Biliary complications after pediatric liver transplantation: risk factors and impact on patient and graft survival

Introduction: Biliary complications (BCs) are seen in upto 50% of pediatric liver transplant (PLT) recipients and can significantly increase procedural morbidity. Methods: Retrospective review of all patients developing BC after PLT at tertiary care hospital from 2002-2016. Outcomes were compared with PLT recipients who did not develop BCs (control) and risk factors were identified. Results: BCs were seen in 18% (34/187) PLT recipients during study period: 5 leaks, 25 strictures, 4 leaks+strictures. There was no difference between BC and control groups in recipient age, sex, weight, etiology, type of biliary reconstruction, and cold and warm ischemia times. BC group had significantly higher proportion of Caucasians (94% vs 77%), living donors (23% vs 8%), internal biliary drainage (biliary stent/T-tubes) (50% vs 24%), rejection (17% vs 5%) and 30- and 90-day readmission rates (p<0.05). 5/34 (15%) required surgery (biliary revision in 3, re-PLT in 2) while remaining were successfully managed with PTC and ERCP. There was no difference in 1-,5- and 10-yr overall survival (100%,90%,86% BC vs 91%,88%,88% control) and graft survival (94%,78%,58% BC vs 84%,80%,79% control). Multivariate analysis identified use of partial grafts (living donor, insitu-split or reduced-size), use of internal biliary drainage, and rejection as independent predictors of BCs, while use of internal biliary drainage was independently associated with decreased patient survival. Conclusions: Partial liver grafts, internal biliary drainage, and rejection are associated with higher BC rates after PLT. BCs do not significantly impact overall patient or graft survival.