Purpose or Case Report: Biliary stenosis continues to be an important source of morbidity in pediatric liver transplantation. Percutaneous transhepatic cholangiography (PTC) with cholangioplasty and placement of an internal/external biliary drainage catheter has been the standard of care for biliary stenosis at our institution for over twenty years. The purpose of this article is to present the largest and most comprehensive pediatric series to date detailing the percutaneous management of liver transplants complicated by biliary stenosis.
Methods & Materials: We retrospectively reviewed a consecutive series of 74 patients with liver transplant complicated by biliary stenosis who underwent PTC with cholangioplasty and internal/external biliary drain placement between 1997 and 2013. Each biliary drain was evaluated for possible removal after a standard three-month dwell time. Absence of a symptomatic biliary stricture for at least two years post biliary drain removal was considered a treatment success. Management of recurrent biliary stenosis, percutaneous or surgical, was tracked. Variables of interest included transplant graft type, location of biliary stricture, time to drainage catheter removal, and number of recurrences.
Results: Subjects included 32 males and 41 females with a mean age at transplant of 3.4 years and median follow-up of 5.7 years. The most common etiology of liver failure leading to liver transplant was biliary atresia (n=37). 64% of patients (n=47) were successfully managed percutaneously, including 43% (n=32) successfully managed via a single trial. Success rate did not significantly decrease with subsequent trials of percutaneous treatment. Success rate of PTC was higher in anastomotic strictures than in non-anastomotic strictures (71% vs. 31% success rate, p<0.01).
Conclusions: Percutaneous management of biliary strictures complicating pediatric liver transplantation allows for successful treatment of most patients, precluding the need for surgical revision. An optimal treatment protocol remains unknown, but we have shown that a minimal dwell time of 3 months is sufficient.