Biliary Complications in Pediatric Liver Transplantation

A strategy to increase the number of size- and weight-appropriate organs and decrease the pediatric waiting list mortality is the wider application of technical variant liver allografts, which consist of split, living donor, and, occasionally, reduced grafts. Comparable patient and graft survival to whole liver recipients has been achieved in most centers. However, the use of partial grafts is associated with higher rates of biliary complications (BCs) than whole deceased donor ones. BCs can occur early or late, with a cutoff ranging between 1 and 3 months. They are classified into biliary strictures (BS), which can be anastomotic or intrahepatic, bile leaks (BL), bilomas, missing or excluded ducts, and stones and cast formation, among others. The overall BC incidence in transplanted children varies from 15% to 40%. The type of graft, number of bile ducts, and type of biliary reconstruction performed influence the variability in the incidence of BCs. The diagnosis requires a high index of suspicion because, in the initial phases, the clinical picture can be confused with rejection, infection, and primary disease recurrence. In children, the majority of biliary reconstruction is a bilioenteric anastomosis performed by Roux-en-Y. Percutaneous transhepatic cholangiography (PTC) to perform the percutaneous biliary intervention (PBI) is the mainstay of diagnosis and treatment in pediatric LT, with a success rate between 70% and 90%. Surgery is reserved for patients who have failed PBI. Only with early diagnosis and aggressive treatment, high success rates can be expected without a significant impact on patient and graft survival.