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• W2015436103 abstract "Biliary complications (BCs) are frequent causes of morbidity after pediatric liver transplantation (LT). Because LT is commonly performed in children with a Roux-en-Y bilioenteric anastomosis, the first-line procedure for the evaluation and treatment of biliary obstructions in this population is percutaneous transhepatic cholangiography (PTC).1 The percutaneous treatment of BCs in pediatric patients is considered safe and effective, and in most cases, it prevents the need for surgical interventions.2, 3 In this issue of Liver Transplantation, Darius et al.4 examine risk factors associated with BCs after pediatric LT and report their long-term experience with the surgical management of BCs in a cohort of 429 primary pediatric LT cases (226 deceased donors and 203 living donors). The incidence of BCs was of 22.8% (98/429): 10.9% were anastomotic biliary strictures (BSs), 3% were anastomotic biliary leaks (BLs), and 8.8% were nonanastomotic BCs. Three independent factors were responsible for the occurrence of anastomotic BCs: hepatic artery thrombosis, acute cellular rejection, and living donation. Split LT and reduced size LT were not associated with an increased risk of BCs. With a cohort of 2192 recipients, the Studies of Pediatric Liver Transplantation research group has shown that technical variant grafts are associated with a higher incidence of BCs.5 The incidence of BLs at 30 days ranged from 12.0% for recipients of reduced grafts to 15.7% for split liver recipients, whereas the incidence was 3.7% with whole grafts. At 24 months, more than 20% of recipients of reduced grafts and 30% of living donation recipients had BSs (intrahepatic or anastomotic). In the series by Darius et al.,4 60 patients were reported to have anastomotic problems (leaks, 13; strictures, 47). All but 1 of these patients were managed operatively, and a primary patency rate of 80% (47/59) was achieved. Ten patients with BLs underwent a second operative procedure (4 for retransplantation, 4 for BSs, and 2 for other reasons). In the end, 46.2% of the patients (6/13) with BLs underwent retransplantation. Even though PTC procedures may be a part of treatment strategies for BLs, such patients have a higher chance of undergoing surgical procedures for the treatment of abdominal collections and/or biliary anastomosis redo. Conservative management can be attempted primarily in clinically stable patients with low-output BLs. In the series by Feier et al.6 concerning the treatment of BCs after pediatric living donor LT, 69.7% of the patients (23/33) with BLs underwent reoperations, but conservative strategies, including percutaneous biliary interventions (PBIs), were used for the remaining patients. The reported retransplantation rate for patients with BLs was 9.1% (3 patients with hepatic artery thrombosis). Seven patients (21%) progressed to BSs, and this was similar to the 30% incidence registered for the Cliniques Universitaires Saint-Luc series.4 Previous publications have addressed treatment strategies, results, and complication rates with PBI procedures used in the management of BSs in pediatric populations.6-10 There are different treatment protocols, and the results vary accordingly. It appears that a higher number of PBIs per patient and a longer drainage time are associated with better success rates.6 With a 3-month drainage time, Sunku et al.10 obtained a 34% success rate for the treatment of BSs with a median follow-up of 4.5 years, whereas Belenky et al.3 obtained 100% resolution for BSs with a 1-year drainage time, with the biliary stents changed every 10 to 20 days (mean follow-up = 3.6 years). In our own experience,6 a 77% success rate was obtained after a median biliary catheter drainage time of 8 months (range = 40 days to 38 months); 8 of 43 patients (18.6%) underwent reoperations because of the failure of the PBI treatment, and a new bilioenteric anastomosis was performed. In most of the series, however, the strategies were implemented according to a patient's response to treatment, and they usually progressed from the most conservative procedure to a more aggressive approach such as a surgical intervention. Most publications report recurrence rates between 20% and 40%.2, 6 From an analysis of the complication rates of PBI procedures in patients with BSs, it is possible to see that most event-related complications are minor, as shown by Moreira et al.11: only 2 of 35 patients (5.7%) developed hemodynamic repercussions associated with hemobilia, and they were successfully treated with arterial embolization. Lorentz et al.12 demonstrated 10.8% and 1.7% rates of minor