Efficacy and safety of percutaneous transhepatic cholangiography (PTC) in children: a 10-year experience

Background.In children, biliary strictures(BS) most commonly occur because of surgical interventions on the biliary tree or as complications following liver transplantation(LT). Although rare, BS can lead to serious complications, including recurrent episodes of cholangitis, and may ultimately compromise liver function. Percutaneous transhepatic cholangiography(PTC) is a well-established treatment for managing BS in adults. However, the use of interventional radiology techniques in the pediatric population remains extremely limited, and no studies to date have evaluated the efficacy and safety of biliary stent placement in children. Aim.To evaluate the efficacy and safety of PTC and biliary stent placement in a cohort of children with BS treated at our center from 2014 to 2024. Methods.A retrospective study was conducted to collect data on all pediatric patients who underwent PTC for the treatment of BS between January 2014 and September 2024 at the University Hospital of Padova. The study evaluated demographic data, BS type and etiology, PTC procedure characteristics, and hospitalization modality (urgent vs. planned). PTC success was defined as the successful placement of the biliary drainage, while PTC efficacy was defined as the absence of stricture recurrence at tube removal. BS recurrence was assessed at any point during follow-up. The incidence of complications was evaluated: CRP elevation, fever, cholangitis, pain, sepsis, bleeding, exit-site infection, vascular thrombosis, pancreatitis, bilio-cutaneous fistula, and dislocation or rupture of the biliary drainage. A descriptive analysis of demographic and clinical characteristics was performed, with medians and ranges calculated for continuous variables and percentages for categorical variables. Generalized Estimating Equations were used to identify potential risk factors for complications, with predictive effects quantified by odds ratios. Results.The study included 18 patients(55.5% males) who underwent a PTC at a median age of 6 years(0.75-18 years). 14(77.8%) subjects were LT recipients, while 4(22.2%) had a native liver. The median follow-up duration was 21 months(3-75 months). BS were defined as anastomotic(55.5%), intrahepatic(5.6%), combined anastomotic and intrahepatic(5.6%), complex(22.2%), other(11.1%). The etiology of BS was categorized as post-surgical(50%), multifactorial(38.9%) and due to external compression(11.1%). A total of 86 PTC procedures were performed. Bilioplasty was performed in 48.8% of procedures. The success rate of PTC was 90.9%, and the efficacy rate reached 100%. Recurrence of BS occurred after 5 out of the 19 completed PTC cycles(26.3%), with a recurrence rate of 25% after the first PTC cycle and 33.3% after the second cycle. Complications were observed in 60.5% of the procedures, with CRP elevation(55.68%), fever(35.96%) and cholangitis(24.36%) being the most frequent. Life-threatening complications were rare, with sepsis occurring in 5.8% of procedures and bleeding in 3%. Risk factor analysis indicated that patients admitted urgently for biliary complications were at higher risk for cholangitis(OR:2.93), fever(OR:6.55), and CRP elevation(OR:3.09) compared to those admitted electively. Complex biliopathy(OR:1.46) and combined anastomotic and intrahepatic BS(OR:2.20) were more likely associated to CRP elevation compared to anastomotic BS alone. Additionally, BS caused by external compression were more frequently associated with fever(OR:2.31) and cholangitis(OR:3.93). Conclusion.PTC is a highly effective in children with BS, achieving success rates of 90-100%. Compared to recurrence rates of 50-60% with standard PTC, the use of resorbable biliary stents lowers the risk of restenosis to approximately 25%. Although life-threatening complications are rare, they should be thoroughly discussed with the family and promptly identified and treated. Prospective studies with larger pediatric cohorts are needed to validate these findings.