Biliary Leak after Pediatric Liver Transplantation Treated by Percutaneous Transhepatic Biliary Drainage—A Case Series

Abstract

Background: Biliary leaks are a severe complication after pediatric liver transplantation (pLT), and successful management is challenging. Objectives: The aim of this case series was to assess the outcome of percutaneous transhepatic biliary drainage (PTBD) in children with bile leaks following pLT. The necessity of additional percutaneous bilioma drainage and laboratory changes during therapy and follow-up was documented. Material and Methods: All children who underwent PTBD for biliary leak following pLT were included in this consecutive retrospective single-center study and analyzed regarding site of leak, management of additional bilioma, treatment response, and patient and transplant survival. The courses of inflammation, cholestasis parameters, and liver enzymes were retrospectively reviewed. Results: Ten children underwent PTBD treatment for biliary leak after pLT. Seven patients presented with leakage at the hepaticojejunostomy, two with leakage at the choledocho-choledochostomy and one with a bile leak because of an overlooked segmental bile duct. In terms of the mean, the PTBD treatment started 40.3 ± 31.7 days after pLT. The mean duration of PTBD treatment was 109.7 ± 103.6 days. Additional percutaneous bilioma drainage was required in eight cases. Bile leak treatment was successful in all cases, and no complications occurred. The patient and transplant survival rate was 100%. CRP serum level, leukocyte count, gamma-glutamyl transferase (GGT), and total and direct bilirubin level decreased significantly during treatment with a very strong effect size. Additionally, the gamma-glutamyl transferase level showed a statistically significant reduction during follow-up. Conclusions: PTBD is a very successful strategy for bile leak therapy after pLT.

Percutaneous Biliary Interventions in Pediatric Patients

“…2) are less frequent than strictures after liver transplantation or liver resection, but still important with a prevalence of 2 to 15%. 6,17 Generally, leaks occur earlier than strictures, with most in the first year after liver transplantation. Bile leaks can also be subdivided into anastomotic and non-anastomotic.…”

“…The most common source is from the cut edge of a reduced liver graft. 4,6,20 Postoperative Complications after Kasai Operation…”

“…PTBD can be considered for cases of biliary leakage from anastomotic or non-anastomotic sites. 4,6 The puncture technique is identical to PTBD for a stricture, but access can be more difficult because generally the bile ducts are not dilated. There is a recommendation to augment the drainage size gradually by 2 Fr every 6 to 8 weeks until reaching the optimal drainage size for the child's bodyweight.…”

“…Although these interventions are widely performed in adult patients, evidence for pediatric biliary interventions is sparse and comprises primarily singlecenter case series. 4,[6][7][8][9] Percutaneous interventions in pediatric patients are quite different and challenging: the biliary system is smaller and often nondilated and the type of liver graft and number/location of biliary anastomoses is variable. Furthermore, general anesthesia is needed, and radiation exposure needs to be minimized due to the higher radiation sensitivity of children and the life-time risk of stochastic radiation damage.…”

“…With the evolvement of split-liver and living-donor liver transplantation particularly for young children, the quantity of pediatric transplantations increased markedly, which also increased the incidence of biliary complications. 3,8,[12][13][14][15] The prevalence of biliary complications after pediatric liver transplantation is estimated to be between 8 and 40% 1,6,7,10,16 and can be subdivided into bile leaks and biliary strictures/obstructions.…”