Pediatric liver transplantation: from the full-size liver graft to reduced, split, and living related liver transplantation

Abstract

Between 1984 and 1996, the authors performed 499 liver transplants in 416 children less than 15 years old. The overall patient survival at 10 years was 76.5%. It was 71.3% for the 209 children grafted in 1984-1990; 78.5% for biliary atresia (n = 286), 87.3% for metabolic diseases (n = 59), and 72.7% for acute liver failure (n = 22). The 5-year survival was 73.6% for the 209 children grafted in 1984-1990 and 85% for the 206 grafted in 1991-1996. Scarcity of size-matched donors led to the development of innovative techniques: 174 children who electively received a reduced liver as a first graft in our center had a 5-year survival of 76% while 168 who received a full-size graft had a survival of 85% (NS). Results of the European Split Liver Registry showed 6-month graft survival similar to results obtained with full-size grafts collected by the European Liver Transplant Registry. Extensive use of these techniques allowed the mortality while waiting to be reduced from 16.5% in 1984-1990 to 10% in 1991-1992. It rose again to 17% in 1993, leading the authors to develop a program of living related liver transplantation (LRLT). The legal and ethical aspects are analyzed. Between July 1993 and October 1997, the authors performed 53 LRLTs with 90% survival. In elective cases, a detailed analysis was made of the 45 children listed for LRLT between July 1993 and March 1997 and the 79 registered on the cadaveric waiting list during the same period. Mortality while waiting was 2% and 14.5% for the LRLT and cadaveric lists, respectively. The retransplantation rate was 4.6% and 16.1% for LRLT and cadaveric transplants, respectively. Overall post-transplant survival was 88% and 82% for children who received a LRLT or a cadaveric graft, respectively. Overall survival from the date of registration was 86% and 70% (P < 0.05) for LRLT or cadaveric LT respectively. The 2-year post-transplant survival in children less than 1 year of age at transplantation was 88.8% and 80. 3% with a LRLT or cadaveric graft, respectively; patient survival after 3 months post-transplant was 95.8% and 91.9% for stable children waiting at home, 93.7% and 93.7% in children hospitalized for complications of their disease, and 89.5% and 77.7% for children hospitalized in an intensive care unit at the time of transplantation for children who received a LRLT or cadaveric graft, respectively. It is concluded that LRLT seems to be justified for multidisciplinary teams having a large experience with reduced and split liver grafting.

Whither living donor liver transplantation?

“…2 However, a number of individual units have reported recipient survival rates in the range of 80% to 90%. [3][4][5] Overall, these results are at least similar to those with cadaveric grafts. When there is no option for a cadaveric graft, LDLT is the only alternative.…”

Living-Related Versus Deceased Donor Pediatric Liver Transplantation: A Multivariate Analysis of Technical and Immunological Complications in 235 Recipients

“…The technical details of the DD whole, reduced-size and split liver grafts were previously reported (7,10). The University of Wisconsin preservation solution was used for graft preservation in both groups.…”

Risk factors and surgical management of anastomotic biliary complications after pediatric liver transplantation

“…[6][7][8][9] The following surgical characteristics were collected: total, cold, and warm (anastomosis) ischemia times; number of hepatic arteries in the graft; number of reconstructed hepatic arteries and number of ligated arteries in the graft; number of biliary anastomoses; site of the biliary anastomosis [common bile duct (CBD), common hepatic duct (CHD), or left hepatic duct (LHD)]; type of biliary reconstruction (hepaticojejunostomy, duct-to-duct anastomosis, or hepaticoduodenostomy); and type of abdominal wall closure (primary or secondary). Biliary reconstruction was most frequently performed with Roux-en-Y hepaticojejunostomy (n 5 396 or 92%) or a duct-to-duct anastomosis (n 5 22 or 5%) without the use of a biliary drain or stent.…”