A plea for surgical redo as first therapeutic option for anastomotic biliary complications after pediatric liver transplantation

PURPOSE: Biliary complications (BC) still remain the 'Achilles heel' in liver transplantation (LT), with an overall incidence between 10-35% in pediatric series. We hypothesized that: (1) the use of alternative techniques (reduced-size, split and living donation) in pediatric LT contributed to increase the incidence of biliary complications BC; (2) surgery as first treatment option for anastomotic BC allowed definitive cure in the majority of the patients. METHOD: 429 primary pediatric LT (of which 88, 91, 47 and 203 were whole liver, reduced-size, split, and living donors grafts, respectively) performed between July 1993 and November 2010 were retrospectively reviewed. Demographic and surgical variables were analyzed and their respective impact on BC was studied using uni- and multivariate analyses. Modalities of management of BC were also reviewed. RESULTS: The 1 and 5-year patient survival rates were 94% and 90%, 89% and 85%, 94% and 89%, and 98% and 94%, respectively for whole liver, reduced-size, split, and living donor grafts. The incidence of BC was 23% (n=98). 60 of them were anastomotic complications (47 (78%) strictures, and 13 (22%) fistulae). The type of the graft was not found as a risk factor for the development of BC. At multivariate analysis, only hepatic artery thrombosis and acute rejection increased the risk of anastomotic BC (p<0.0001 and p=0.003, respectively). Anastomotic BC were managed using primary surgical repair in 59/60 cases (98%) with a success rate of 80% (n=48). CONCLUSION: These results suggest that: (1) most of the BC were anastomotic complications without influence of the type of graft and (2) surgical management of anastomotic BC may constitute the first and best therapeutic option.