Although the outcomes of these grafts may be inferior to whole organs, the detrimental impact needs to be balanced with the impact of technical variants on improved access and survival to transplantation. Vigilance in detecting and managing posttransplant complications is critical in ensuring the optimal outcome. Infants under 5 kg pose a particular challenge in terms of graft selection with hyperreduced and monosegment grafts proposed for this population. Grafts from donors after cardiac death show promise in expanding the donor pool. However, experience in pediatric patients with these grafts is quite limited, particularly in young children who form the majority of pediatric transplant recipients. Auxiliary transplantation is proposed as a strategy for children presenting with fulminant hepatic failure and for children with metabolic diseases. The majority of children will receive a technical variant graft, with graft choice being largely determined by organ availability.
    Current opinion in organ transplantation 08/2011; 16(5):494-8. DOI:10.1097/MOT.0b013e32834a8c9c · 2.88 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications. A retrospective review of the paediatric orthotopic liver transplantation database (2000-2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted. Sixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged. Aggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.
    HPB 12/2011; 13(12):893-8. DOI:10.1111/j.1477-2574.2011.00394.x · 2.68 Impact Factor
Show more