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Vingrovich O, Cooper S, Gurevich M, Cohen A, Mozer-Glassberg Y, Bar-Lev MR, Shamir R, Waisbourd-Zinman O. Biliary strictures post pediatric liver transplantation-incidence and risk factors in a single tertiary referral transplant center. Pediatr Transplant 2024; 28:e14727. [PMID: 38613151 DOI: 10.1111/petr.14727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Biliary strictures are a significant cause of morbidity and graft loss in pediatric liver transplant recipients. Risk factors for the development of biliary strictures are not fully established. We aimed to evaluate the incidence of biliary strictures and treatment modalities outcomes and to identify potential risk factors for occurrence. METHODS Pediatric patients who underwent liver transplantation in the single tertiary pediatric liver transplant center in Israel were evaluated. We compared demographics, presentation, laboratory results, imaging, treatment, and outcomes between patients with and without biliary stricture. Multivariate regression analyses were used to identify risk factors for biliary strictures. RESULTS Among 121 pediatric liver transplant patients, 65 (53.7%) were males; the median age at the time of liver transplantation was 43 (3-215) months. Fifteen patients (12.4%) had biliary strictures following transplantation. One (7%) patient with biliary stricture was treated via endoscopic retrograde cholangiopancreatography, and 12 patients (80%) underwent interventions via a percutaneous transhepatic approach. Nine of the 12 patients were treated successfully, requiring one or multiple procedures, while the remaining had surgery or laser therapy. Risk factors for the development of biliary strictures were biliary leak, acute cellular rejection, and the presence of two biliary anastomoses. CONCLUSIONS In our cohort, the presence of two biliary anastomoses and post-transplant complications including acute cellular rejection and early biliary leaks were associated with biliary strictures in pediatric liver transplantation recipients. Percutaneous transhepatic interventions result in good outcomes in most patients.
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Affiliation(s)
- Odelia Vingrovich
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Shiri Cooper
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Michael Gurevich
- Liver Transplant Unit, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Aenov Cohen
- Invasive Radiology Unit, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Michal Rosenfeld Bar-Lev
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Xu M, Dong C, Sun C, Wang K, Zhang W, Wu D, Qin H, Han C, Yang Y, Zhang F, Wang Z, Zheng W, Gao W. Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age. J Pediatr Surg 2022; 57:656-665. [PMID: 35688691 DOI: 10.1016/j.jpedsurg.2022.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/01/2022] [Accepted: 05/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND/PURPOSE The incidence of hepatic artery thrombosis (HAT) in recipients is high after pediatric LT using young donors. In this study we investigated the management and outcome of HAT after whole-LT using donors less than one year of age. And evaluate the safety of pediatric donors, and increase the utilization of pediatric donors overall. METHODS We retrospectively analyzed the clinical data encompassing children who underwent whole-liver transplantation in our department from January 2014 to December 2019. Recipients receiving a liver from a donor ≥1 month and ≤12 months were included, and a total of 110 patients were included in this study. RESULTS The results showed an incidence for HAT of 20% and the median time to HAT diagnosis was 3.0 (2.0, 5.3) days post-operation. Anticoagulant therapy was used for 19 cases and 94.7% of them achieved hepatic artery recanalization or collateral formation. The median time of recanalization was 12 (5, 15) days. Bile leakage and biliary strictures occurring in the HAT group were higher than in the non HAT group (13.6% vs. 1.1% and 31.8% vs. 3.4%). There were no significant differences in the survival rates of recipients or grafts among the two groups (P = 0.474, P = 0.208, respectively). CONCLUSION We confirmed that the incidence of HAT in LT recipients use donors less than 1 year is high, but recanalization can be performed using anticoagulant therapy. Although biliary complications increased significantly after HAT, the survival rates of patients and grafts were satisfactory. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Min Xu
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Chong Dong
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Chao Sun
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Kai Wang
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Wei Zhang
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Di Wu
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Hong Qin
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Chao Han
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Yang Yang
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Fubo Zhang
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Zhen Wang
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Weiping Zheng
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China
| | - Wei Gao
- Department of Pediatric transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nakao District, Tianjin 300192, PR China; Tianjin Key Laboratory of Organ Transplantation, Tianjin, PR China.
