Improved Outcomes from Prolonged Percutaneous Biliary Drainage in Pediatric Patients with Biliary Stenosis after Liver Transplantation.

Abstract

Purpose: Biliary complications affect 15-40% of pediatric liver transplants (pLT), with biliary strictures (BS) occurring in 5-23%. Roux-en-Y hepaticojejunostomy is the primary reconstructive technique. This study evaluates patency rates, outcomes of percutaneous transhepatic biliary drainage (PTBD), and predictors of stenosis recurrence.

Methods: A retrospective analysis of 47 PTBDs in 40 pediatric patients post-pLT (2009-2019) was performed. Six patients underwent repeated PTBD for recurrent BS. Kaplan-Meier, log-rank, and Cox regression analyses evaluated patency and influencing factors. Management followed institutional protocols with drain upsizing every 6-8 weeks. Median age was 1.8 years (IQR: 0.8-8.2), weight 9.9 kg (IQR: 7.5-19.6).

Results: The median interval from pLT to PTBD was 122 days (IQR 55-626). Primary patency was 89.4 % at 1 year and 86.3 % at 5 years, with 15 % restenosis after a median of 8.5 months. Repeat PTBD achieved patency rates of 100 % at 1 year and 83.3 % at 5 years (exploratory). Patency declined with dwell times < 5 months (p = 0.015), biliary leaks limited to the period before or during PTBD (post-PTBD leaks showed no association); hepaticojejunostomy revision, complex portal-vein reconstruction; and low- to moderate-grade hepatic-artery stenosis. Longer dwell time reduced recurrence risk (HR 0.52, 95 % CI 0.30-0.89). Elevated alkaline phosphatase, bilirubin, GGT, and AST were predictive of recurrence (p < 0.05).

Conclusion: PTBD ≥5 months improves biliary patency and reduces restenosis risk. Shorter durations increase recurrence risk. Outcomes depend on PTBD duration, vascular status, bile leaks, and surgical complexity. Laboratory changes during and after therapy may indicate recurrent stenosis.