Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience

Ten years of a pediatric living donor liver transplantation program in Brazil

BACKGROUND

Pediatric living-donor liver transplantation is considered a safe alternative for the treatment of children with end-stage liver disease. Experienced tertiary centers and specialized medical staff are necessary to ensure compatible long-term survival rates and quality-of-life for these children.

AIM

To report the results and the 10-year learning curve of a pediatric living-donor liver transplantation program.

METHODS

We conducted a retrospective cohort study of pediatric recipients from 2013 to 2023. Post-transplant outcomes and patient survival rates were compared between two 5-year periods of the program.

RESULTS

A total of 25 and 48 patients underwent transplantation in the first (2013-2017) and second period (2018-2023), respectively. Portal vein and hepatic artery thrombosis occurred in 11 (15.1%) and seven (9.6%) patients, respectively. Biliary complications were observed in 39 of 73 patients (53.4%). A lower warm ischemia time was observed in the second period compared to the first (32.6 ± 8.6 minutes vs 38.4 ± 9.8 minutes, P = 0.018, respectively). Patient survival rates at 1 and 5 years were 84% in the first period and 91.7% in the second period, with no significant difference (P = 0.32).

CONCLUSION

The reported indications and outcomes align with the current literature. Our findings provide crucial evidence regarding the feasibility of establishing a living donor program with consistent results over time.

Treatment Strategies for Bile Leak Following Pediatric Liver Transplantation

There are no standard management protocols for the treatment of bile leak (BL) after liver transplantation. The objective of this study is to describe treatment options for BL after pediatric LT.

METHODS

Retrospective analysis (January 2010-March 2023).

VARIABLES STUDIED

preoperative data, status at diagnosis, and postoperative outcome. Four groups: observation (n = 9), percutaneous transhepatic cholangiography (PTC, n = 38), ERCP (2), and surgery (n = 27).

RESULTS

Nine hundred and thirty-one pediatric liver transplantation (859 LDLT and 72 DDT); 78 (8.3%) patients had BL, all in LDLT. The median (IQR) peritoneal bilirubin (PB) level and fluid-to-serum bilirubin ratio (FSBR) at diagnosis was 14.40 mg/dL (8.5-29), and 10.7 (4.1-23.7). Patients who required surgery for treatment underwent the procedure earlier, at a median of 14 days (IQR: 7-19) versus 22 days for PTC (IQR: 15-27, p = 0.002). PB and FSBR were significantly lower in the observation group. In 11 cases, conservative management had resolution of the BL in an average time of 35 days, and 38 patients underwent PTC in a median time of 22 days (15-27). Twenty-seven (34.6%) patients were reoperated as initial treatment for BL in a median time of 17 days (1-108 days); 25 (33%) patients evolved with biliary stricture, 5 (18.5%) after surgery, and 20 (52.6%) after PTC (p = 0.01).

CONCLUSION

Patients with BL who were observed presented significantly lower levels of PB and FSBR versus those who underwent PTC or surgery. Patients treated with PTC presented higher rates of biliary stricture during the follow-up.

Long-term outcome of combined radiologic and surgical strategy for the management of biliary complications after pediatric liver transplantation

OBJECTIVES

We aimed to analyze the risk factors for management failure of BC after pediatric liver transplantation (pLT) by retrospectively analyzing primary pLT performed between 1997 and 2018 (n = 620 patients).

RESULTS

In all, 117/620 patients (19%) developed BC. The median (range) follow-up was 9 (1.4-21) years. Patient survival at 1, 5 and 10 years was 88.9%, 85.7%, 84.4% and liver graft survival was 82.4%, 77.4%, and 74.3% respectively. Graft not patient survival was impaired by BC (p = 0.01). Multivariate analysis identified the number of dilatation courses > 2 (p = 0.008), prolonged cold ischemia time (p = 0.004), anastomosed multiple biliary ducts (p = 0.019) and hepatic artery thrombosis (p = 0.01) as factors associated with impaired graft survival. The number of dilatation courses > 2 (p < 0.001) and intrahepatic vs anastomotic stricture (p = 0.014) were associated with management failure. Thus, repeated (> 2) radiologic dilatation courses are associated with impaired graft survival and management failure. Overall, graft but not patient survival was impaired by BC.