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Valentino PL, Wang T, Shabanova V, Ng VL, Bucuvalas JC, Feldman AG, Gonzalez-Peralta RP, Gupta NA, Miloh TA, Mohammad S, Pace E, Sundaram SS, Yazigi NA, Soltys K. North American Biliary Stricture Management Strategies in Children After Liver Transplantation: A Multicenter Analysis From the Society of Pediatric Liver Transplantation (SPLIT) Registry. Liver Transpl 2022; 28:819-833. [PMID: 34837468 PMCID: PMC10167704 DOI: 10.1002/lt.26379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 01/09/2023]
Abstract
Biliary strictures affect 4%-12% of pediatric liver transplantations. Biliary strictures can contribute to graft loss if left untreated; however, there remains no consensus on the best course of treatment. Study objectives included analyses of outcomes associated with biliary stricture management strategies via percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or surgery. We identified pediatric liver transplantation recipients (2011-2016) with biliary strictures from the Society of Pediatric Liver Transplantation (SPLIT) registry and retrieved imaging, procedural, and operative reports from individual centers. Subanalyses were performed to specifically evaluate PTC and ERCP for "optimal biliary outcome" (OBO), defined as graft survival with stricture resolution and without recurrence or surgery. A total of 113 children with a median follow-up of 3.9 years had strictures diagnosed 100 days (interquartile range, 30-290) after liver transplantation; 81% were isolated anastomotic strictures. Stricture resolution was achieved in 92% within 101 days, more frequently with isolated anastomotic strictures (96%). 20% of strictures recurred, more commonly in association with hepatic artery thrombosis (32%). Patient and graft survival at 1 and 3 years were 99% and 98% and 94% and 92%, respectively. In a subgroup analysis of 79 patients with extrahepatic strictures managed by PTC/ERCP, 59% achieved OBO following a median of 4 PTC, and 75% following a median of 3 ERCP (P < 0.001). Among patients with OBO, those with ERCP had longer time intervals between successive procedures (41, 47, 54, 62, 71 days) than for PTC (27, 31, 36, 41, 48 days; P < 0.001). Allograft salvage was successful across all interventions. Stricture resolution was achieved in 92%, with 20% risk of recurrence. Resolution without recurrence was highest in patients with isolated anastomotic strictures and without hepatic artery thrombosis.
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Affiliation(s)
- Pamela L Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Tianhao Wang
- Department of Statistics and Data Science, Yale University, New Haven, CT
| | - Veronika Shabanova
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Vicky Lee Ng
- Transplant and Regenerative Medicine Center, Hospital for Sick Kids, University of Toronto, Toronto, ON, Canada
| | | | - Amy G Feldman
- Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO
| | - Regino P Gonzalez-Peralta
- Division of Pediatric Gastroenterology, Hepatology and Liver Transplantation, AdventHealth for Children, AdventHealth Transplant Institute, Orlando, FL
| | | | - Tamir A Miloh
- Division of Hepatology, Holtz Children's Hospital, University of Miami, Miami, FL
| | - Saeed Mohammad
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Erika Pace
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Shikha S Sundaram
- Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO
| | - Nada A Yazigi
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Kyle Soltys
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA
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Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques. Pediatr Radiol 2022; 52:570-586. [PMID: 34713322 DOI: 10.1007/s00247-021-05212-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/16/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
In pediatric liver transplantation, bile duct complications occur with a greater incidence than vascular anastomotic dysfunction and represent a major source of morbidity and mortality. While surgical re-anastomosis can reduce the need for retransplantation, interventional radiology offers minimally invasive and graft-saving therapies. The combination of small patient size and prevailing Roux-en-Y biliary enteric anastomotic techniques makes endoscopic retrograde cholangiopancreatography difficult if not impossible. Expertise in percutaneous management is therefore imperative. This article describes post-surgical anatomy, pathophysiology and noninvasive imaging of biliary complications. We review percutaneous techniques, focusing heavily on biliary access and interventions for reduced liver grafts. Subsequently we review the results and adverse events of these procedures and describe conditions that masquerade as biliary obstruction.
