Liver Transplantation, Including the Concept of Reduced-size Liver Transplants in Children

Broelsch, Christoph E.; Emond, Jean C.; Thistlethwaite, J. Richard; Whitington, Peter F.; Zucker, Aaron R.; Baker, Alfred L.; Aran, Peter; Rouch, Dale; Lichtor, J. Lance

doi:10.1097/00000658-198810000-00003

Cited by 185 publications

(57 citation statements)

References 20 publications

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“…University of Wisconsin solution enhanced the safe cold ischemia time and contributed to the improvements in reduced-size liver transplantation, including splitting the liver for two recipients. [35][36][37][38][39][40] The continuing improvement in surgical techniques, 3,38,41 immunosuppressive drugs, 4,6,29,33 experience with reduced-size grafts, 38 and better monitoring and follow-up of patients led not only to improved survival posttransplantation in children but also to a decrease in posttransplantation complications requiring ReTx. This study shows a significant reduction in primary graft failure and the necessity for ReTx with increasing experience.…”

Section: Discussionmentioning

confidence: 99%

Outcome of liver retransplantation in children

et al. 1999

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Irreversible liver graft failure is a life-threatening complication. We reviewed the first 200 pediatric liver transplantations in Birmingham. Forty-one children developed primary graft failure, 9 of whom developed secondary graft failure. The main indications for graft failure were primary nonfunction (PRNF; 8 patients), vascular complications (VASC; 23 patients), and chronic rejection (CHRE; 19 patients). Thirty-two children underwent retransplantation (ReTx) (21 children received reduced grafts; 11 children, whole hepatic grafts). Patient survival was significantly worse for retransplant recipients compared with children receiving a single graft (63% v 76.5% actuarial patient survival at 1 year; P F .05). Primary graft 1-year actuarial survival was 74% in first grafts compared with 47% for regrafts (P F .05), but improved with time. The graft 1-year survival rate was 55% for whole grafts and 45% for reduced and/or split grafts in the first 100 grafts compared with 83% and 66% in the second 100 grafts, respectively (P F .01). Emergency ReTx within a month of transplantation was associated with more complications and a worse outcome (1-year survival rate, 37%) compared with patients who underwent ReTx later (1-year survival rate, 72%; P F .01). The incidence of primary graft failure decreased from 33% in the first 100 grafts to 16% in the second 100 grafts (P F .01), as did the incidence of PRNF, which decreased from 8% to 0% (P F .05). Although the rates of graft failure from VASC decreased from 15% to 8% (P ‫؍‬ .2) and CHRE decreased from 11% to 8% (P ‫؍‬ .6), neither reached statistical significance. The improved results overall are because of advances in surgical techniques, intensive care management, and graft preservation and refinements in immunosuppression. We conclude that ReTx for a child with primary graft failure is justified.

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Section: Discussionmentioning

confidence: 99%

Outcome of liver retransplantation in children

et al. 1999

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“…In liver transplantation in infants and small children, the number of candidates far exceeds organ availability, resulting in significant mortality of patients on waiting lists [4,23]. Possible options include the use of reduced-size or split liver grafts [1,2,7,8,12] and the use of livers from neonatal donors. Results of our experience with the use of neonatal livers for transplantation in very small pediatric recipients is herein reported.…”

