Biliary tract complications in pediatric orthotopic liver transplantation

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.

Successful percutaneous transhepatic recanalization of a completely obstructed hepatico-jejunal anastomosis in a child with liver transplantation: Unusual employment of the transseptal puncture system

Stenosis of the HJ is a common complication of pediatric split LT with high morbidity and possible evolution to secondary biliary cirrhosis and re-transplantation if not treated. Because the endoscopy is generally infeasible in the Roux-en-Y, percutaneous interventional radiology management is usually the safest and most effective approach to avoid surgical revision of a stenotic bilio-enteric anastomosis. We present the case of a child with acute onset of cholestasis 7 months after left lateral segment partial LT due to occlusion of the HJ. The biliary stricture was found to be non-crossable with conventional interventional radiological techniques. The obstruction was resolved creating a new bilio-digestive communication via percutaneous transhepatic approach using the TPS. This device is usually employed by the interventional cardiologist to perform some procedures requiring the direct access to the left atrium through interatrial septal puncture. In conclusion, percutaneous transhepatic recanalization of the hepato-jejuno anastomosis is a rare but feasible and valuable procedure alternative to the surgical resolution even in small infants. Although few cases have been reported in literature, it has to be considered an additional treatment option when the conventional approaches fail.

Percutaneous interventional management of biliary complications after pediatric liver transplantation: A 16-year single-institution experience

The aim of the study was to investigate the BiCx after the pediatric OLT and to assess the efficacy of the fluoroscopic-guided PBI in the patients with BiCx as compared to the SR. A total of 340 OLTs were performed in 302 patients over the last 16 years. The inclusion criteria were the presence of BS or BL as a complication after OLT. The management of the BiCx was studied. Graft revision, graft loss, and survival were evaluated following PBI and SR. BiCx occurred in 17.1% (58/339) of the transplants; 6.2% (21/339) of transplants demonstrated BL and 12.7% (43/339) of the transplants had BS. Overall graft survival rates at 1 and 3 years in OLT with BL treated with PBI were 75.0% and 68.8% as compared with 75% and 66.7% in OLT treated with SR (P>.05). Overall graft survival rates at 1 and 3 years in OLT with BS treated with PBI were 70.6% and 54.5% as compared with 71.4% and 50% in OLT with SR or ERCP, respectively (P>.05). Based on the results, we conclude that PBI is as effective as SR in patients with the BL and BS after OLT.

Clinical outcomes and costs associated with in-hospital biliary complications after liver transplantation: a cross-sectional analysis

INTRODUCTION

In-hospital biliary complications (BCs) after liver transplantation (LT) are reported in up to 20 % of patients and contribute to poor outcomes and increased costs. Existing single-center outcome and cost analyses studies are limited in scope.

METHODS

This is a cross-sectional analysis of national data involving 7,967 patients transplanted between 2011 and 2012 with the primary aim of determining the association between BCs and clinical outcomes and costs. Age, race, diagnosis, and severity of illness are associated with the development of BCs.

RESULTS

BCs develop in 14.6 % of LT recipients and have substantial implications for perioperative outcomes, including length of hospital and ICU stay (27.9 vs 19.6 mean days, p < 0.001 and 12.0 vs 8.3 mean days, p < 0.001, respectively), in-hospital morbidity (39 vs 27 %, p < 0.001), 30-day readmissions (14.8 vs 11.2 %, p < 0.001), and in-hospital mortality (5.8 vs 4.0 %, p < 0.001). BCs contributed to a mean increase in in-hospital costs of $36,212 (p < 0.001), due to increases in accommodations ($9,539, p < 0.001), surgical services ($3,988, p < 0.001), and pharmacy services ($8,445, p < 0.001).

DISCUSSION

BCs are a predominant etiology for in-hospital morbidity and mortality, while contributing significantly to the high cost of LT. Efforts should be focused on understanding salient and modifiable risk factors, while developing innovative strategies to reduce BCs.