and major complications, respectively, after 120 PTC procedures in 76 patients. The problems included transient hemobilia, a reduced hematocrit, mild pancreatitis, and fever with bacteremia. Two patients developed life-threatening events (sepsis and hemoperitoneum). In the series by Feier et al.,6 5 of 43 patients developed complications related to the procedure such as cholangitis, intestinal bleeding, and BLs. Even though the incidence of nonsurgical complications was not tracked in the series by Miraglia et al.,9 none of the patients presented with life-threatening events. The risk of complications after PBIs is offset by the benefit of avoiding surgical interventions in a large segment of the population.10 Fifty-nine patients (98.3%) with anastomotic BCs in the series by Darius et al.4 underwent surgical exploration and bilioenteric re-anastomosis. The reported incidence of major complications according to the Clavien-Dindo classification (≥3)13 was 8.5% (5 patients); 4 of these patients required a second surgical revision, and 1 child needed a third procedure. The reported 30-day mortality rate was 3.4% (2 patients). Both deaths occurred after surgery for the correction of BSs (biliary sepsis and peritoneal carcinomatosis). Six of the 46 patients (13%) who underwent primary surgery for the treatment of BSs required a second surgical biliary revision. Treatment-related morbidity/mortality rates, recurrence rates, quality of life, and retransplantation rates were the parameters considered by the authors for the comparison of therapeutic alternatives. First, the differences in morbidity associated with the reported spectrum of complications after PBIs and complications after surgical treatment appear to be clear: in the PBI series, the complications were usually minor and amenable to medical treatment in most cases. PBIs allow decompression/drainage of the biliary tree and are part of the treatment of patients with biliary sepsis. It was not possible to evaluate the clinical scenario of the 1 patient who died because of biliary sepsis after a primarily surgical approach, but perhaps a surgical procedure might have been avoided for the peritoneal carcinomatosis case in the series by Darius et al.4 It may be feasible to evaluate differences in the quality of life of patients using PTC catheters, but the authors did not provide objective documentation on the matter, and the evaluation was based on the personal experience of senior staff members involved in patient care. On the other hand, none of the patients in their series underwent PBI treatment. Lastly, the reported overall retransplantation rate for patients with surgically treated anastomotic BCs was 12% (7/59), whereas 46% of the patients (6/13) in the BL group underwent retransplantation. Only 1 patient treated for a BS underwent retransplantation because of secondary biliary cirrhosis. Interestingly, in the study by Feier et al.6 reporting outcomes of PTC for BSs after living donor LT (45/489 transplants), 3 of the 45 patients (6.7%) underwent retransplantation because of secondary biliary cirrhosis.6 This finding might raise the question whether PBIs increase the risk of secondary biliary cirrhosis, but the numbers are limited, and the series are not comparable, so it is not possible to draw conclusions. The small liver volume, the possible absence of intrahepatic biliary dilatation, and the possibility of multiple biliary anastomoses make biliary interventional procedures in pediatric patients challenging.14 PTC is an invasive procedure, and complications such as bleeding, fever, bacteremia, and perforation can occur at a frequency as high as 11%.1 Despite the risk of complications, PTC is the gold standard for the diagnosis and treatment of patients with BSs and particularly those with bilioenteric anastomoses.1, 15 Patients treated with PBIs require multiple interventions, but these are planned, staged procedures such as balloon dilatations, catheter upsizing, and routine-maintenance catheter exchanges.16 Even though the treatment strategies differ among centers, many reported series have shown excellent outcomes with PBIs for BCs with low complication rates. For BLs, a surgical approach cannot be avoided in most patients; however, for the treatment of BSs, surgery should be reserved for times when the PBI procedure fails." @default.
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• W2015436103 date "2014-07-29" @default.
• W2015436103 modified "2023-10-02" @default.
• W2015436103 title "When is surgery required for the treatment of biliary complications after pediatric liver transplantation?" @default.
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