Publications by authors named "Tamir A Miloh"

12 Publications

  • Page 1 of 1

North American biliary stricture management strategies in children post liver transplant: multicenter analysis from the SPLIT Registry.

Liver Transpl 2021 Nov 27. Epub 2021 Nov 27.

Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

Background: Biliary strictures affect 4-12% of pediatric liver transplants (P-LT). Biliary strictures can contribute to graft loss if left untreated, however there remains no consensus on the best course of treatment. Study objectives included analyses of outcomes associated with biliary stricture management strategies via PTC, ERCP or surgery.

Methods: We identified P-LT recipients (2011-2016) with biliary strictures from the Society of Pediatric Liver Transplantation (SPLIT) registry and retrieved imaging, procedural and operative reports from individual centers. Sub-analyses were performed to specifically evaluate PTC and ERCP for "Optimal Biliary Outcome" (OBO), defined as survival with stricture resolution without recurrence or surgery.

Results: 113 children with median 3.9 years of follow-up had strictures diagnosed 100 days (IQR 30, 290) post LT; 81% were isolated anastomotic strictures. Stricture resolution was achieved in 92% within 101 days, more frequently with isolated anastomotic strictures (96%). 20% of strictures recurred, more commonly in association with hepatic artery thrombosis (32%). Patient and graft survival at 1- and 3-years were 99%, 98% and 94%, 92% respectively. In a subgroup analysis of 79 patients with extrahepatic strictures managed by PTC/ERCP: 59% achieved OBO following a median 4 PTC, and 75% following a median 3 ERCP (P=0.0003). Among patients with OBO, those with ERCP had longer time intervals between successive procedures (41, 47, 54, 62, 71 days) than for PTC (27, 31, 36, 41, 48 days; P=0.0006).

Conclusions: Allograft salvage was successful across all interventions. Stricture resolution was achieved in 92%, with 20% risk of recurrence. Resolution without recurrence was highest in patients with isolated anastomotic strictures and without HAT.
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http://dx.doi.org/10.1002/lt.26379DOI Listing
November 2021

The pediatric solid organ transplant experience with COVID-19: An initial multi-center, multi-organ case series.

Pediatr Transplant 2021 05 9;25(3):e13868. Epub 2020 Nov 9.

Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

The clinical course of COVID-19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi-center, multi-organ cohort analysis of COVID-19-positive transplant recipients ≤ 18 years at time of transplant. Data were collected via institutions' respective electronic medical record systems. Local review boards approved this cross-institutional study. Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. Six were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n = 12 (46%)), fever (n = 9 (35%)), dry/sore throat (n = 3 (12%)), rhinorrhea (n = 3 (12%)), anosmia (n = 2 (8%)), chest pain (n = 2 (8%)), diarrhea (n = 2 (8%)), dyspnea (n = 1 (4%)), and headache (n = 1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post-transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Our multi-institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID-19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required.
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http://dx.doi.org/10.1111/petr.13868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537006PMC
May 2021

Measles, mumps, rubella (vaccine) and varicella vaccines in pediatric liver transplant: An initial analysis of post-transplant immunity.

Pediatr Transplant 2019 08 20;23(5):e13490. Epub 2019 Jun 20.

Section of Infectious Diseases, Transplant Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.

Varicella and measles infection represents a significant source of morbidity and mortality for pediatric LT recipients. We evaluated the prevalence and correlates of post-transplant immunity in pediatric LT recipients previously immunized against measles (n = 72) and varicella (n = 67). Sixteen of seventy-two (22%) patients were measles non-immune, and 42/67 (63%) were varicella non-immune after LT. Median time from LT to titers for measles and varicella was 4.0 and 3.3 years, respectively. In the measles cohort, non-immune patients received fewer pretransplant vaccine doses (P = 0.026) and were younger at both time of vaccination (P = 0.006) and LT (P = 0.004) compared with immune patients. Upon multivariable analysis, weight > 10 kg at LT (OR 5.91, 95% CI 1.27-27.41) and technical variant graft (OR 0.07, 95% CI 0.01-0.37) were independently, significantly associated with measles immunity. In the varicella cohort, non-immune patients received fewer pretransplant vaccine doses (P = 0.028), were younger at transplant (P = 0.022), and had less time lapse between their last vaccine and transplant (P = 0.012) compared with immune patients. Upon multivariate analysis, time > 1 year from last vaccine to LT was independently, significantly associated with varicella immunity (OR 3.78, CI 1.30-11.01). This study demonstrates that non-immunity to measles and varicella is a prevalent problem after liver transplantation in children and identifies 3 unique risk factors for non-immunity in this high-risk population.
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http://dx.doi.org/10.1111/petr.13490DOI Listing
August 2019

Surgical outcomes in Alagille syndrome and PFIC: A single institution's 20-year experience.

