Impact of Liver Ex Situ Transection on Pediatric Liver Transplantation

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation

Purpose:

To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation.

Methods:

Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge).

Results:

The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference.

Conclusion:

The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

Preoperative risk factors for intra-operative bleeding in pediatric liver transplantation

This study analyzes the preoperative risk factors for intra-operative bleeding in our recent series of pediatric LTs. Between November 2009 and November 2014, 84 consecutive isolated pediatric LTs were performed in 81 children. Potential preoperative predictive factors for bleeding, amount of intra-operative transfusions, postoperative course, and outcome were recorded. Cutoff point for intra-operative HBL was defined as intra-operative RBC transfusions ≥1 TBV. Twenty-six patients (31%) had intra-operative HBL. One-year patient survival after LT was 66.7% (CI 95%=[50.2-88.5]) in HBL patients and 83.8% (CI 95%=[74.6-94.1]) in the others (P=.054). Among 13 potential preoperative risk factors, three of them were identified as independent predictors of high intra-operative bleeding: abdominal surgical procedure(s) prior to LT, factor V level ≤30% before transplantation, and ex situ parenchymal transsection of the liver graft. Based on these findings, we propose a simple score to predict the individual hemorrhagic risk related to each patient and graft association. This score may help to better anticipate intra-operative bleeding and improve patient's management.

PEDIATRIC LIVER TRANSPLANTATION WITH EX-SITU LIVER TRANSECTION AND THE APPLICATION OF THE HUMAN FIBRINOGEN AND THROMBIN SPONGE IN THE WOUND AREA

Background

Surgical strategy to increase the number of liver transplants in the pediatric population is the ex-situ liver transection (reduction or split). However, it is associated with complications such as hemorrhage and leaks. The human fibrinogen and thrombin sponge is useful for improving hemostasis in liver surgery.

Aim

Compare pediatric liver transplants with ex-situ liver transection (reduction or split) with or without the human fibrinogen and thrombin sponge.

Methods

Was performed a prospective analysis of 21 patients submitted to liver transplantation with ex-situ liver transection with the application of the human fibrinogen and thrombin sponge in the wound area (group A) and retrospective analysis of 59 patients without the sponge (group B).

Results

The characteristics of recipients and donors were similar. There were fewer reoperations due to bleeding in the wound area in group A (14.2%) compared to group B (41.7%, p=0.029). There was no difference in relation to the biliary leak (group A: 17.6%, group B: 5.1%, p=0.14).

Conclusion

There was a lower number of reoperations due to bleeding of the wound area of ​​the hepatic graft when the human fibrinogen and thrombin sponge were used.

Outcomes of Technical Variant Liver Transplantation versus Whole Liver Transplantation for Pediatric Patients: A Meta-Analysis

Objective

To overcome the shortage of appropriate-sized whole liver grafts for children, technical variant liver transplantation has been practiced for decades. We perform a meta-analysis to compare the survival rates and incidence of surgical complications between pediatric whole liver transplantation and technical variant liver transplantation.

Methods

To identify relevant studies up to January 2014, we searched PubMed/Medline, Embase, and Cochrane library databases. The primary outcomes measured were patient and graft survival rates, and the secondary outcomes were the incidence of surgical complications. The outcomes were pooled using a fixed-effects model or random-effects model.

Results

The one-year, three-year, five-year patient survival rates and one-year, three-year graft survival rates were significantly higher in whole liver transplantation than technical variant liver transplantation (OR = 1.62, 1.90, 1.65, 1.78, and 1.62, respectively, p<0.05). There was no significant difference in five-year graft survival rate between the two groups (OR = 1.47, p = 0.10). The incidence of portal vein thrombosis and biliary complications were significantly lower in the whole liver transplantation group (OR = 0.45 and 0.42, both p<0.05). The incidence of hepatic artery thrombosis was comparable between the two groups (OR = 1.21, p = 0.61).

Conclusions

Pediatric whole liver transplantation is associated with better outcomes than technical variant liver transplantation. Continuing efforts should be made to minimize surgical complications to improve the outcomes of technical variant liver transplantation.

Clinical evaluation of hepatic transection on pediatric liver transplantation

OBJECTIVES

Liver transplantation is an effective technique in the treatment of end-stage liver disease. The aim of this study was to evaluate the impact of hepatic transection, an advanced surgical technique able to tailor size to generate two grafts to from a single donor.

MATERIALS AND METHODS

A retrospective study between January 2000 and September 2013, reviewing 91 pediatric patients who underwent 96 liver transplants from deceased donors. Patients were distributed into two groups: whole organ (WO, n = 39) and transected liver grafts (TLG, n = 57). The following were evaluated: etiology, anthrophometric parameters (age, weight, height, z score weight/age, and height/age), model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD), previous surgeries, transfusion of blood components, 1-year survival rate, preoperative laboratory testing, from the second and seventh postoperative days, lactate during surgery, postoperative complications, duration of surgery, duration of cold and warm ischemia, types of biliary reconstruction, and laboratory testing of the donor.

RESULTS

The anthropometric values showed significant differences (P < .05) between the groups. The average age was 124.7 months in the WO group and 33.6 months in the TLG group (P < .0001), while the weight was 28.0 kg and 7.4 kg, respectively (P < .0001). The analysis of z score weight/age showed that the TLG had greater acute and chronic malnutrition, probably due to the etiology of liver disease, present from birth in patients as young. Red blood transfusion was higher in the TLG group (P < .0006) due to the cut surface of the graft, emphasizing the use and improvement of hemostatic techniques.

CONCLUSION

Despite differences between the groups, clinical and surgical complications were similar, showing that liver transection injury didn't change the results of transplantation. There was no impact on liver function, graft, or 1-year patient survival after liver transection. Second postoperative lactate is a predictive factor of death. Transection liver transplantation is an effective method as an alternative to pediatric liver transplantation.