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

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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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References

  1. Griffith JF, John PR (1996) Imaging of biliary complications following paediatric liver transplantation. Pediatr Radiol 26:388–394

    CAS  PubMed  Google Scholar 

  2. Laor T, Hoffer FA, Vacanti JP, Jonas MM (1998) MR cholangiography in children after liver transplantation from living related donors. AJR Am J Roentgenol 170:683–687

    CAS  PubMed  Google Scholar 

  3. Norton KI, Lee JS, Kogan D et al (2001) The role of magnetic resonance cholangiography in the management of children and young adults after liver transplantation. Pediatr Transplant 5:410–418

    CAS  PubMed  Google Scholar 

  4. Hsiao CY, Ho CM, Wu YM et al (2019) Biliary complication in pediatric liver transplantation: a single-center 15-year experience. J Gastro Surg 10:1–9

    CAS  Google Scholar 

  5. Seda-Neto J, Antunes da Fonseca E, Pugliese R et al (2016) Twenty years of experience in pediatric living donor liver transplantation: focus on hepatic artery reconstruction, complications, and outcomes. Transplantation 100:1066–1072

    PubMed  Google Scholar 

  6. Kling K, Lau H, Colombani P (2004) Biliary complications of living related pediatric liver transplant patients. Pediatr Transplant 8:178–184

    PubMed  Google Scholar 

  7. Feier FH, da Fonseca EA, Seda-Neto J, Chapchap P (2015) Biliary complications after pediatric liver transplantation: risk factors, diagnosis and management. World J Hepatol 7:2162–2170

    PubMed  PubMed Central  Google Scholar 

  8. Mitchell JW, Maduabia AI, Cristescu M, Peters GL (2019) Percutaneous management of posttransplant biliary complications. Dig Dis Interv 3:287–294

    Google Scholar 

  9. Akram A, Klapheke R, Kwong W (2019) Endoscopic management of biliary complications after liver transplant. Dig Dis Interv 3:295–304

    Google Scholar 

  10. Berrocal T, Parrón M, Alvarez-Luque A et al (2006) Pediatric liver transplantation: a pictorial essay of early and late complications. Radiographics 26:1187–1209

    PubMed  Google Scholar 

  11. Vilca-Melendez H, Heaton ND (2004) Paediatric liver transplantation: the surgical view. Postgrad Med J 80:571–576

    CAS  PubMed  PubMed Central  Google Scholar 

  12. Tanaka H, Fukuda A, Shigeta T et al (2010) Biliary reconstruction in pediatric live donor liver transplantation: duct-to-duct or Roux-en-Y hepaticojejunostomy. J Pediatr Surg 45:1668–1675

    PubMed  Google Scholar 

  13. Karakayal F, Kırnap M, Akdur A et al (2013) Biliary complications after pediatric liver transplantation. Transplant Proc 45:3524–3527

    Google Scholar 

  14. Catalano OA, Singh AH, Uppot RN et al (2008) Vascular and biliary variants in the liver: implications for liver surgery. Radiographics 28:359–378

    PubMed  Google Scholar 

  15. Heffron TG, Emond JC, Whitington PF et al (1992) Biliary complications in pediatric liver transplantation. A comparison of reduced-size and whole grafts. Transplantation 53:391–395

    CAS  PubMed  Google Scholar 

  16. Northover JM, Terblanche J (1979) A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 66:379–384

    CAS  PubMed  Google Scholar 

  17. Zajko AB, Campbell WL, Logsdon GA et al (1987) Cholangiographic findings in hepatic artery occlusion after liver transplantation. AJR Am J Roentgenol 149:485–489

    CAS  PubMed  PubMed Central  Google Scholar 

  18. Sanchez-Urdazpal L, Batts KP, Gores GJ et al (1993) Increased bile duct complications in liver transplantation across the ABO barrier. Ann Surg 218:152

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Egawa H, Uemoto S, Inomata Y et al (1998) Biliary complications in pediatric living related liver transplantation. Surgery 124:901–910

    CAS  PubMed  Google Scholar 

  20. Egawa H, Inomata Y, Uemoto S et al (2001) Biliary anastomotic complications in 400 living related liver transplantations. World J Surg 25:1300–1307