Radiation exposure in biliary procedures performed to manage anastomotic strictures in pediatric liver transplant recipients: comparison between radiation exposure levels using an image intensifier and a flat-panel detector-based system

PURPOSE

The aim of this study was to estimate radiation exposure in pediatric liver transplants recipients who underwent biliary interventional procedures and to compare radiation exposure levels between biliary interventional procedures performed using an image intensifier-based angiographic system (IIDS) and a flat panel detector-based interventional system (FPDS).

MATERIALS AND METHODS

We enrolled 34 consecutive pediatric liver transplant recipients with biliary strictures between January 2008 and March 2013 with a total of 170 image-guided procedures. The dose-area product (DAP) and fluoroscopy time was recorded for each procedure. The mean age was 61 months (range 4-192), and mean weight was 17 kg (range 4-41). The procedures were classified into three categories: percutaneous transhepatic cholangiography and biliary catheter placement (n = 40); cholangiography and balloon dilatation (n = 55); and cholangiography and biliary catheter change or removal (n = 75). Ninety-two procedures were performed using an IIDS. Seventy-eight procedures performed after July 2010 were performed using an FPDS. The difference in DAP between the two angiographic systems was compared using Wilcoxon rank-sum test and a multiple linear regression model.

RESULTS

Mean DAP in the three categories was significantly greater in the group of procedures performed using the IIDS compared with those performed using the FPDS. Statistical analysis showed a p value = 0.001 for the PTBD group, p = 0.0002 for the cholangiogram and balloon dilatation group, and p = 0.00001 for the group with cholangiogram and biliary catheter change or removal.

CONCLUSION

In our selected cohort of patients, the use of an FPDS decreases radiation exposure.

Hepatobiliary scintigraphy for the assessment of biliary strictures after pediatric liver transplantation

HBS is used in the management of liver transplantation, a significant complication of which is biliary stricture. Strictures may be intraparenchymal within segments and main duct (non-anastomotic) or at the biliary-enteric anastomosis (anastomotic). Strictures are definitively diagnosed, and often managed, by PTC. This is invasive, technically challenging, and requires general anesthesia in young children. HBS may allow early detection of these complications and is non-invasive. The aim of this study was to review the scintigraphic pattern of biliary strictures using (99m)TcDISIDA HBS following pediatric orthotopic liver transplantation, and to assess its role in the diagnostic algorithm of suspected biliary strictures. All available hepatobiliary studies performed post-transplant in 101 episodes of liver transplantation in 92 pediatric patients were reviewed. Twenty-three (23%) patients had known biliary strictures. Twenty-two patients had adequate studies available for review; five had intrahepatic (non-anastomotic) strictures alone, nine had a stricture of the anastomosis alone, and eight had both intrahepatic and anastomotic strictures. HBS patterns (either segmental or global changes) correlated very highly with clinically significant biliary strictures. All patients with known strictures had abnormal HBS; hence, in patients with abnormal liver function tests post-liver transplant, a normal HBS makes strictures very unlikely. We propose that HBS can thus be used to determine if further investigation is required.

Ethics Committees at Work

The Research Center for Surgery (RCS) in Moscow is recognized as one of the largest and most prestigious surgical institutions in Russia. In this 400-bed facility more than 3,000 surgical procedures are performed annually, including heart, liver, and pancreas interventions and the reimplantation of limbs. The main focus of the research program at the RCS is on the transplantation of organs and reconstructive surgery. All procedures are free of charge to the patient.

Percutaneous retrograde colangiography of segment III bile duct, through the previously catheterized segment II bile duct, in 15-month-old patient after partial liver transplantation with two separate bilio-enteric anastomoses

We report one case of percutaneous retrograde colangiography of segment III bile duct, through the previously catheterized segment II bile duct, in 15-month-old patient after partial liver transplantation and two separate biliary anastomoses. The retrograde diagnostic cholangiogram confirmed the suspicion of anastomotic stricture and distended the bile ducts, which were easily punctured with percutaneous approach with a 20 Ga Chiba needle.

