Endoscopy in the management of pancreaticobiliary complications after liver, intestine, or composite visceral transplantation in children

A common complication following isolated liver, intestinal, or composite visceral transplantation is pancreaticobiliary (PB) disease. The occurrence of PB complications is an inherent risk by nature of the type of transplant performed especially when biliary reconstruction or anastomosis is required or when the pancreas is included. In a review of 2192 pediatric liver transplant recipients from the Studies in Pediatric Liver Transplant (SPLIT) registry of patients surviving to 24 months, the biliary complication rate varied with the type of graft: whole liver 17.3%, split 28.5%, reduced 25.3%, live donor 40.1% (1). Composite visceral grafts include liver and small bowel combined grafts or multivisceral grafts. Multivisceral transplantation may involve the whole or partial pancreas with the donor graft. In a review of 271 consecutive patients (134 children) and 289 composite visceral grafts, PB complications occurred in 44 grafts with an overall incidence of 15% per graft and 17% per patient (2). There were 20 biliary, 19 pancreatic, and five combined PB complications in the 44 cases. Multivisceral graft recipients had a 25% rate of PB complications as opposed to a 9% rate in the liver/small intestine grafts. There has been an evolution of surgical techniques to decrease PB complications as indicated in that publication. In addition to surgical techniques, ischemia may play a role in association with vascular thrombosis, stenosis, or donor after cardiac death (DCD) grafts. Rejection can result in biliary stenosis or strictures. Biliary strictures may be anastomotic or non-anastomotic with the latter more difficult to treat. Biliary stents or drains may become displaced with resultant bile leaks or bilomas. The biliary tract may develop casts, sludge, or stones. The pancreatic complications include strictures, leaks, pancreatitis, and pancreatic duct stones. There may be sphincter of Oddi dysfunction. These PB complications result in considerable morbidity and risks of retransplantation or mortality (3). Typically, the children present with abdominal pain, abnormal liver or pancreatic chemistries and possibly fever or sepsis. Occasionally, the diagnosis is suspected by routine imaging or liver biopsy. The usual initial approach to diagnosis is an abdominal ultrasound (4). If a biliary drain is present, an abdominal radiograph and/or cholangiogram using the bile catheter may help detect an abnormality. Several recent studies have shown the value of magnetic resonance cholangiopancreatography, or MRCP, to accurately detect PB complications (5, 6). Options for therapy include surgery, interventional radiology (IR), or endoscopy. The standard approach to the pediatric liver transplant patient (especially with a choledochojejeunostomy) includes IR to perform percutaneous transhepatic cholangiogram (PTC) with interventions such as stents, drains, balloon dilations, or stone removal. In appropriate cases, an external drain is necessary to leave in place until the next IR procedure. Endoscopic retrograde cholangiopancreatography (ERCP) has the advantage especially for children of placing an internal stent rather than percutaneous external drainage. The multivisceral transplant patient depending on the surgical approach has a significant risk of pancreatitis or pancreatic leak such that ERCP may be needed both for diagnosis and therapy. The accompanying article (7) provides considerable support for the safety and effectiveness of endoscopy in the diagnosis and management of PB complications. In this retrospective review