    CAS  PubMed  Google Scholar 

  21. Pariente D, Riou JY, Schmit P et al (1990) Variability of clinical presentation of hepatic artery thrombosis in pediatric liver transplantation: role of imaging modalities. Pediatr Radiol 20:253–257

    CAS  PubMed  Google Scholar 

  22. Fulcher AS, Turner MA (1999) Orthotopic liver transplantation: evaluation with MR cholangiography. Radiology 211:715–722

    CAS  PubMed  Google Scholar 

  23. Chu WC, Yeung DT, Lee KH et al (2005) Feasibility of morphologic assessment of vascular and biliary anatomy in pediatric liver transplantation: all-in-one protocol with breath-hold magnetic resonance. J Pediatr Surg 40:1605–1611

    PubMed  Google Scholar 

  24. Kinner S, Schubert TB, Said A et al (2017) Added value of gadoxetic acid-enhanced T1-weighted magnetic resonance cholangiography for the diagnosis of post-transplant biliary complications. Eur Radiol 27:4415–4425

    PubMed  PubMed Central  Google Scholar 

  25. Tamrazi A, Vasanawala SS (2011) Functional hepatobiliary MR imaging in children. Pediatr Radiol 41:1250–1258

    PubMed  Google Scholar 

  26. Ayyala RS, Anupindi SA, Gee MS et al (2019) Intravenous gadolinium-based hepatocyte-specific contrast agents (HSCAs) for contrast-enhanced liver magnetic resonance imaging in pediatric patients: what the radiologist should know. Pediatr Radiol 49:1256–1268

    PubMed  Google Scholar 

  27. Treves ST, Gelfand MJ, Fahey FH, Parisi MT (2016) Update of the North American consensus guidelines for pediatric administered radiopharmaceutical activities. J Nucl Med 57:15N–18N

    PubMed  Google Scholar 

  28. Tulchinsky M, Ciak BW, Delbeke D et al (2010) SNM practice guideline for hepatobiliary scintigraphy 4.0. J Nucl Med Technol 38:210–218

    PubMed  Google Scholar 

  29. Concannon RC, Howman-Giles R, Shun A, Stormon MO (2009) Hepatobiliary scintigraphy for the assessment of biliary strictures after pediatric liver transplantation. Pediatr Transplant 13:977–983

    PubMed  Google Scholar 

  30. Kim YJ, Lee KT, Jo YC et al (2011) Hepatobiliary scintigraphy for detecting biliary strictures after living donor liver transplantation. World J Gastroenterol 17:2626

    PubMed  PubMed Central  Google Scholar 

  31. Demetris AJ, Jaffe R, Starzl TE (1987) A review of adult and pediatric post-transplant liver pathology. Pathol Annu 22:347–386

    PubMed  Google Scholar 

  32. Venkatesan AM, Kundu S, Sacks D et al (2010) Practice guideline for adult antibiotic prophylaxis during vascular and interventional radiology procedures. J Vasc Interv Radiol 21:1611–1630

    PubMed  Google Scholar 

  33. Kimberlin DW, Brady MT, Jackson MA (eds) (2018) Red book: 2018–2012: report of the Committee on Infectious Diseases. American Academy of Pediatrics, Itasca

  34. Thompson CM, Saad NE, Quazi RR et al (2013) Management of iatrogenic bile duct injuries: role of the interventional radiologist. Radiographics 33:117–134

    PubMed  Google Scholar 

  35. Harris VJ, Kopecky KK, Harman JT, Crist DW (1993) Percutaneous transhepatic drainage of the nondilated biliary system. J Vasc Interv Radiol 4:591–595

    CAS  PubMed  Google Scholar 

  36. Bret PM, de Stempel JV, Atri M et al (1988) Intrahepatic bile duct and portal vein anatomy revisited. Radiology 169:405–407

    CAS  PubMed  Google Scholar 

  37. Lim JH, Ryu KN, Ko YT, Lee DH (1990) Anatomic relationship of intrahepatic bile ducts to portal veins. J Ultrasound Med 9:137–143

    CAS  PubMed  Google Scholar 

  38. Guimaraes M, Uflacker A, Schonholz C, Uflacker R (2010) Successful recanalization of bile duct occlusion with a radiofrequency puncture wire technique. J Vasc Interv Radiol 21:289–294