Percutaneous management of biliary strictures after pediatric liver transplantation

We analyze our experience with the management of biliary strictures (BSs) in 27 pediatric patients who underwent liver transplantation with the diagnosis of BS. Mean recipient age was 38 months (range, 2.5-182 months). In all patients percutaneous transhepatic cholangiography, biliary catheter placement, and bilioplasty were performed. In 20 patients the stenoses were judged resolved by percutaneous balloon dilatation and the catheters removed. Mean number of balloon dilatations performed was 4.1 (range, 3-6). No major complications occurred. All 20 patients are symptom-free with respect to BS at a mean follow-up of 13 months (range, 2-46 months). In 15 of 20 patients (75%) one course of percutaneous stenting and bilioplasty was performed, with no evidence of recurrence of BS at a mean follow-up of 15 months (range, 2-46 months). In 4 of 20 patients (20%) two courses of percutaneous stenting and bilioplasty were performed; the mean time to recurrence was 9.8 months (range, 2.4-24 months). There was no evidence of recurrence of BS at a mean follow-up of 12 months (range, 2-16 months). In 1 of 20 patients (5%) three courses of percutaneous stenting and bilioplasty were performed; there was no evidence of recurrence of BS at a mean follow-up of 10 months. In conclusion, BS is a major problem following pediatric liver transplantation. Radiological percutaneous treatment is safe and effective, avoiding, in most cases, surgical revision of the anastomosis.

Percutaneous recanalization of an occluded hepatico-jejunostomy, using Colapinto needle, in a two-yr-old patient after partial liver transplantation

We report one case of percutaneous recanalization of an hepatico-jejunostomy, using Colapinto needle, in a two-yr-old patient after partial liver transplantation and occlusive anastomotic biliary stricture non-crossable with conventional interventional radiology techniques. The procedure was successfully performed and followed by biliary trans-anastomotic catheter placement. Later, the patient underwent multiple session of conventional percutaneous balloon dilatation of the anastomosis as a good flow of contrast from bile ducts to bowel loops was achieved. The patient is now without percutaneous biliary catheter since 10 months in good general conditions and with good liver function tests.

Feasibility of morphologic assessment of vascular and biliary anatomy in pediatric liver transplantation: all-in-one protocol with breath-hold magnetic resonance

BACKGROUND/PURPOSE

Noninvasive imaging for children with liver transplantation for possible sites of vascular and biliary complication remains a challenge. The aim of this study was to investigate the feasibility of magnetic resonance (MR) imaging as a comprehensive noninvasive test for the above purpose.

METHODS

Thirteen children (age, 8-16 years) with biliary atresia and who received liver transplantation underwent a comprehensive MR study including MR cholangiography and gadolinium-enhanced MR angiography. Images were interpreted by 3 radiologists for liver parenchymal abnormalities; definition of hepatic arterial and venous, portal venous, and biliary anatomy; and detection of any complications. Findings were correlated with surgical records. Conventional angiography and percutaneous cholangiography were obtained for correlation in 2 patients. Confidence level scores (1-5) for depiction of anatomy were given for source, multiplanar, and 3-dimensional images.

RESULTS

Hepatic artery anastomosis was visualized in 12 patients (92%) and the intrahepatic arteries were demonstrated in 10 (77%). The portal, hepatic venous, and biliary anastomoses were clearly demonstrated in all patients. Stenosis of hepatic artery anastomosis and multiple biliary strictures were detected in 1 patient each and confirmed by conventional imaging. High confidence scores (higher than 4) were obtained for all kinds of MR images.

CONCLUSIONS

Comprehensive MR imaging can be used in long-term follow-up of pediatric liver transplant recipients for depiction of hepatic structures and possible complications.

Balloon dilatation of biliary-enteric strictures in children

OBJECTIVE

The objective of our study was to evaluate the efficacy and safety of balloon dilatation in the treatment of anastomotic strictures in children with liver transplants.

