Biliary strictures post pediatric liver transplantation-incidence and risk factors in a single tertiary referral transplant center.

BACKGROUND: Biliary strictures are a significant cause of morbidity and graft loss in pediatric liver transplant recipients. Risk factors for the development of biliary strictures are not fully established. We aimed to evaluate the incidence of biliary strictures and treatment modalities outcomes and to identify potential risk factors for occurrence. METHODS: Pediatric patients who underwent liver transplantation in the single tertiary pediatric liver transplant center in Israel were evaluated. We compared demographics, presentation, laboratory results, imaging, treatment, and outcomes between patients with and without biliary stricture. Multivariate regression analyses were used to identify risk factors for biliary strictures. RESULTS: Among 121 pediatric liver transplant patients, 65 (53.7%) were males; the median age at the time of liver transplantation was 43 (3-215) months. Fifteen patients (12.4%) had biliary strictures following transplantation. One (7%) patient with biliary stricture was treated via endoscopic retrograde cholangiopancreatography, and 12 patients (80%) underwent interventions via a percutaneous transhepatic approach. Nine of the 12 patients were treated successfully, requiring one or multiple procedures, while the remaining had surgery or laser therapy. Risk factors for the development of biliary strictures were biliary leak, acute cellular rejection, and the presence of two biliary anastomoses. CONCLUSIONS: In our cohort, the presence of two biliary anastomoses and post-transplant complications including acute cellular rejection and early biliary leaks were associated with biliary strictures in pediatric liver transplantation recipients. Percutaneous transhepatic interventions result in good outcomes in most patients.

Percutaneous core needle biopsy of neuroblastoma in the pediatric population: what have we learned in the last decade.

INTRODUCTION: Historically, neuroblastoma has been diagnosed by surgical open biopsy (SB). In recent decades, core needle biopsy (CNB) has replaced surgical biopsy due to its safe and adequate method of obtaining tissue diagnosis. AIM: Our study aimed to assess the effectiveness of CNB in obtaining tissue diagnosis for neuroblastoma and evaluate its safety profile in terms of post-operative complications, in comparison to SB. METHODS: A retrospective cohort study, including all patients younger than 18 years who were diagnosed with neuroblastoma from 2012 until 2022 in a single tertiary medical center. Patients' demographics, tumor size and location, pathological results, and clinical outcomes were collected. RESULTS: 79 patients were included in our study: 35 biopsies were obtained using image-guided CNB and 44 using SB. Patients' and tumor characteristics including age, gender, tumor volume, and stage were similar in both groups. The biopsy adequacy rate in the CNB group was 91% and 3 patients in this group underwent repeated biopsy. The safety profile in the CNB group was similar to the SB group. CONCLUSIONS: CNB is a safe method and should be considered the first choice for obtaining tissue diagnosis when feasible due to its high adequacy in terms of tumor histopathological features.

How Reliable Is the Intraoperative Assessment of Residual Fragments During Percutaneous Nephrolithotomy? A Prospective Study.

OBJECTIVES: To determine the accuracy of the surgeon's impression as to the stone-free rate at the end of percutaneous nephrolithotomy (PCNL), and to evaluate predictors for inaccurate estimation. MATERIALS AND METHODS: A prospective study conducted between 2010 and 2015. Surgeon's impression, categorized as "insignificant residual fragments (RFs)" (<4 mm) or "significant RF" (>4 mm), was recorded at the end of PCNL, and was compared with postoperative imaging results, using CT or a combination of US and kidney, ureter, and bladder radiograph for radiolucent and radio-opaque stones, respectively. The association between missed significant RF and the patient and operative variables was evaluated with univariable and multivariable logistic regression analysis. RESULTS: The study cohort included 312 patients. Significant RFs were found in 75 (24%) patients, comprising all 22 patients in whom RFs were suspected (100%) and 53 patients who were considered stone free (18.6%). The sensitivity, specificity, and positive and negative predictive value of the surgeon's estimation for the absence of significant RFs were 100%, 39%, 0.83, and 1 for radiopaque stones, and 100%, 12.5%, 0.75, and 1 for radiolucent stones. On multivariate analysis, multiple stones (OR = 4, 95% CI: 1.85-8.7, p < 0.001) and cumulative stone size (OR = 1.04, 95% CI: 1.02-1.1, p = 0.005) were independent predictors for missed RFs. CONCLUSION: In approximately fifth of the patients undergoing PCNL, the surgeon's impression of "insignificant RF" may be inaccurate. Stone size and number were independently associated with higher miss rate. These data should be shared with the patients when the postoperative drainage method and the option for an auxiliary procedure are discussed.

Endovascular interventions of juxtaanastomotic stenoses and thromboses of hemodialysis arteriovenous fistulas.

PURPOSE: To assess the primary and secondary patency rates for juxtaanastomotic stenoses, with or without superimposed thromboses, of arteriovenous hemodialysis fistulas treated with angioplasty and to compare it with National Kidney Foundation Dialysis Outcomes Quality Initiative treatment guidelines for stenosed and occluded arteriovenous fistulas (50% primary patency rate at 12 months). MATERIALS AND METHODS: This study was a retrospective analysis, covering a period of 5(1/2) years. Forty-three hemodialysis patients were referred due to secondary fistula dysfunction, and angiography was diagnostic of a juxtaanastomotic lesion. Interventions consisted of standard angioplasty techniques along with thrombolysis and/or thrombectomy and intravascular stent placement as needed. Follow-up was performed at the attending dialysis center, and repeat angiography was performed as clinically required. RESULTS: Immediate postprocedural angiography demonstrated an angiographic success rate of 98%. Clinical success, with at least one session of normal dialysis, occurred in 95% of interventions. Primary patency rates at 12 months for the stenosed and stenosed/thrombosed fistulas were 56% and 64%, respectively. Secondary patency rates at 12 months were 64% and 63%, respectively. Half of the stenosed fistulas were patent at 1.5 years, 28% were patent at 4 years, and 13% remained patent at 6 years. No major complications were documented. Four minor complications, which did not require therapy, were noted. CONCLUSIONS: The results achieved are comparable to those reported for interventions at nonjuxtaanastomotic sites and exceed those quoted by the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Angioplastic interventions in a juxtaanastomatic area of arteriovenous fistulas are safe, promote prolonged patency, and postpone the need for surgical intervention or creation of a new fistula.