title: Management of excluded bile ducts in paediatric orthotopic liver transplant recipients of technical variant allografts.
abstract: BACKGROUND
  A strategy to increase the number of size- and weight-appropriate organs and decrease the paediatric waiting list mortality is wider application of sectional orthotopic liver transplantation (OLT). These technical variants consist of living donor, deceased donor reduced and split allografts. However, these grafts have an increased risk of biliary complications. An unusual and complex biliary complication which can lead to graft loss is inadvertent exclusion of a major segmental bile duct. We present four cases and describe an algorithm to correct these complications.
  
  
  METHODS
  A retrospective review of the paediatric orthotopic liver transplantation database (2000-2010) at Washington University in St. Louis/St. Louis Children's Hospital was conducted.
  
  
  RESULTS
  Sixty-eight patients (55%) received technical variant allografts. Four complications of excluded segmental bile ducts were identified. Percutaneous cholangiography provided diagnostic confirmation and stabilization with external biliary drainage. All patients required interval surgical revision of their hepaticojejunostomy for definitive drainage. Indwelling biliary stents aided intra-operative localization of the excluded ducts. All allografts were salvaged.
  
  
  CONCLUSIONS
  Aggressive diagnosis, percutaneous decompression and interval revision hepaticojejunostomy are the main tenets of management of an excluded bile duct. Careful revision hepaticojejunostomy over a percutaneous biliary stent can result in restoration of biliary continuity and allograft survival.
authors.affiliation: Department of Surgery, School of Medicine, Washington University in St. Louis, MO, USA.
authors.forename: Kendra D
authors.initials: KD
authors.lastname: Conzen
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Lowell
authors.forename: William C
authors.initials: WC
authors.lastname: Chapman
authors.forename: Michael
authors.initials: M
authors.lastname: Darcy
authors.forename: James R
authors.initials: JR
authors.lastname: Duncan
authors.forename: Michelle
authors.initials: M
authors.lastname: Nadler
authors.forename: Yumirle P
authors.initials: YP
authors.lastname: Turmelle
authors.forename: Ross W
authors.initials: RW
authors.lastname: Shepherd
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Anderson
mesh_terms: D002404:Catheterization / Q000295:instrumentation; D002648:Child; D002675:Child, Preschool; D002758:Cholangiography; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D019299:Decompression, Surgical; D004322:Drainage; D005260:Female; D006085:Graft Survival; D006801:Humans; D007223:Infant; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008923:Missouri; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents; D014019:Tissue Donors / Q000600:supply & distribution*; D014184:Transplantation, Homologous; D016896:Treatment Outcome
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