Management of Biliary Stricture in Pediatric Liver Transplant Patients: Long Term Outcomes.

Background Post-operative biliary complications have been reported to occur in 10-33% of pediatric liver transplantation (LTx) recipients. (2-10) Percutaneous intervention has become the primary treatment method for these complications; however, efficacy and outcomes of these patients have not been well studied. Methods Institutional pediatric LTx from 1998 to 2019 were retrospectively reviewed to determine the patients referred for percutaneous treatment of post-LTx biliary strictures. Clinical parameters, percutaneous transhepatic biliary cholangiograms (PTC), biliary catheter placement, cholangioplasty, and long-term outcomes were analyzed. Results Of the 396 consecutive pediatric LTx recipients during our study period, 50 (12.6%) were diagnosed with biliary strictures on PTC. LTx biliary reconstruction was Roux-en-Y hepaticojejunostomy (HJ) in 28 (56%), choledochojejunostomy (CJ) in 11 (22%), and choledochocholedochostomy (CC) in 11 (22%). Median age at LTx was 23.2 months (IQR, 10.9-90.6) and 14 (28%) patients developed hepatic artery thrombosis. Forty-four (88%) patients were treated with internal/external biliary catheters, of whom 38 (76%) underwent balloon cholangioplasty. By 12 months, 84% of patients had complete stricture resolution and catheter removal. Median total duration of catheter drainage was 152 days (IQR, 76-308). Eight patients required additional surgery (biliary reconstruction or re-LTx) or died with drainage catheter in place from complications unrelated to PTC intervention. Amongst the six (12%) treated with unilateral external biliary drainage catheters, two had catheters removed for inadequate drainage but then had spontaneous biliary obstruction resolution, one underwent duct reconstruction, and three required long-term catheterization. Conclusions Biliary strictures following pediatric LTx can be successfully treated with internal/external biliary drainage catheters and cholangioplasty if the stricture can be crossed. However, patients with isolated strictured ducts may require long-term external catheter drainage until re-LTx or percutaneous obliteration of isolated ducts.