J Pediatr Surg 2018 May 9;53(5):976-979. Epub 2018 Feb 9.

Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States. Electronic address:

Background: Alagille Syndrome (AGS) and Progressive Familial Intrahepatic Cholestasis (PFIC) are rare pediatric biliary disorders that lead to progressive liver disease. This study reviews our experience with the surgical management of these disorders over the last 20years.

Methods: We retrospectively reviewed the records of children diagnosed with AGS or PFIC from January 1996 to December 2016. Data collected included demographics, surgical intervention (liver transplant or biliary diversion), and complications.

Results: Of 37 patients identified with these disorders, 17 patients (8 AGS,9 PFIC) underwent surgical intervention. Mean postsurgical follow-up was 6.9±4.7years. Liver transplantation was the most common procedure (n=14). Two patients who were initially thought to have biliary atresia underwent hepatoportoenterostomy, but were subsequently shown to have Alagille syndrome. Biliary diversion procedures were performed in 3 patients (external n=1, internal n=2). PFIC patients tended to be older at the time of liver transplant compared to AGS (4.3±3.9years vs. 2.4±1.1years, p=0.25). The AGS patient with external diversion had resolution of symptoms and no complications (follow-up: 12.5years). Both PFIC patients with internal diversion (conduit between gallbladder and transverse colon) had resolution of pruritus and no progression of liver disease (follow-up: 3.8 and 4.5years).

Conclusions: AGS and PFIC are rare biliary disorders in children which result in pruritus and progressive liver failure. Three patients in this series (8%) benefited from biliary diversion for control of pruritus and have not to date required transplantation for progressive liver disease. 38% underwent transplantation owing to pruritus and severe liver dysfunction.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.026DOI Listing
May 2018

Trends in pediatric liver transplant donors and deceased donor circumstance of death in the United States, 2002-2015.

Pediatr Transplant 2018 05 30;22(3):e13156. Epub 2018 Jan 30.

Michael E DeBakey Department of Surgery, Division of Abdominal Transplantation, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.

While much of the discussion regarding expanding the donor pool for pediatric liver transplantation has surrounded the use of technical variant grafts, little attention has been directed toward changes in the deceased donor population. The aim of this study was to investigate trends in the circumstance of the death of deceased donors used for pediatric liver transplantation. All pediatric liver transplant recipients transplanted between 2002 and 2015 were identified in the UNOS database and were categorized based on the donor circumstance of death. There was no significant correlation between year of transplantation and number of pediatric liver transplants performed, pediatric donors, split livers, or living donors. There was a significant downward trend in donors from motor vehicle fatalities and an upward trend in suicide, non-MVA, and death due to natural causes. There was also an upward trend in drowning, one of the most common mechanisms of death among non-MVA in 2015. While the number of donors who died in MVA has fallen, the number of deceased donors who died from suicide, natural causes, and non-MVA, especially drowning, has increased, maintaining the overall number of pediatric deceased donor livers transplanted.
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http://dx.doi.org/10.1111/petr.13156DOI Listing
May 2018

Viral upper respiratory infection at pediatric liver transplantation is associated with hepatic artery thrombosis.

Liver Transpl 2017 11;23(11):1477-1481

Gastroenterology, Hepatology and Nutrition Division of Pediatric Hepatology and Liver Transplant Medicine, Texas Children's Hospital, Houston, TX.

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http://dx.doi.org/10.1002/lt.24866DOI Listing
November 2017

Portosystemic shunt as a bridge to liver transplantation in infants: A comparison of two techniques.

Pediatr Transplant 2017 Jun 13;21(4). Epub 2017 Mar 13.

Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA.