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Lee AY, Lehrman ED, Perito ER, Kerlan RK, Kohi MP, Kolli KP, Taylor AG, Ostroff JW, Kang SM, Roberts JP, Rhee S, Rosenthal P, Fidelman N. Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience. Pediatr Transplant 2021; 25:e14028. [PMID: 33951255 DOI: 10.1111/petr.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/05/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. METHODS Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. RESULTS Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). CONCLUSIONS Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.
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Affiliation(s)
- Andrew Y Lee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Evan D Lehrman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Emily R Perito
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Robert K Kerlan
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Kanti P Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - James W Ostroff
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Sang-Mo Kang
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sue Rhee
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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Yakupovich A, Rajeswaran S, Green J, Donaldson JS. Role of Interventional Radiology in Children with Biliary and Gallbladder Diseases. Semin Intervent Radiol 2021; 38:356-363. [PMID: 34393346 DOI: 10.1055/s-0041-1731374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Biliary and gallbladder diseases in infants and children often present unique diagnostic and therapeutic challenges that require a fundamental understanding of notable biliary diseases and anatomical variations. Surgical and endoscopic approaches that are often the gold standard in adult biliary treatment may be technically challenging and are associated with a high morbidity that may warrant a multidisciplinary treatment approach. This article will provide a comprehensive overview of the biliary conditions where interventional radiology can play a vital role in the diagnosis, management, and treatment. Differences in approach or technique between children and adults will be highlighted.
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Affiliation(s)
- Anel Yakupovich
- Department of Radiology, Rush University Medical Center, Chicago, Illinois
| | - Shankar Rajeswaran
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Jared Green
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - James S Donaldson
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
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Serum bile acid levels assist the prediction of biliary stricture and survival after liver transplantation in children. Eur J Pediatr 2021; 180:2539-2547. [PMID: 33963902 DOI: 10.1007/s00431-021-04098-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 10/25/2022]
Abstract
Biliary stricture is an important biliary complication after liver transplant in children. We aimed to investigate the utility of serum bile acid levels for prediction of biliary stricture in children after liver transplant. This study enrolled 60 children who underwent liver transplantation at a mean age of 2.04±0.30 years; serum bile acid levels were surveyed in a cross-sectional design. These patients were followed regularly at our institute, and the clinical data were collected prospectively. The major indication of liver transplant in this pediatric cohort was biliary atresia (78.33%). During the follow-up period (3.08±0.30 years), nine patients (15%) developed biliary stricture after the check of serum bile acid. A receiver operating characteristic curve analysis yielded a serum bile acid cutoff of >40 μM for the prediction of biliary stricture (P = 0.002). A serum bile acid level >40 is the most important predictor of a biliary stricture after liver transplant (odds ratio=65.65, P = 0.003) after adjusting for gender and GGT levels. The phenomenon remained on Cox's proportional hazard survival analysis (hazard ratio =15.42, P = 0.001). The mortality risk after liver transplant was significantly higher in subjects with serum bile acid levels >40 μM than in those with levels ≤40 μM (log-rank test, P = 0.004).Conclusion: Serum bile acid levels can be used for non-invasive screening and prediction of biliary stricture and mortality in children after liver transplantation. What is Known: • Biliary stricture is a major biliary complication after pediatric liver transplantation, and we showed the serum bile acid level significantly associates with biliary stricture. What is New: • In this study, we demonstrated the serum bile acid level may assist in the early detection of biliary stricture and mortality non-invasively.
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