    PubMed  Google Scholar 

  39. Miraglia R, Luca A, Maruzzelli L et al (2007) Percutaneous recanalization of an occluded hepatico-jejunostomy, using Colapinto needle, in a two-yr-old [sic] patient after partial liver transplantation. Pediatr Transplant 11:676–679

    PubMed  Google Scholar 

  40. Paolantonio G, Pietrobattista A, Parapatt GK et al (2018) Successful percutaneous transhepatic recanalization of a completely obstructed hepatico‐jejunal anastomosis in a child with liver transplantation: unusual employment of the transseptal puncture system. Pediatr Transplant 22:e13293

  41. Shah JN, Haigh WG, Lee SP et al (2003) Biliary casts after orthotopic liver transplantation: clinical factors, treatment, biochemical analysis. Am J Gastroenterol 98:1861–1867

    PubMed  Google Scholar 

  42. Barton P, Steininger R, Maier A et al (1995) Biliary sludge after liver transplantation: 2. treatment with interventional techniques versus surgery and/or oral chemolysis. AJR Am J Roentgenol 164:865–869

    CAS  PubMed  Google Scholar 

  43. Srinivasa RN, Pampati R, Patel N et al (2018) Interventional radiology-operated endoscopy: indications, implementation, and innovation. Semin Intervent Radiol 35:477–485

    PubMed  Google Scholar 

  44. Makary MS, Farrell JJ, Khayat M et al (2019) Biliary endoscopy for benign and malignant biliary strictures. Tech Vasc Interv Radiol 22:135–138

    PubMed  Google Scholar 

  45. Dopazo C, Diez I, Quintero J et al (2018) Role of biodegradable stents as part of treatment of biliary strictures after pediatric and adult liver transplantation: an observational single-center study. J Vasc Interv Radiol 29:899–904

    PubMed  Google Scholar 

  46. Huespe PE, Oggero S, de Santibañes M et al (2018) Percutaneous patency recovery and biodegradable stent placement in a totally occluded hepaticojejunostomy after paediatric living donor liver transplantation. Cardiovasc Interv Radiol 42:466–470

    Google Scholar 

  47. Siiki A, Sand J, Laukkarinen J (2018) A systematic review of biodegradable biliary stents: promising biocompatibility without stent removal. Eur J Gastroenterol Hepatol 30:813–818

    CAS  PubMed  Google Scholar 

  48. Holguin AJ, Rodriguez-Takeuchi S, Ospina L et al (2017) Biliary strictures complicating liver transplantation in pediatric patients: experience in a South American transplant center. Clin Transplant. https://doi.org/10.1111/ctr.12877

    Article  PubMed  Google Scholar 

  49. Imamine R, Shibata T, Yabuta M et al (2015) Long-term outcome of percutaneous biliary interventions for biliary anastomotic stricture in pediatric patients after living donor liver transplantation with Roux-en-Y hepaticojejunostomy. J Vasc Interv Radiol 26:1852–1859

    PubMed  Google Scholar 

  50. Uller W, Wohlgemuth WA, Hammer S et al (2014) Percutaneous treatment of biliary complications in pediatric patients after liver transplantation. Rofo 186:1127–1133

    CAS  PubMed  Google Scholar 

  51. Moreira AM, Carnevale FC, Tannuri U et al (2010) Long-term results of percutaneous bilioenteric anastomotic stricture treatment in liver-transplanted children. Cardiovasc Interv Radiol 33:90–96

    Google Scholar 

  52. Fonio P, Calandri M, Faletti R et al (2015) The role of interventional radiology in the treatment of biliary strictures after paediatric liver transplantation. Radiol Med 120:289–295

    PubMed  Google Scholar 

  53. Miraglia R, Maruzzelli L, Caruso S et al (2008) Percutaneous management of biliary strictures after pediatric liver transplantation. Cardiovasc Interv Radiol 31:993–998

    Google Scholar 

  54. Sunku B, Salvalaggio PR, Donaldson JS et al (2006) Outcomes and risk factors for failure of radiologic treatment of biliary strictures in pediatric liver transplantation recipients. Liver Transpl 12:821–826

    PubMed  Google Scholar 

  55. Belenky A, Mor E, Bartal G et al (2004) Transhepatic balloon dilatation of early biliary strictures in pediatric liver transplantation: successful initial and mid-term outcome. Cardiovasc Interv Radiol 27:491–494

