Pediatr Transplantation 2015: 19: 170–174

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Pediatric Transplantation DOI: 10.1111/petr.12421

Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation Teplisky D, Urue~ na Tincani E, Halac E, Garriga M, Cervio G, Imventarza O, Sierre S. (2015) Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation. Pediatr Transplant, 19: 170–174. DOI: 10.1111/petr. 12421. Abstract: The aim of this study is to correlate the US, laboratory, and cholangiography findings in pediatric liver transplant patients with biliary complications, trying to identify reliable decision-making tools for the management of these complications. Retrospective review was carried out of US results in 39 consecutive patients, from 2011 to 2013, with biliary complications after LT, documented by PTC. According to US biliary dilation, patients were classified as: mild, moderate, and severe, and according to laboratory findings as: normal or abnormal serum bilirubin and level of serum GGT. Data were correlated with PTC findings, divided in three groups: mild, moderate, and severe/occlusive BDS. There was no statistically significant correlation between the US findings and the laboratory findings and between US findings with PTC. There was a statistically significant correlation between GGT and cholangiography. In our series, abnormal US could not predict the severity of BDS on PTC. Bilirubin results were not able to predict the US findings either. GGT results demonstrated a statistically significant correlation with the severity of BDS found on PTC. These findings emphasize the role of GGT in the evaluation and decision of biliary interventions in pediatric liver transplant recipients.

For over three decades, LT has been accepted as a therapeutic choice for those patients with endstage liver disease or acute liver failure, with no other treatment alternatives. Nowadays, liver transplant patients present a high overall survival considering that 90% of patients are alive at one yr and more than 80% at five yr (1, 2). The current LT high survival and clinical success rates may be attributed to, among other factors, the development of immunosuppression therapies and the evolution of new surgical tech-

Abbreviations: BDS, bile duct stenosis; GGT, gammaglutamyl transpeptidase; LT, liver transplantation; PTC, percutaneous transhepatic cholangiography; US, ultrasonography.

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Darıo Teplisky1, Eliana Urue~na Tincani1, Esteban Halac2, Matıas Garriga1, Guillermo Cervio2, Oscar Imventarza2 and Sergio Sierre1 1

Department of Interventional Radiology, Hospital Nacional de Pediatrıa “Prof. J.P. Garrahan,” Buenos Aires, Argentina, 2Department of Liver Transplantation, Hospital Nacional de Pediatrıa “Prof. J.P. Garrahan,” Buenos Aires, Argentina

Key words: liver transplantation – children – interventional radiology – ultrasonography – bile ducts – cholangiography Sergio Sierre, Department of Interventional Radiology, Hospital Nacional de Pediatrıa “Prof. J.P. Garrahan,” Combate de los Pozos 1881 (1245), Buenos Aires, Argentina Tel.: 54 11 4308 4300 (x7093) Fax: 54 11 4308 5325 E-mail: [email protected] None of the authors have identified a conflict of interest. Accepted for publication 25 November 2014

niques. Also, significant advances have been achieved with diagnostic and interventional radiology techniques as tools for diagnosis and minimally invasive treatment of complications in this population (1, 3–5). Interventional radiology plays a key role in the diagnosis and treatment of these complications. PTC and biliary drainage are considered important diagnostic and therapeutic tools for the management of biliary complications in this population (5–8). The purpose of this study is to correlate the US, laboratory, and cholangiography findings in pediatric liver transplant patients with biliary complications, to identify reliable decisionmaking tools for the management of these complications.

Biliary complications in liver transplantation Materials and methods Our hospital does not require an Institutional Review Board approval for a study such as this.

Population During a period of 24 months, 39 patients under 18 yr of age with reduced LT, with indication for cholangiography and percutaneous biliary drainage, were admitted consecutively at our Interventional Radiology Department. All patients had received an organ from a deceased donor (segments II–III), with Split technique. Eighteen patients were boys and 21 were girls. The age group was 2–204 months with a mean of 69 months (5.7 yr). Indications for percutaneous cholangiography and drainage were cholangitis, in eight patients, defined by fever, jaundice, leucocytosis, and US dilation of bile ducts. In the remaining 31 patients, the indication was cholestasis, defined as elevation of serum GGT and US biliary dilation.

US and Color Doppler imaging assessment Ultrasound exams were performed by pediatric radiologists, in the interventional radiology room, with patients under general anesthesia, immediately before the percutaneous drainage procedure. Bile duct dilation was measured in the segment of greater dilation. Color Doppler was also

(a)

performed to look for vascular structures in the evaluated segment. According to the biliary dilation on US, patients were classified as mild (biliary duct/s of less or equal to 2.5 mm), moderate (greater than a 2.5 mm and less than 5 mm), and severe (equal or greater than 5 mm), Fig. 1.

Percutaneous cholangiography According to our protocol, immediately before the procedure, all patients receive prophylactic antibiotic treatment (ampicillin–sulbactam IV, 75 mg/kg). Under general anesthesia and US guidance, a dilated bile duct was accessed with a 22-G Chiba needle. Once the access is achieved, contrast media is gently injected to confirm needle position and identify the biliary tree anatomy. Then, under fluoroscopic guidance, the needle is replaced by a modified Neff percutaneous access set (Cook, Bloomington, IN, USA) and cholangiography was performed. Cholangiography findings were recorded and retrospectively reviewed. Patients were classified in three categories according to the cholangiographic features at the bilioenteric anastomosis portion and the passage of contrast media through the anastomosis: mild (irregular non-occlusive – 50% to 80% – strictures with passage of contrast agent to intestine), moderate (significant – >80% – stricture with filiform passage of contrast agent to intestine), and severe/occlusive (no passage of contrast agent to intestine), Fig. 2.

(b)

(c)

Fig. 1. Color Doppler US of the hepatic graft: a, b, and c demonstrate mild, moderate, and severe biliary ducts dilation, respectively (white arrows).

(a)

(b)

(c)

Fig. 2. Percutaneous cholangiography. (a) Mild anastomotic biliary stenosis (white arrow). (b) Moderate anastomotic stenosis (white arrow). (c) Severe/occlusive biliary stenosis, with no passage of contrast media through the biliodigestive anastomosis to the bowel.

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Teplisky et al. Laboratory studies

Table 2. Laboratory (total bilirubin)–cholangiography correlation

Medical records were reviewed and total and direct bilirubin values of each patient, as well as GGT values, were collected. Normal bilirubin levels were considered as

Ultrasonography, laboratory, and cholangiography correlation of biliary complications in pediatric liver transplantation.

The aim of this study is to correlate the US, laboratory, and cholangiography findings in pediatric liver transplant patients with biliary complicatio...
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