title: Biliary dilatation and strictures after composite liver-small bowel transplantation in children: defining a newly recognized complication.
abstract: BACKGROUND
  Biliary dilatation and strictures (BDS) are well recognized after liver transplantation but not reported after composite liver-small bowel transplantation (CLSBT). We aimed to describe and propose a classification of BDS in children undergoing CLSBT and analyze the potential risk factors.
  
  
  METHODS
  Biliary complications of 47 consecutive children undergoing CLSBT were reviewed and classified according to presentation, location, and intervention required. The following variables were studied: small recipient (weight, <10 kg), donor-recipient weight ratio, liver/bowel graft reduction/not, partial/full pancreas, liver/bowel rejection, and median cold ischemia time (>454 min).
  
  
  RESULTS
  Twenty-one (45%) children developed BDS at median 190 days (22 [7-138] months follow-up). Five distinct biliary lesions were identified. Most of the BDS (14/21; 67%) consisted of sphincter dysfunction-related bile duct dilatation (type I), whereas others (7/21; 33%) comprised extrahepatic bile duct (type II; n=3), hilar (type III; n=1), segmental (type IV; n=1), and diffuse (type V; n=2) intrahepatic strictures. None of the graft reduction strategies or other variables studied demonstrated a significant association with BDS. Therapeutic intervention was required in 1 of 14 type I and four of seven type II to V BDS in the form of percutaneous biliary dilatation with or without drainage.
  
  
  CONCLUSIONS
  This article identifies BDS after CLSBT as a frequent late complication after CLSBT, which has a benign outcome in most cases. The natural history of children with extrahepatic and intrahepatic strictures is not yet clear and will need multicenter prospective studies.
authors.affiliation: The Liver Unit (including Small Bowel Transplantation), Birmingham Children's Hospital, Birmingham B4 6NH, United Kingdom.
authors.forename: M Thamara P R
authors.initials: MT
authors.lastname: Perera
authors.forename: Girish L
authors.initials: GL
authors.lastname: Gupte
authors.forename: Khalid
authors.initials: K
authors.lastname: Sharif
authors.forename: Bassem
authors.initials: B
authors.lastname: Hegab
authors.forename: Cristina
authors.initials: C
authors.lastname: doPazo
authors.forename: Simon P
authors.initials: SP
authors.lastname: Olliff
authors.forename: Deirdre A
authors.initials: DA
authors.lastname: Kelly
authors.forename: Paolo
authors.initials: P
authors.lastname: Muiesan
authors.forename: A David
authors.initials: AD
authors.lastname: Mayer
authors.forename: Darius F
authors.initials: DF
authors.lastname: Mirza
mesh_terms: D000293:Adolescent; D001659:Biliary Tract / Q000473:pathology*; D002648:Child; D002675:Child, Preschool; D003251:Constriction, Pathologic; D004108:Dilatation, Pathologic; D005260:Female; D005355:Fibrosis; D006084:Graft Rejection / Q000209:etiology / Q000473:pathology; D006801:Humans; D007223:Infant; D007421:Intestine, Small / Q000637:transplantation*; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D012307:Risk Factors; D013997:Time Factors