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ProgrammeHighlight topicsStents in children: pro/cons, when, how and where

Hepatobiliary interventions in children – Stents in children: pro/cons, when, how and where


Three reasons to watch my lecture on demand

  1. You will learn the main indications for biliary interventions in newborns and children
  2. You will understand the importance of imaging in the diagnosis and treatment planning
  3. You will be presented an overview of percutaneous techniques with some practical tips and focus on new strategies of biliary stenting

Dr. Paolo Marra
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Biliary interventions are among the most common non-vascular procedures every interventional radiologist should be familiar with. While they are mainly performed in the adult population to manage hepatobiliopancreatic malignancies, in paediatric patients the indications to perform transhepatic biliary procedures are usually related to benign conditions that can be subdivided into two main categories: strictures and leakages. Biliary strictures are the most common source of morbidity after liver transplantation, as they may occur in up to 45% of patients and hamper graft survival [1]. Other relatively rare diseases that may require percutaneous biliary interventions in the paediatric population include obstructive neonatal cholestasis, congenital bile duct malformations, intrahepatic lithiasis, post-surgical complications and liver tumours [2]. Autoimmune cholangitis could be considered a rare indication only in case of failure of medical therapy and presence of dominant stenosis. It is worth remarking that biliary interventions rely on a multidisciplinary approach.

Fig.1: Percutaneous cholangiography image of a typical perianastomotic stenosis after split liver transplantation in a 9-year-old female
Fig.2: Percutaneous cholangiography images of a 2 m.o. baby with obstructive jaundice. Pre-papillary stones (arrow) were fragmented by bilioplasty and pushed in the duodenum

Before performing a percutaneous transhepatic biliary intervention, the operating IR should be aware of the exact anatomy of the biliary tract and liver vascular system, taking into account anatomic variants to choose the best approach and minimize the risks of complications. Moreover, the possibility of accessing the biliary tract though the endoscopic route must be previously considered: rendez-vous strategies could significantly improve the benefit-risk balance.

Imaging is crucial both for diagnosis and preoperative planning, as it should provide the following information:

  • characterization of the biliary disease requiring intervention
  • the exact location of the biliary issue, especially in case of a multifocal disease
  • anatomical peculiarities that may hinder the procedure

Ultrasound (US)-based techniques, including B-mode and Color-Doppler, are the key tools for the assessment of the paediatric liver and biliary tract. They are widely available, radiation-free and provide the highest spatial and temporal resolution. However, US imaging is hampered by a limited panoramic view. When US findings are not conclusive or doubtful, magnetic resonance cholangiopancreatography (MRCP) should be performed. Besides providing high-resolution and panoramic images, MR is supported by the use of hepatocyte specific contrast agents (HSCA) which add functional information to the morphological assessment of MRCP [3]. Cholestasis is associated with reduced HSCA uptake that, in case of intrahepatic strictures, may show up as sectorial or segmental liver parenchyma hypointensity. The diagnosis of biliary leaks may rely on the hepatobiliary excretion phase of HSCAs to exactly localize the source of the bile extravasation with MRCP [4]. This is crucial to guide the treatment, since anastomotic leaks should be managed by percutaneous biliary drainage, while biliary leaks from the cut liver surface may heal spontaneously or require surgery.

Fig.3: MR images of a 8 y.o. male who developed cholestasis after split liver transplantation. On the left, the T2w image shows a sectorial dilation of the biliary ducts (arrow) due to intrahepatic stenosis; on the right, the corresponding T1w image acquired in the delayed hepatobiliary phase shows gradient opacification of the liver parenchyma due to sectorial cholestasis (area within the white line)

To properly perform PTC, the paediatric interventional radiologist should operate in accordance with standard of practice recommendations [5] aimed to minimize the risk of periprocedural complications such as bleeding and infections. Different protocols in terms of the duration of biliary stenting have been reported, varying from 3 to 24 months, depending on the type and aetiology of the stenosis and the need for repeat balloon angioplasty [2]. However, in babies and children, the tolerance of external biliary drainages could be very limited, requiring the development of new strategies, such as stenting without external drainage catheters.

The most important and recent developments in this field are represented by the increasing clinical adoption of biodegradable biliary stents [6, 7]. Currently, there are three different devices on the market, one self-expandable, one balloon-expandable, and one non-expandable. They may provide a twofold advantage: they can be used to replace internal-external biliary drainages, reducing the infectious risk and discomfort, and prolong the effects of the bilioplasty [8].