Indocyanine green fluorescence imaging as an adjunct for the localization of a bile leak after split liver transplantation

BACKGROUND

The intraoperative identification of a bile leak after liver transplantation can be challenging, especially when using technical variant grafts. Possible sources of leakage include the sometimes multiple biliary anastomoses or orphan ducts leading to cut surface leak. Preoperative imaging is often unable to precisely identify the location of the leak. Indocyanine green (ICG) fluorescence imaging has been utilized in adult hepatobiliary and transplant surgery, but not for the management of postoperative biliary complications.

METHODS

We present a case where ICG fluorescence imaging was used to identify a cut surface bile leak after pediatric split liver transplantation.

RESULTS

A 5-year-old girl with methylmalonic acidemia underwent a left lobe split liver transplantation. A single Roux-en-Y choledochojejunostomy was performed. Nine days after transplant, bile was noted in the surgical drain. Imaging confirmed the patency of the hepatic artery and the absence of intraabdominal collection. A hepatobiliary iminodiacetic acid scan showed the majority of radiotracer was excreted through the surgical drain. The patient was explored surgically: 4.5× loupe magnification did not allow for the localization of the leak. ICG was administered intravenously, after which a cut surface bile leak could be identified and repaired. There was no recurrence of bile leak after repair. Eighteen months after transplant, the patient is alive and well and has not suffered from any additional biliary complications.

CONCLUSION

Indocyanine green constitutes an additional tool in the arsenal of measures available to facilitate the intraoperative detection and management of bile leaks occurring after pediatric technical variant graft transplant.

Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques

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.

Therapeutic Endoscopic Retrograde Cholangiopancreatography for Pediatric Hepato-Pancreato-Biliary Diseases: A Systematic Review and Meta-Analysis

BACKGROUND

Hepato-pancreato-biliary (HPB) disease has different causes and types between children and adults, which has been increasingly diagnosed in the pediatric group. Endoscopic retrograde cholangiopancreatography (ERCP) has been gradually considered as a therapeutic method in adults, while in pediatric patients, there are not many reports of its usage. This systematic review and meta-analysis aims to assess the use condition of therapeutic ERCP in the management of pediatric HPB diseases.

METHODS

This systematic literature search was conducted in the PubMed, Embase, Web of Science, and Cochrane library databases to identify all relevant articles published from inception to February 2022 that evaluated therapeutic ERCP in pediatric patients with HPB diseases. The researchers included studies in which patients were less than 18 years old and underwent therapeutic ERCP procedures. A random-effects model was used to analyze the usage rate of therapeutic ERCP procedures, procedural success rates, adverse event rates, and the rate of different therapeutic procedures. Subgroup analysis, sensitivity analysis, and meta-regression were conducted to analyze the source of heterogeneity.

RESULTS

A total of 33 articles were included. After homogenization, the overall use of therapeutic interventions accounts for 77% [95% confidence interval (CI) 74-81%] of all ERCP procedures. After excluding outlier studies, the estimation success rate of the therapeutic procedure is 74% (95% CI 69-79%), and adverse event rate is 8% (95% CI 6-10%). In our study, stent placement is the most common procedure, which makes up 75% (95% CI 65-86%) of all therapeutic procedures. In addition, the usage proportion of sphincterotomy (ST), stone extraction/removal, bougienage/balloon dilation is, respectively, 46% (95% CI 39-53%), 34% (95% CI 31-38%), and 26% (95% CI 22-29%).

CONCLUSION

The ERCP procedure is gradually considered a therapeutic technique in pediatric patients, the proportion of therapeutic ERCP is 77% of total usage, which is increasing every year. Meanwhile, its success rate is relatively high. It reflects that this operation modality is promising in the treatment of HPB disorders and is gradually expanded as more branch technologies are being used. A variety of operations can be achieved through ERCP procedures, and more functions should be developed in the future.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022302911].