MATERIALS AND METHODS

For a period of 7 years, we treated 20 consecutive biliary-enteric strictures in 19 children (age range, 13 months to 17.9 years, mean, 7.3 years) with balloon dilatation. Dilatation was performed between 30 days and 8.4 years (mean, 2.6 years) following surgical creation of the biliary-enteric anastomosis. Thirteen patients had left lateral segment liver transplant grafts, one patient had a split-liver, left-lobe graft, and five patients had whole liver grafts.

RESULTS

Technical success was 100% and there were no procedure-related complications. One patient with a patent anastomosis underwent repeat transplantation 183 days after the procedure for chronic rejection. In 58% (11/19) of the remaining procedures, balloon dilatation resulted in biliary-enteric patency at one year, and continued patency ranges from 1.4 to 5.4 years (mean, 3.6 years). In 40% (8/20) of the procedures, the biliary-enteric stricture persisted after balloon dilatation, and these patients eventually underwent surgical revision, retransplantation, or endobiliary metallic stent placement.

CONCLUSION

Balloon dilatation is a safe and effective treatment for biliary-enteric strictures following pediatric liver transplantation.

Presence of multiple bile ducts in the liver graft increases the incidence of biliary complications in pediatric liver transplantation

We studied the impact of multiple bile duct anastomosis on the development of biliary complications after liver transplantation in children. A total of 101 patients received a primary liver transplant and were divided into 2 groups: those with a single bile duct (n = 77) and those with multiple bile ducts (n = 24). Mean follow-up was 39.8 +/- 20.8 months. A total of 27 patients presented with biliary complications (26.7%), 18 patients (18.7%) presented with early complications (12 leaks and 6 strictures), and 9 patients (8.9%) had late strictures. Hepatic artery thrombosis (HAT) and multiple bile ducts were significant risk factors for the development of biliary complications, and the presence of multiple bile ducts was an independent risk factor. Patients with multiple bile ducts had a significantly greater incidence of total biliary complications compared to those with single ducts. Patients with multiple ducts had a higher incidence of leaks when compared to those in the single duct group, but the incidence of strictures, both early and late, was similar in both groups. One-year patient and graft survivals were not statistically different in the 2 groups. In conclusion, the presence of more than one bile duct in the graft is an independent risk factor for the development of biliary complications after pediatric liver transplantation.

An endoscopic approach to biliary complications following orthotopic liver transplantation

Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12-year period.

METHODS

OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications.

RESULTS

Seventy-nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty-four (15.1%) patients had at least one or more biliary complications. The mean follow-up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T-tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty-five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re-transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage.

CONCLUSIONS

ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.

Surgical complications and outcome of pediatric liver transplantation in Hong Kong

PURPOSE

The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention.

METHODS

The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed.

RESULTS

Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well.

CONCLUSIONS

Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved.

Sonographic needle guidance in cholangiography in children

PURPOSE

To evaluate feasibility and benefits of sonographic guidance of percutaneous transhepatic cholangiography (PTC) in children with liver transplants.

MATERIALS AND METHODS

The authors prospectively followed 24 PTC procedures in 19 pediatric patients (11 females, 8 males; age 3 months to 17 years) randomized to fluoroscopic or sonographic guidance. The number of needle passes, the contrast material dose, fluoroscopy time, and procedure time for each procedure were recorded. All patients were transplant recipients-six whole and 13 reduced-size grafts. Cases were randomly assigned to two groups: group I, fluoroscopically guided PTC (12 procedures); group II, sonographically guided PTC (12 procedures).

RESULTS

The technical success rate was 92% (11 of 12) for each group. In group I, there were two procedure-related complications: postprocedural fever caused by biliary to portal vein fistula, and peritoneal bleeding requiring surgery. In group II, there were no procedure-related complications. A mean of 8.2 +/- 3.7 needle passes were required in group I compared to only 2.0 +/- 1.3 in group II (P < .0001). A mean contrast material dose of 19.5 mL +/- 13.4 was required in group I compared to only 2.5 mL +/- 1.9 in group II (P < .001). A mean procedure time of 15.7 minutes +/- 7.4 was required in group I compared to only 6.1 minutes +/- 4.5 in group II (P < .001). A mean fluoroscopy time of 10.4 minutes +/- 5.0 was required in group I compared to only 1.0 minutes +/- 0.7 in group II (P < .0001).

