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Introduction: Biliary ducal sequelae including occlusions, strictures, leaks, or necrosis frequently complicate pediatric liver transplantation. The underlying etiology includes prolonged intraoperative ischemia or postoperative arterial inflow obstruction. In adult patients the role of endoscopic retrograde cholangiography (ERC) is well established in the management of biliary complications post-liver transplantation. In contrast, in the pediatric population, due to the combination of small patient size and the complexity of Roux-en-Y anastomotic techniques, ERC has been described as difficult or virtually impossible. This limits the options available for managing biliary duct complications to percutaneous techniques Endoscopic management of biliary complications in pediatric patients with Roux-en-Y anatomy has not been previously reported in the pediatric population. Case: We present the case of an 8-yr-old patient with history of unresectable hepatoblastoma who underwent liver transplantation with Roux-en-Y anastomosis at the age of 15 months. His transplant was initially complicated by hepatic artery spasm and developing biliary strictures requiring biliary internal/external drain placement by interventional radiology (IR) twice in the first year following transplantation. He then presented at the age of 7 with recurrence of his biliary stricture at the site of choledocho-jejunal anastomosis and initial attempt for placing an internal/external biliary drain by IR was unsuccessful having not been able to pass a guidewire through the stricture. Another attempt 2 months later was successful, and an 8.5 French drain was placed then upsized to a 12 French 2 months later and removed after a total of 4 months. His biliary stricture recurred once more, and IR drain placement was unsuccessful despite multiple attempts. The patient was therefore referred for an ERC. A Pentax EC-2990Li with a 2.8mm working channel was initially used and access to the hepatic duct, through anastomosis site was successful using a standard sphincterotome and the stricture was dilated. An attempt to place a 7 Fr stent was unsuccessful as it couldn’t be passed through the scope channel, so the scope was switched to a Pentax EC-3490LK with a 3.8mm working channel and a 7Fr stent was successfully placed. Discussion: Biliary complications post liver transplantation represent a considerable cause of morbidity and mortality. Biliary complication rate has been reported as 20-38% in pediatric liver transplantation with higher rate in duct-to-duct anastomosis compared to hepato-jujenal anastomosis . The most common complications are bile leaks and biliary strictures. Endoscopic management of biliary complications remains the preferred approach, due to its safety profile, as opposed to the percutaneous route and has been extensively reported in the adult population, and has been increasingly used in patients with Roux-en-Y reconstruction. Studies have shown that endoscopic management of biliary complications can minimize the need for post-transplant biliary surgery and is generally safe and effective The ideal endoscope and technique for endoscopic management in Roux-en-Y patients remains unclear. Nabeel et al. compared using a single-balloon enteroscope with variable stiffness colonoscopes in patient with Roux-en-Y anatomy in 199 procedures and NASPGHAN 1 1 1 1 2 2 1 1 (1). (2) (4). found that rates of biliary cannulation, therapeutic success and procedural success were higher with the use of single-balloon endoscopes and lowest with the use of pediatric colonoscopes . Herein we report the first pediatric case of performing ERC in a liver transplant patient with Roux-en-Y anatomy. Conclusions: Endoscopic management of biliary complications post liver transplantations in pediatric patients with Roux-en-Y anatomy is possible and considered as a safer alternative to percutaneous management.
Gastroenterology | Pediatrics | Surgery
Ibrahimi, Nadia; Attard, Thomas M.; Fischer, Ryan T.; Slowik, Voytek; Hendrickson, Richard J.; Mullapudi, Bhargava; Alatorre-Jimenez, Moises; and Jafri, Syed, "Endoscopic Retrograde Cholangiography Using A Colonoscope In A Pediatric Liver Transplant Patient With Roux-en-y Biliary Anastomosis" (2022). Posters. 297.