Outcomes after discontinuation of routine use of transanastomotic biliary stents in pediatric liver transplantation at a single site

Abstract

Routine use of transanastomotic biliary stents (RTBS) for biliary reconstruction in liver transplantation (LT) is controversial, with conflicting outcomes in adult randomized trials. Pediatric literature contains limited data. This study is a retrospective review of 99 patients who underwent first LT (2005-2014). In 2011, RTBS was discontinued at our center. This study describes biliary complications following LT with and without RTBS. 56 (56%) patients had RTBS. Median age at LT was 1.9 yr (IQR 0.7, 8.6); 55% were female. Most common indication for LT was biliary atresia (36%). Most common biliary reconstruction was Roux-en-Y choledochojejunostomy (75% with RTBS, 58% without RTBS, p = 0.09). Biliary complications (strictures, bile leaks, surgical revision) occurred in 23% without significant difference between groups (20% with RTBS, 28% without RTBS, p = 0.33). Patients with RTBS had routine cholangiography via the tube at 6-8 wk; thus, significantly more patients with RTBS had cholangiograms (91% vs. 19%, p < 0.0001). There was no difference in the number of patients who required therapeutic intervention via endoscopic or percutaneous transhepatic cholangiography (11% with RTBS, 19% no RTBS, p = 0.26). Routine use of RTBS for biliary reconstruction in pediatric LT may not be necessary, and possibly associated with need for costlier, invasive imaging without improvement in outcomes.

North American Biliary Stricture Management Strategies in Children After Liver Transplantation: A Multicenter Analysis From the Society of Pediatric Liver Transplantation (SPLIT) Registry

“…The majority of biliary strictures are diagnosed in the first 6 months after LT, most commonly at the site of surgical biliary reconstruction. (1,4) Previous studies of pediatric transplantation recipients have identified risk factors for biliary strictures including technical variant grafts, hepatic artery thrombosis (HAT), prolonged cold ischemia time, acute rejection, ABO blood group incompatibility, donation after circulatory death, and primary duct-to-duct biliary reconstruction. (3,(5)(6)(7) As 60% of pediatric LT candidates are under 5 years of age at time of wait listing, (8) and technical variant grafts are the mainstay to increase access to transplantation due to size restrictions, biliary strictures will continue to significantly impact the success of pediatric LT.…”