    Google Scholar 

  56. Lorenz JM, Funaki B, Leef JA et al (2001) Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients. AJR Am J Roentgenol 176:761–765

    CAS  PubMed  Google Scholar 

  57. Sanada Y, Katano T, Hirata Y et al (2019) Long-term outcome of percutaneous transhepatic biliary drainage for biliary strictures following pediatric liver transplantation. Clin Transplant 33:e13570

  58. Lee AY, Lehrman ED, Perito ER et al (2021) Non‐operative management of biliary complications after liver transplantation in pediatric patients: a 30‐year experience. Pediatr Transplant 5:e14028

  59. Anderson CD, Turmelle Y, Darcy M et al (2010) Biliary strictures in pediatric liver transplant recipients — early diagnosis and treatment results in excellent graft outcomes. Pediatr Transplant 14:358–363

    PubMed  Google Scholar 

  60. Prajapati HJ, Kavali P, Kim HS (2017) Percutaneous interventional management of biliary complications after pediatric liver transplantation: a 16‐year single‐institution experience. Pediatr Transplant 21:e12837

  61. Kirkpatrick DL, Hasham H, Collins Z et al (2018) The utility of a benign biliary stricture protocol in preventing symptomatic recurrence and surgical revision. J Vasc Interv Radiol 29:688–694

    PubMed  Google Scholar 

  62. Ahlawat SK, Fishbien TM, Haddad NG (2008) Cystic duct remnant mucocele in a liver transplant recipient. Pediatr Radiol 38:884–886

    PubMed  Google Scholar 

  63. Chatterjee S, Das D, Hudson M et al (2011) Mucocele of the cystic duct remnant after orthotopic liver transplant: a problem revisited. Exp Clin Transplant 9:214–216

    PubMed  Google Scholar 

  64. Colina F, García-Prats MD, Moreno E et al (1994) Amputation neuroma of the hepatic hilum after orthotopic liver transplantation. Histopathology 25:151–157

    CAS  PubMed  Google Scholar 

  65. Quillin III RC, Bongu A, Kasper V et al (2018) Roux‐en‐Y enterolith leading to obstruction and ischemic necrosis after pediatric orthotopic liver transplantation. Pediatr Transplant 22:e13160

  66. Schemmer P, Schultze DP, Contin P et al (2011) Antireflux jejunoplasty for recurrent cholangitis. J Am Coll Surg 212:e28-32

    PubMed  Google Scholar 

  67. Vrochides D, Fischer SA, Soares G, Morrissey PE (2007) Successful treatment of recurrent cholangitis complicating liver transplantation by Roux-en-Y limb lengthening. Transplant Infect Dis 9:327–331

    CAS  Google Scholar 

  68. Marangoni G, Ali A, Faraj W et al (2011) Clinical features and treatment of sump syndrome following hepaticojejunostomy. Hepatobiliary Pancreat Dis Int 10:261–264

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Section of Vascular and Interventional Radiology, Department of Radiology, American Family Children’s Hospital, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA

    Eric J. Monroe

  2. Section of Vascular and Interventional Radiology, Department of Radiology, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA

    David S. Shin, Jeffrey Forris Beecham Chick, Kevin S. H. Koo, Andrew Woerner & Christopher R. Ingraham

  3. Department of Pediatric Interventional Radiology, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, CA, USA

    Victoria A. Young

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  1. Eric J. Monroe
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  2. David S. Shin
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  3. Victoria A. Young
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  4. Jeffrey Forris Beecham Chick
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  5. Kevin S. H. Koo
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  6. Andrew Woerner
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Correspondence to Eric J. Monroe.

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Eric J. Monroe is a scientific adviser and speaker for Biogen. Jeffrey Forris Beecham Chick is a consultant and speaker for Inari Medical, Guerbet, C.R. Bard, Argon Medical Devices and Boston Scientific. Kevin S.H. Koo is a consultant for Medtronic.

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Monroe, E.J., Shin, D.S., Young, V.A. et al. Evaluation and management of biliary complications after pediatric liver transplantation: pearls and pitfalls for percutaneous techniques. Pediatr Radiol 52, 570–586 (2022). https://doi.org/10.1007/s00247-021-05212-7

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  • DOI: https://doi.org/10.1007/s00247-021-05212-7

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