CONCLUSION

In pediatric patients who have undergone liver transplantation, sonographic guidance significantly decreases the number of needle passes, contrast material dose, and fluoroscopy time required for PTC.

Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients

OBJECTIVE

In children with liver transplants, percutaneous transhepatic cholangiography has a critical role in evaluation and treatment of biliary complications. The purpose of this study was to evaluate the technical success and complication rates of percutaneous transhepatic cholangiography and biliary drain placement in children who underwent liver transplantation.

MATERIALS AND METHODS

Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years). Patients had received left lateral segment, whole-liver, or split-liver transplant grafts. Retrospective review of all pertinent radiology studies and electronic chart review were performed.

RESULTS

A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts. In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts. Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1).

CONCLUSION

Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.

Characterization and treatment of biliary anastomotic stricture after segmental liver transplantation

BACKGROUND/PURPOSE

Biliary anastomotic strictures (BAS) after left lateral segment liver transplantation (LLST) may cause graft dysfunction, sepsis, and patient mortality. A review of the authors' experience was performed to better characterize the risk factors and corrective management.

METHODS

The medical records of 9 children who underwent a LLST in whom a BAS developed from 1989 to the present were reviewed retrospectively.

RESULTS

Seventy-five of 199 liver transplants (38%) at the authors' institution since 1989 have been LLST. BAS developed in 12% of these cases. BAS were diagnosed less than 12 months after transplantation in 4 children (mean, 7.5 months; range, 5 to 11 months) and greater than 12 months in 5 children (mean, 37 months; range, 14 to 72 months). Early strictures (<12 months) were associated with hepatic artery thrombosis (n = 1), and posttransplant bile leak (n = 1) and ducts from segment II and III exiting separately from the left lateral segment (n = 2). The diagnosis of BAS was heralded by episodes of liver biopsy-proven cholangitis in all patients and confirmed radiographically. Seven children underwent successful biliary exploration and revision of the hepaticojejunostomy. Two of these children ultimately required retransplantation secondary to chronic graft rejection.

CONCLUSIONS

BAS in LLST are a source of significant morbidity and should be considered in children after LLST who present with cholangitis. Surgical correction is possible in most cases.

[Liver transplantation in infants and children. Evaluation of the first 40 cases (March 1991-March 1997)]

BACKGROUND

Liver transplantation (LT) is the treatment of end-stage liver disease in children. We report our experience with LT using grafts from living related (LRD) and cadaver donors (CD).

POPULATION

From March 1991 to March 1997, 40 children and infants received a total of 42 liver grafts. A reduced-size liver was used in 28 cases. We studied pre-transplantation status, survival rate, and medical and surgical complications in these patients.

RESULTS

The survival rate in our series was respectively 85 and 80% at 1 and 7 years after LT. Low weight infants required a prolonged ventilatory assistance. Five of the six deaths noticed during the first three months after LT occurred in children weighing less than 12 kg. One year after LT, no significant difference in the incidence of rejection was found, neither between low-weight children and the others, nor between patients transplanted from CD or LRD. Biliary tract stricture was the major surgical complication.

CONCLUSION

This series consisted of a majority of low-weight children. The survival rate in the patients weighting less than 12 kg is lower than in the others. This may be explained by the nutritional status of these patients and early postsurgical complications. The use of grafts from living donors offers more flexibility since the operation is performed electively, but it did not seem to modify the incidence of acute rejections and surgical complications.

Late biliary complications in pediatric liver transplantation

PURPOSE

The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children.

METHODS

The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge.

RESULTS

Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001).

CONCLUSIONS

Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.

The incidence and management of biliary complications following liver transplantation in children

Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988-1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) - one intrahepatic and one anastomotic stricture - developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.

The incidence and management of biliary complications following liver transplantation in children

Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988-1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) - one intrahepatic and one anastomotic stricture - developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.