Pediatric Transplantation. 2018;e13293. wileyonlinelibrary.com/journal/petr | 1 of 5 https://doi.org/10.1111/petr.13293 © 2018 Wiley Periodicals, Inc. 1 | INTRODUCTION Anastomotic BO is a common complication of pediatric LT, particularly for split liver, with an incidence of 10%‐35% and high morbidity. 1‐3 If not treated, BO could evolve toward secondary biliary cirrhosis and re‐transplantation. 1 Because the endoscopy is generally infeasible in the Roux‐en‐Y, percutaneous interventional radiology management is usually the safest and most effective approach to avoid surgical revi‐ sion of a stenotic bilio‐enteric anastomosis. 1‐4 We report the case of a child with partial LT and severe occlusion of the HJ non‐crossable with conventional interventional radiological techniques. A new bilio‐ digestive communication was performed via percutaneous transhep‐ atic approach using the transseptal puncture system. Received: 6 May 2018 | Revised: 26 July 2018 | Accepted: 27 August 2018 DOI: 10.1111/petr.13293 CASE REPORT Successful percutaneous transhepatic recanalization of a completely obstructed hepatico‐jejunal anastomosis in a child with liver transplantation: Unusual employment of the transseptal puncture system Guglielmo Paolantonio 1 | Andrea Pietrobattista 2 | George Koshy Parapatt 1 | Daniela Liccardo 2 | Gian Luigi Natali 1 | Manila Candusso 2 | Marco Spada 3 | Massimo Rollo 1 | Paolo Tomà 4 Abbreviations: ALT, alanine transaminase; AST, aspartate transaminase; BO, biliary ob‐ struction; CE‐MDCT, contrast‐enhanced multidetector‐row computed tomography; EBD, external biliary drainage; EIBD, external‐internal biliary drainage; F, French; HJ, hepatico‐ jejunostomy; LFTs, liver function tests; LT, liver transplantation; TPS, transseptal puncture system; US, ultrasound; γ‐GT, gamma glutamyl transpeptidase. 1 Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy 2 Hepatology and Gastroenterology Unit, Department of Specialist Pediatrics, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy 3 Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy 4 Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy Correspondence Guglielmo Paolantonio, Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy. Emails: guglielmo.paolantonio@opbg.net and guglielmo.paolantonio@gmail.com Abstract Stenosis of the HJ is a common complication of pediatric split LT with high morbidity and possible evolution to secondary biliary cirrhosis and re‐transplantation if not treated. Because the endoscopy is generally infeasible in the Roux‐en‐Y, percutane‐ ous interventional radiology management is usually the safest and most effective approach to avoid surgical revision of a stenotic bilio‐enteric anastomosis. We pre‐ sent the case of a child with acute onset of cholestasis 7 months after left lateral segment partial LT due to occlusion of the HJ. The biliary stricture was found to be non‐crossable with conventional interventional radiological techniques. The obstruc‐ tion was resolved creating a new bilio‐digestive communication via percutaneous transhepatic approach using the TPS. This device is usually employed by the inter‐ ventional cardiologist to perform some procedures requiring the direct access to the left atrium through interatrial septal puncture. In conclusion, percutaneous transhe‐ patic recanalization of the hepato‐jejuno anastomosis is a rare but feasible and valu‐ able procedure alternative to the surgical resolution even in small infants. Although few cases have been reported in literature, it has to be considered an additional treatment option when the conventional approaches fail. KEYWORDS biliary obstruction, hepatico‐jejunal anastomosis, liver transplantation, transhepatic recanalization, transseptal puncture system