Risk factors and surgical management of anastomotic biliary complications after pediatric liver transplantation

Abstract

Biliary complications (BCs) still remain the Achilles heel of liver transplantation (LT) with an overall incidence of 10% to 35% in pediatric series. We hypothesized that (1) the use of alternative techniques (reduced size, split, and living donor grafts) in pediatric LT may contribute to an increased incidence of BCs, and (2) surgery as a first treatment option for anastomotic BCs could allow a definitive cure for the majority of these patients. Four hundred twenty-nine primary pediatric LT procedures, including 88, 91, 47, and 203 whole, reduced size, split, and living donor grafts, respectively, that were performed between July 1993 and November 2010 were retrospectively reviewed. Demographic and surgical variables were analyzed, and their respective impact on BCs was studied with univariate and multivariate analyses. The modalities of BC management were also reviewed. The 1-and 5-year patient survival rates were 94% and 90%, 89% and 85%, 94% and 89%, and 98% and 94% for whole, reduced size, split, and living donor liver grafts, respectively. The overall incidence of BCs was 23% (n 5 98). Sixty were anastomotic complications [47 strictures (78%) and 13 fistulas (22%)]. The graft type was not found to be an independent risk factor for the development of BCs. According to a multivariate analysis, only hepatic artery thrombosis and acute rejection increased the risk of anastomotic BCs (P < 0.001 and P 5 0.003, respectively). Anastomotic BCs were managed primarily with surgical repair in 59 of 60 cases with a primary patency rate of 80% (n 5 47). These results suggest that (1) most of the BCs were anastomotic complications not influenced by the type of graft, and (2) the surgical management of anastomotic BCs may constitute the first and best therapeutic option. Liver Transpl 20:893-903, 2014. V C 2014 AASLD.

Living Donor Liver Transplantation in Children

“…All the anastomotic strictures were reoperated on, with an overall 80% success rate. 13 None but one of the children who encountered biliary complications lost their graft, nor died; in this child having 2 ductal Roux-en-Y anastomoses, the anastomotic stricture was surgically reconstructed on POD 494 but subsequent cholangitis development due to vancomycin-resistant enterococci led to patient death on POD 500. No correlation was found between the number of biliary ducts to be reconstructed in the graft and the biliary complication rate.…”

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“…In addition, retransplant rates after PBD or ERC are 0% to 20%, and in surgical series, the incidence of retransplant was 12%. 18 The risk of complications (such as hemobilia, pancreatitis, sepsis, cholangitis, or intestinal bleeding) after percutaneous or endoscopic treatment also is ignored due to the benefit of avoiding surgical interventions. In a previous study, minor and major complication rates of PBD were 11% and 2%.…”

The results of biliary reconstructions after liver fragments transplantation

“…В случаях, когда причиной формирования желчного свища становится отключенный желчный проток, эндоскопические методы лечения неприменимы, поскольку ретроградный доступ к «отключенному» желчному протоку не может быть осуществлен [22,41,53,64,66]. В связи с этим при обнаружении неана-стомозированного желчного протока трансплантата наиболее часто используемым методом лечения яв-ляется реконструкция желчеотведения [7,11]. При наличии билиарных стриктур применяют миниинва-зивные методы лечения (эндоскопическую или чрес-кожно-чреспеченочную баллонную дилатацию с установкой стентов) либо реконструкциию.…”

“…Сто-ронники первичного применения оперативных вме-шательств в качестве контраргументов приводят дан-ные исследований, демонстрирующих частоту реци-дивов стриктуры анастомоза после миниинвазивных вмешательств, составляющую 27-66% [1,4,20,28,29,33,34,43,52], отрицательное влияние на качество жизни при длительном сохранении наружно-вну-тренних билиарных дренажей, необходимость пери-одического выполнения повторных вмешательств в условиях общей анестезии [7]. В связи с этим они считают целесообразным использование миниинва-зивных нехирургических методов лечения лишь при развитии неанастомотических стриктур внутрипече-ночных желчных протоков либо при неэффективно-сти первично выполненных хирургических операций по поводу стриктур анастомоза и «отключенных» желчных протоков [7]. В целом общие тенденции отражает исследова-ние R. Vallera и соавт.…”