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confidence: 99%

Pediatric liver transplantation from neonatal donors

Yokoyama¹,

Tzakis²,

Imventarza³

et al. 1992

Transplant Int

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Sixteen recipients of neonatal liver grafts were compared with 114 contemporaneous pediatric recipients of grafts from older donors. Graft and patient survival were worse in the neonatal group although the differences were not statistically significant. Patients with neonatal livers who had no technical complications required a longer time postoperatively to correct jaundice and a prolonged prothrombin time. These functional differences were limited to the 1st postoperative month and the end result was the same as with liver transplantation from older donors. Keywords Liver transplantation; neonatal liver -Neonatal liver; in liver transplantationThe available liver donor pool has been expanded with the use of grafts from older donors [13,19]. In liver transplantation in infants and small children, the number of candidates far exceeds organ availability, resulting in significant mortality of patients on waiting lists [4,23]. Possible options include the use of reduced-size or split liver grafts [1,2,7,8,12] and the use of livers from neonatal donors. Results of our experience with the use of neonatal livers for transplantation in very small pediatric recipients is herein reported. A minimum of 14 months follow-up is provided. Patients and methodsThe charts of all patients who underwent primary liver transplantation at the Children's Hospital of Pittsburgh under cyclosporine-steroid therapy and had liver grafts preserved with University of Wisconsin solution [7] were reviewed. These transplants took place between October 1987, when University of Wisconsin solution became available to us for clinical use, and September 1989, when FK 506 was introduced as the primary immunosuppressive agent [20]. Follow-up is provided to December 31, 1990, and consequently ranged from 14 to 39 months (median 25 months).One hundred and thirty patients were studied: their primary liver disease is shown in Table 1. The recipient age ranged from 1 to 204 months (mean 51.1 ± 4.9 months) and the male/female ratio was 7/6. Two groups were identified depending on the age of the donor: group A were recipients of neonatal (age 28 days or less) donor grafts (n = 16) and group B recipients of grafts from older donors (n = 114). In case of retransplantation, the age of only the primary donor was considered. Donor age, body weight, prothrombin time, serum total bilirubin and alanine aminotransferase (ALT) were recorded. These laboratory data were missing for 10 donors in group B.An accounting of the donors and recipients in group A is given in Table 2. Anoxic injury due to birth asphyxia was the most common cause of donor death (75%). Thirteen donors (81%) were less than 2 weeks old and all weighed less than 5 kg. All but two recipients were less than 1 year old and all weighed less than 10 kg. Biliary atresia was the underlying disease in 11 patients. Nine of them (82%) had had previous failed portoenterostomies.A summary of the donor and recipient demographic data in group B is shown in Table 3.The surgical techniques employed for graft...

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“…1,2 In transplant surgery, this situation first occurred in pediatric transplants, 3,4 which frequently use reduced livers, either split or from living donors. 5,6 This sometimes results in left lobe or left liver transplants placed into a recipient with a larger body than the donor.…”

Section: Discussionmentioning

confidence: 99%

Use of the breast implant for liver graft malposition

et al. 1999

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Transplantation of a small liver into a large patient may cause problems with correct reperfusion of the graft because of torsion of the hepatic pedicle, leading to malfunction of the transplanted organ. We describe the case of a 60-year-old man with alcoholic cirrhosis and hepatitis B virus who received a small-sized liver graft. Owing to the lack of adequate reperfusion of the transplanted organ arising from pedicular kinking caused by disparate sizes, a breast implant was placed behind the graft as a means of support, thereby resolving the problem. The use of prosthetic materials for the correct placement of grafts with size incongruity is also discussed, and the literature is reviewed.Copyright 1999 by the American Association for the Study of Liver Diseases L iver transplantation has become the best alternative treatment for patients with end-stage liver disease because of advances in anesthesiological and surgical techniques, immunosuppression, and postoperative care. However, some technical aspects, such as correct matching of the graft size and recipient, are critical for its success. Discordance in size between the graft and its future cavity may cause disruptions in the position of the vascular structures, with consequent alterations in organ function. Case ReportA 60-year-old man had Child' s class B-7 hepatic cirrhosis of mixed viral (hepatitis B positive) and alcoholic cause. Physical examination showed the patient to be in a good nutritional state. His height was 176 cm; weight, 88 kg; abdominal circumference, 109 cm; and chest circumference, 102 cm.The patient received a full-size orthotopic liver transplant from a female donor weighing 51 kg (ratio of recipient to donor, 1.7). Hepatectomy was performed with preservation of the retrohepatic vena cava (piggyback). Poor reperfusion of the graft was noticed after performing vascular anastomoses despite repeated checks, leading to prolonged hemorrhage caused by alterations in coagulation and fibrinolysis. After observing a posterior kinking of the hepatic pedicle as a result of the difference in size between the graft and the cavity, it was decided to place a saline-filled breast implant behind the graft to correct the hilar angulation. This resulted in rapid, optimal reperfusion of the graft without liver congestion and with appreciable functional improvement. The operation was then finished uneventfully. It is remarkable that a method was not used to fix the prosthesis, because it remained well placed between the liver and the diaphragm.Control computed tomography showed the correct position of the graft resting on the prosthesis and a biloma in the left hepatic lobe (caused by a small traumatic lesion in the donor liver), which was punctured and drained uneventfully (Fig. 1). At present, more than 1 year later, several control computed tomographic abdominal scans have not shown displacement of the prosthesis or other complications caused by the implant. Moreover, both the helical computed tomographic scan and Doppler studies have proven the patency...

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Liver Transplantation, Including the Concept of Reduced-size Liver Transplants in Children

Cited by 185 publications

References 20 publications

Outcome of liver retransplantation in children

Outcome of liver retransplantation in children

Pediatric liver transplantation from neonatal donors

Use of the breast implant for liver graft malposition

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