Reduced-size liver transplantation in children

Additional techniques adopted for major vascular anastomoses during orthotopic liver transplantation

Of 372 patients who underwent liver transplants between January 1985 and March 1995, 7 required variations in vascular anastomoses due to discrepancies in the size-match of the donor and recipient vessels, the presence of a thrombosed hepatic artery or portal vein, or complete absence of the portal vein. The techniques described herein enabled us to perform successful transplantation in all patients. Although rethrombosis of the portal vein developed in one patient after a third transplant, this patient remains clinically well. The use of an operating microscope and the harvesting of an extended length of donor superior mesenteric vein or vascular grafts of the donor iliac or saphenous vessels, for potentially difficult transplants, are invaluable techniques.

Infant pediatric liver transplantation results equal those for older pediatric patients

METHODS

From July 1984 to July 1995, 99 pediatric patients underwent 127 orthotopic liver transplants (OLT) at the University of Wisconsin Children's Hospital. The patients were divided into four groups according to age at time of transplant: group I, 0 to 6 months (n = 20); group II, 6 to 12 months (n = 18); group III, 1 to 2 years (n = 10); and group IV, 2 to 18 years (n = 51). A retrospective analysis was performed to compare these four groups with regard to preoperative indications and demographics, intraoperative technique, complications, and survival. All patients were followed up for 2 to 13 years.

RESULTS

Biliary atresia was the most common indication for OLT in all four groups. The average waiting period varied from 19+/-18 days for group I to 44+/-64 days for group IV. Reduced-size liver transplant (I, 41%; II, 52%; III, 28%; IV, 21%), split-liver transplant (I, 0%; II, 7.4%; III, 17%; IV, 2.9%), or whole-liver transplant techniques were used. Although postoperative Intensive Care Unit stay was longer for the 0- to 6-month-old patients (I, 20+/-64; II, 7.6+/-9; III, 13+/-17; IV, 6.8+/-14 days), the total hospital stay (I, 43+/-63; II, 33+/-34; III, 32+/-20; IV, 29+/-31 days) was similar for all patients. The incidence of hepatic artery thrombosis (I, 19%; II, 19%; III, 27%; IV, 16%), biliary tract complications (I, 4.8%; II, 15%; III, 20%; IV, 14%), and retransplantation (I, 9.5%; II, 41%; III, 33%; IV, 14%) were not significantly different between the four groups. Portal vein thrombosis (I, 9.5%; II, 11%; III, 6.6; IV, 0%) and primary nonfunction (I, 9.5%; II, 7.4%; III, 0%; IV, 3.1%) occurred more frequently in the 0- to 6-month and 6- to 12-month groups, however, the 1-, 5-, and 10-year survival rate for patients (I, 85%, 79%, 79%; II, 89%, 74%, 74%; III, 80%, 80%, 80%; IV, 84%, 75%, 75%, respectively) and primary liver allografts (I, 69%, 69%, 69%; II, 72%, 72%, 63%; III, 70%, 70%, 70%; IV, 71%, 57%, 57%, respectively) were not significantly different (P = .98 and P = .83).

CONCLUSION

These results demonstrate that OLT can be effectively performed on infants of all ages and that OLT should not be delayed because of age.

Retrieval of organs for transplantation: experience of the Australian National Liver Transplantation Unit

The Australian National Liver Transplantation Unit carried out 251 multiple organ-retrieval procedures between January 1986 and December 1994: 53% were in the Sydney metropolitan area, 22% in country New South Wales and the Australian Capital Territory, 21% interstate and 4% in New Zealand; mean total procurement times were, respectively, 4 hours 57 minutes, 6 hours 58 minutes, 9 hours 20 minutes and 12 hours 20 minutes. Donor operation times steadily decreased over the nine years. One-year patient and graft survival rates were 77.1% and 70.3%, respectively; primary non-function occurred in only one case. The importance of coordination of donor organ procurement and efficient organ retrieval to the success of transplantation programs is discussed.

The infant with primary hyperoxaluria and oxalosis: from diagnosis to multiorgan transplantation

The care of an infant with primary hyperoxaluria and oxalosis is discussed. After an unheralded presentation, followed by 9 months of intensive treatment that included combined hemodialysis and peritoneal dialysis, the infant successfully underwent combined liver and kidney transplantation to definitely address both kidney failure and the underlying metabolic defect. Discussion of this approach, including ongoing input from the parents, addresses both the implications of undertaking the "best therapy" for this disease as well as the ethical dilemma passed by the decision whether to proceed or not to proceed with therapy.

The management of difficult abdominal closure after pediatric liver transplantation

Between January 1985 and December 1994, 164 liver transplantations were performed on 141 children. There were 100 reduced-size and 64 whole-liver grafts. Primary closure of the abdominal wound was not possible in 21 patients because of liver size, bowel edema, and distension. Temporary SILASTIC patch closure of the abdominal wound was used. For 16 of the 21 patients, removal of the SILASTIC patch and abdominal wall closure were completed by the seventh postoperative day; for the others, these were accomplished by the end of 2 weeks. The method is recommended when primary wound closure is not possible.

Liver transplantation in the presence of situs inversus totalis: application of reduced-size graft

Because of the anatomical features associated with situs inversus, technical difficulties will be encountered during orthotopic liver transplantation. This report describes the case of a patient with situs inversus totalis and end-stage liver disease from biliary atresia who was treated by segmental orthotopic liver transplantation. The segmental graft was safely placed in the left subphrenic space, and a suitable orientation was obtained for anastomoses of the hilar vessels. Chronic rejection necessitated retransplantation, by the same method, 19 months later. This technique has potential advantages in coping with anatomical obstacles encountered in patients with situs inversus.

Posttransplant gastrointestinal perforation in pediatric liver transplantation

The results of 119 consecutive orthotopic liver transplants in 105 pediatric recipients were reviewed to determine the incidence and management of posttransplant gastrointestinal perforation (PTGIP). Transplantation of 22 children (21%) having had no previous surgery resulted in no PTGIP. However, 15 patients (14%) had PTGIP, and this group had had a greater number of previous laparotomies than did 68 children without PTGIP (2.3 +/- 0.9 v 1.5 +/- 0.8; P < .01). Up to 31% of children with two or more previous operations developed PTGIP. The incidence of PTGIP in patients with a preexisting stoma (26%, n = 23) was not significantly different from that in children whose previous portoenterostomy consisted of a simple Roux loop (15%, n = 60). A total of 32 laparotomies were performed for 35 PTGIP. The operative procedures included an oversewing of the perforated site (n = 22), segmental bowel resection/primary anastomosis (n = 5), creation of enterostomy (n = 7), and drainage (n = 1). After these laparotomies, reperforation occurred in 31% of patients, varying from none after defunctioning enterostomy for colonic perforations to 63% after simple oversew of perforated small bowel. Bolus methylprednisolone therapy or cytomegalovirus infection did not show any link with PTGIP. Children having undergone multiple laparotomies before liver transplantation are more susceptible to PTGIP. There was no death directly caused by PTGIP, but morbidity was considerable.