Fig.4: Percutaneous cholangiography images of a 2 y.o. male who developed hepatico-jejunostomy stricture after split liver transplantation. The stricture was treated by transhepatic bilioplasty and placement of two biodegradable non-expandable biliary stents with the “side-by-side” technique
Fig.5: Percutaneous cholangiography images of a 7 y.o. female who developed hepatico-jejunostomy stricture after surgical removal of a choledochal cyst. The stricture involves both the left and the right biliary ducts, requiring a bilateral approach. Two self-expandable biodegradable stents were placed and post-dilated with the “kissing-balloon” technique

While the treatment of benign biliary strictures may rely on effective strategies, refractory non anastomotic strictures could be challenging, finally leading to biliary cirrhosis. Although it has not been shown to prolong graft survival, the use of metal stents in case of advanced biliary cirrhosis may be considered as a bridge to retransplantation, to palliate cholestatic symptoms avoiding the use of poorly tolerated external drainage catheters.

Fig.6: Percutaneous cholangiography images of a 3 y.o. female who developed severe cholestasis after split liver transplantation due to complex strictures refractory to multiple cycles of bilioplasty. Note the dual percutaneous access from segment 3 and segment 2, due to the presence of two separate hepatico-jejunostomies. Two self-expandable metal stents were placed to palliate cholestatic symptoms as a bridge to retransplantation


Paolo Marra

ASST Papa Giovanni XXIII Hospital, Bergamo/IT

Dr. Marra completed his radiology training at San Raffaele Hospital, Milan, focusing on hepatobiliary and pancreatic diagnostic and interventional radiology and experimental preclinical imaging. His work has included advanced clinical and preclinical liver and pancreatic imaging and interventions, with independent research projects. Since October 2019, he has been employed as a general consultant radiologist at ASST Papa Giovanni XXIII Hospital where he has been the contact person for ultrasound and interventional radiology since 2020. Dr. Marra is a tutor at the School of Medicine and Surgery of the University of Milano-Bicocca, giving lectures on several topics regarding interventional radiology in adults and paediatric patients.
Besides general responsibilities in multimodality imaging, including thoraco-abdominal CT and MR examinations, Dr. Marra is dedicated to interventional radiology in adults and paediatric patients, covering all thoraco-abdominal pathologies, including peri-surgical assessment, trauma, oncology, vascular, and chronic diseases. His main activities involve the diagnosis and interventional management of complications of liver transplantations, dealing with more than 400 paediatric transplants in the last twenty years. Dr. Marra regularly runs multidisciplinary meetings for lung cancer, liver and biliary tract cancers, and adult and paediatric hepatology and liver transplantations. His professional goal is to improve the quality of IR work, optimizing organizational aspects, and defining operational standards. Dr. Marra does his best work in a team with a multidisciplinary perspective and is involved in various international research projects dedicated to paediatric liver diseases, such as the PORTAL registry, the HEPATIC registry, and the IRCPSS registry. Dr. Marra is committed to professional development, research, and teaching colleagues in training.



  1. Dulcetta L, Marra P, Carbone FS, et al. Biliary complications in pediatric liver transplantation: findings of percutaneous transhepatic cholangiography in a large single-center cohort. Pediatr Radiol 2022;52:1061-74
  2. Franchi-Abella, S., Cahill, A.M., Barnacle, A.M. et al. Hepatobiliary Intervention in Children. Cardiovasc Intervent Radiol 2014;37, 37–54
  3. Geisel D, Lüdemann L, Hamm B, et al. Imaging-Based Liver Function Tests–Past, Present and Future. Rofo 2015;187:863-71
  4. Lim CJ, Hong K, Lee JM, et al. Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation. Ann Hepatobiliary Pancreat Surg 2021;25:39-45
  5. Das M, van der Leij C, Katoh M, et al. CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting. Cardiovasc Intervent Radiol 2021;44:1499-509
  6. Battistel M, Senzolo M, Ferrarese A, et al. Biodegradable Biliary Stents for Percutaneous Treatment of Post-liver Transplantation Refractory Benign Biliary Anastomotic Strictures. Cardiovasc Intervent Radiol 2020;43:749-55
  7. Mauri, G., Michelozzi, C., Melchiorre, F. et al. Benign biliary strictures refractory to standard bilioplasty treated using polydoxanone biodegradable biliary stents: retrospective multicentric data analysis on 107 patients. Eur Radiol 2016;26, 4057–4063
  8. Marra P, Carbone FS, Dulcetta L, et al. A New Biodegradable Stent to Improve the Management of Biliary Strictures in Pediatric Split Liver Transplantation. Cardiovasc Intervent Radiol 2022;45:867-72