Portosystemic shunts can serve as a bridge to liver transplantation in patients with end-stage liver disease by providing portal decompression to treat life-threatening variceal bleeding and prevent recurrent episodes until an organ becomes available. The conventional TIPS procedure, however, is technically challenging to perform in infants due to the small size of their intrahepatic vasculature. We report two cases of emergent creation of portosystemic shunts as a bridge to liver transplantation in infants with life-threatening variceal bleeding using a conventional TIPS technique in the first case and a percutaneous DIPS technique in the other. Both procedures were successful at reducing the portosystemic pressure gradient and preventing further variceal bleeds until a liver transplant could be performed. The novel percutaneous DIPS procedure is a valuable alternative to the conventional TIPS in infants, as it is better suited for small or challenging intrahepatic vascular anatomy.
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http://dx.doi.org/10.1111/petr.12915DOI Listing
June 2017

Recommendations for Probiotic Use--2015 Update: Proceedings and Consensus Opinion.

J Clin Gastroenterol 2015 Nov-Dec;49 Suppl 1:S69-73

*Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT †Harvard Medical School ‡Mucosal Immunology and Biology Research Center, Massachusetts General Hospital for Children, Boston ††Department of Transplantation, Lahey Hospital and Medical Center, Burlington, MA §Dairy & Food Culture Technologies, International Scientific Association of Probiotics and Prebiotics (ISAPP), Sacramento **Department of Medicine, University of California, San Diego, San Diego, CA ∥Departments of Internal Medicine, Academic Medical Center and VUmC, Amsterdam, The Netherlands ¶Wallenberg Laboratory, Gothenborg University, Gothenburg, Sweden #Minnesota Gastroenterology P.A., Minnesota, MN ‡‡Pediatric Liver & Liver Transplant, Gastroenterology/Transplantation, Phoenix Children's Hospital ∥∥Mayo Clinic, Phoenix §§Department of Pediatrics, University of Arizona, Tucson, AZ ¶¶Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples ##Clinical Hepato-Gastroenterology Unit, Division of Gastroenterology & Digestive Endoscopy, S. Raffaele University Hospital, Milano, Italy ***Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada †††Department of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill, NC ‡‡‡The Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, TX §§§Department of Medicine, Weill Cornell Medical College, New York ∥∥∥Department of Medicine and Surgery, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

This paper describes the consensus opinion of the participants in the 4th Triennial Yale/Harvard Workshop on Probiotic Recommendations. The recommendations update those of the first 3 meetings that were published in 2006, 2008, and 2011. Recommendations for the use of probiotics in necrotizing enterocolitis, childhood diarrhea, inflammatory bowel disease, irritable bowel syndrome and Clostridium difficile diarrhea are reviewed. In addition, we have added recommendations for liver disease for the first time. As in previous publications, the recommendations are given as A, B, or C ratings.
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http://dx.doi.org/10.1097/MCG.0000000000000420DOI Listing
July 2016

Benign liver masses and lesions in children: 53 cases over 12 years.

Isr Med Assoc J 2011 Sep;13(9):542-7

Pediatric Hepatology, Division of Pediatric Hepatology and RMTI, Department of Surgery, Mount Sinai School of Medicine, New York City, NY 10029, USA.

Background: Primary liver masses in children may require intervention because of symptoms or concern about malignant transformation.

Objectives: To review the management and outcome of benign liver masses in children.

Methods: We conducted a retrospective chart review of children with liver masses referred to our institution during the period 1997-2009.

Results: Benign liver masses were identified in 53 children. Sixteen of these children (30%) had hemangioma/infantile hepatic hemangioendothelioma (IHH) and 15 (28%) had focal nodular hyperplasia. The remainder had 6 cysts, 4 hamartomas, 3 nodular regenerative hyperplasia, 2 adenomas, 2 vascular malformations, and one each of polyarteritis nodosa, granuloma, hepatic hematoma, lymphangioma, and infarction. Median age at presentation was 6 years, and 30 (57%) were female. Masses were initially noticed on imaging studies performed for unrelated symptoms in 33 children (62%), laboratory abnormalities consistent with liver disease in 11 (21%), and palpable abdominal masses in 9 (17%). Diagnosis was made based on characteristic radiographic findings in 31 (58%), but histopathological examination was required for the remaining 22 (42%). Of the 53 children, 27 (51%) were under observation while 17 (32%) had masses resected. Medications targeting masses were used in 9 (17%) and liver transplantation was performed in 4 (8%). The only death (2%) occurred in a child with multifocal IHH unresponsive to medical management and prior to liver transplant availability.

