Percutaneous Transhepatic Treatment for Obstructing Retained Surgical Biliary Stents After Pediatric Liver Transplantation Without Placement of Biliary Drain

**Background:** Pediatric liver transplantation has improved survival rates, but biliary complications remain a significant cause of morbidity. Retained surgical biliary stents can cause obstruction, typically managed by percutaneous transhepatic stent retrieval followed by placement of an internal–external biliary drain for several weeks to months. This case report presents a novel technique that avoids drain placement after stent removal.

**Methods:** A 16-month-old, 8.7 kg female with syndromic biliary atresia had undergone left lateral segment liver transplantation at 8 months of age with two duct anastomoses over stents created from shortened 3.5 French feeding tubes. One stent displaced into the bowel and was excreted; the other was retained, causing persistently elevated alkaline phosphatase and moderate biliary dilatation on ultrasound. The patient was afebrile and nontoxic. Under general anesthesia and prophylactic antibiotics, a dilated peripheral bile duct was accessed using a 22-gauge needle, 0.018″ Nitrex wire, and a 5 Fr sheath. Initial cholangiogram confirmed obstruction at the retained stent. A 10-mm, 4 Fr gooseneck snare was passed over the wire, and the stent was snared at its distal end and advanced into the roux limb alongside the wire. Cholangioplasty was not needed. Completion cholangiogram showed patent ducts with the stent in the roux component. No biliary drain was placed. A Gel foam pledget tract embolization was performed during sheath removal for hemostasis. Procedure time was 61 minutes, fluoroscopy time 6.3 minutes, and dose 28.8 mGy. The patient was admitted overnight; follow-up ultrasound the next day showed resolution of biliary dilation.

**Key Results:** The retained biliary stent was successfully advanced into the bowel using a snare technique through a small (5 Fr) sheath without requiring cholangioplasty or biliary drain placement. The completion cholangiogram demonstrated a patent bilioenteric anastomosis. The patient's biliary dilation resolved on ultrasound the following day. No complications were reported.

**Clinical Implications:** This technique offers a potential alternative to standard management of retained biliary stents in pediatric liver transplant recipients. By avoiding biliary drain placement, it may eliminate drain-related complications such as obstruction, infection, dislodgement, and impaired quality of life from discomfort and prolonged catheter care. The authors suggest this approach is suitable for non-cholangitic patients with resolution of obstruction on completion cholangiogram. Further studies are needed to confirm safety and efficacy in larger cohorts.