Impact of Biliary Complications on Outcomes after Pediatric Liver Transplant

Introduction: Biliary complications (BCs) are seen in up to 50% of pediatric liver transplant (PLT) recipients and contribute to considerable post-procedural morbidity. Methods: Retrospective review of all patients developing BC's after PLT at tertiary care hospital from 2002-2019. Outcomes of BC patients were compared with PLT recipients who did not develop BCs (control) and risk factors were identified. Results: BC's were seen in 39 (18%) of the 221 PLT's performed during the study-period: 8 leaks, 26 strictures, 5 leaks+strictures. There was no difference between BC and control groups in recipient age, gender, weight, etiology, type of biliary reconstruction, and cold and warm ischemia times. Univariate and multivariate analysis identified Caucasian race, use of living donor and/or partial grafts, use of T-tubes and/or internal stents, operative time>7hrs, acute cellular rejection (ACR), PLT before 2010 and donor age>10 kg as independent risk factors of BC's(P< 0.05), while use of T-tubes/internal stents was independently associated with decreased survival. The 39 BC patients required 10 surgeries, 23 ERCPs and 223 PTC procedures for definitive repair, and demonstrated higher rates of 30- and 90- day readmission (p< 0.05). There was no difference in overall patient and graft survival between the two groups. Conclusions: T-tubes/internal stents, partial grafts, prolonged operative-time and ACR in post-transplant period are risk factors for BC's and add considerable morbidity and cost through frequent readmissions and need for multiple procedures. Timely and effective intervention strategies based on multidisciplinary approach can help successfully treat BC's without impacting patient and graft survival.