Conclusions: IHH and focal nodular hyperplasia were the most common lesions. The majority of benign lesions were found incidentally and diagnosed radiologically. Expectant management was sufficient in most children after diagnosis, although surgical intervention including liver transplant was occasionally necessary.
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September 2011

Developmental and disease-related influences on self-management acquisition among pediatric liver transplant recipients.

Pediatr Transplant 2011 Dec 4;15(8):819-26. Epub 2011 Oct 4.

Department of Psychology, Fordham University, Bronx, NY 10458, USA.

Pediatric LT recipients are vulnerable to disruptions in their healthcare management and transitioning to self-managed care. This study aimed to examine whether age at transplant and indication for transplant (acute vs. chronic liver disease) influence later self-management skills. Sixty-three LT recipients, aged 14 and older (M = 17.68, s.d. = 3.01), were recruited and asked to complete a healthcare management survey, the Developmentally Based Skills Checklist, adapted for transplant patients, listing 22 behaviors that medically ill adolescents should progressively master. While there were no significant differences between those who received an LT owing to an acute disease vs. those who received an LT owing to a chronic disease, the age at which patients received their transplant did yield significant results, although, overall, these findings were attenuated by current age. However, our findings indicated that males transplanted at a younger age struggled with mastery over their healthcare responsibilities relative to males transplanted later and females in both age groups. There are many possible reasons why the experience of transplant at a younger age could negatively affect or derail healthcare transitions. Future research is necessary to further untangle this relationship; yet, it seems as though longer time living with LT may make transition harder for families.
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http://dx.doi.org/10.1111/j.1399-3046.2011.01582.xDOI Listing
December 2011

Hepatopulmonary syndrome in children - is conventional liver transplantation always needed?

Clin Transplant 2011 Nov-Dec;25(6):849-55. Epub 2010 Dec 22.

Division of Hepatology, Department of Pediatrics and Recanati Miller Transplant Institute, The Mount Sinai School of Medicine, New York, NY, USA.

Background: Hepatopulmonary syndrome (HPS) is the association of liver disease, hypoxemia, and intrapulmonary vascular dilatations. There are little data on the management of HPS in children other than conventional orthotopic liver transplantation (OLT).

Aims: To describe the patient characteristics, mode of diagnosis, treatment, and outcomes of children with HPS at our center.

Methods: Retrospective review of patients diagnosed with HPS between 1997 and 2007 after IRB approval.

Results: There were 10 patients, six females; median age at diagnosis of HPS was 12 yr. Six with cirrhosis underwent OLT and had subsequent resolution of HPS and are stable at last follow-up. Of the remaining four, two had cirrhosis. HPS resolved without conventional OLT in the following four patients: hepatitis C after antiviral treatment, biliary atresia with portal hypertension after transjugular intrahepatic portosystemic shunting, Abernethy syndrome after auxiliary partial OLT, and in a child with splenic vein thrombosis after splenectomy.

Conclusions: Our series shows resolution of HPS in all patients and 100% survival after conventional OLT. Four children had resolution of HPS after surgical or medical treatments other than conventional OLT. Careful review of clinical status and underlying pathophysiology and anatomy at diagnosis of HPS should inform treatment decisions.
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http://dx.doi.org/10.1111/j.1399-0012.2010.01378.xDOI Listing
May 2012

Roux-en-Y loop varices in children with portal hypertension after liver transplantation: an unusual cause of "obscure" gastrointestinal bleeding.

Pediatr Transplant 2011 Dec 1;15(8):E156-61. Epub 2010 Jul 1.

Division of Pediatric Hepatology, Mount Sinai Medical Center, New York, NY, USA.

PHALT may result from graft dysfunction, portal vein thrombosis, arterio-venous fistulas and can lead to GIB, commonly from bleeding esophageal varices. We present three children with GIB requiring multiple blood transfusions that were diagnosed with RY Loop bleeding. Routine EGD, colonoscopy, and CE failed to reveal the bleeding source. However, enteroscopy revealed large varices at the site of hepaticojejunostomy anastomosis in all. Our experience demonstrates that RY loop varices in children with PHALT are a rare and treatable cause of obscure GI bleeding.
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http://dx.doi.org/10.1111/j.1399-3046.2010.01351.xDOI Listing
December 2011
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