Pediatric third liver transplantation—A single‐center experience

Abstract

Liver retransplantation is the only corrective long-term management for graft failure and insurmountable graft complications. Previous single-center cohorts have shown that 9%-29% of pediatric liver transplantation patients need to undergo retransplantation. 1 In Australia, since 2000 an additional 15% of children post-retransplantation have required a third and possibly fourth transplants. 2Pediatric retransplantation has previously been approached with caution. This is because of concerns about poorer graft and patient survival as well as a limited supply of donors. 1,3,4 The consensus opinion has however recently shifted. A 2020 retrospective cohort analysis of Australian and New Zealand liver transplant registry data demonstrated for children retransplanted between 2001 and 2017 actuarial graft survival of 84%, 75%, 70%, and 54% and patient survival of 89%, 87%, 87%, and 71% at 1 year, 5 years, 10 years, and 15 years, respectively. 2 This was not dissimilar to pooled survival rates for all Australasian children transplanted during that period with actuarial survival rates of 94%, 89%, 88%, and 83% at 1 year, 5 years, 10 years, and 15 years, respectively. 5 In addition, the pediatric wait list mortality for Australia and New Zealand in 2017 was 1.4%. An intention since 2002 to split livers wherever possible and improvements in organ donation have played a large role in achieving this. 5

Good outcomes after repeated pediatric liver retransplantations: A justified procedure even in times of organ shortage

“…These results indicate that specialized high volume centers can perform reLT with a high surgical and technical standard, resulting good patient outcomes even after multiple reLTs. These findings are contrary to previous reported data where 2nd reLTs were associated with increased operative times 18 …”

“…Here we report long‐term survival rates of >80%; despite critical patient situations, this survival rate reLT for pediatric recipients is similar to survival rates for adult recipients (76%–82%), 19 which suggests justifiable use of organs even in this time of severe organ shortages. This is in accordance with a study from MR Couper et al., where 2nd reLT had similar 5‐year survival rates to primary and 1st reLT 18 . Indeed, in our study we show that pediatric liver reLT can be done safely and with good patient outcomes in a specialized center.…”

“…This is in accordance with a study from MR Couper et al, where 2nd reLT had similar 5-year survival rates to primary and 1st reLT. 18 Indeed, in our study we show that pediatric liver reLT can be done safely and with good patient outcomes in a specialized center. Careful patient and graft selection, as well as good preoperative preparation, are essential for success.…”

“…These findings are contrary to previous reported data where 2nd reLTs were associated with increased operative times. 18 Early reLT, technical variant grafts and a PELD score >20 have been described as risk factors for reduced graft and patient survival. [6][7][8] In case of early reLT and a high PELD score, a poorer patient condition and more urgent transplant indication can explain worse F I G U R E 2 Shown are warm ischemia times, cold ischemia times and complete operation times for primary LT, as well as first, second and third reLTs.…”

Gastric sleeve as an extra‐anatomical roux for biliary reconstruction in a pediatric third liver transplant

“…Pediatric liver retransplantation accounts for 10%–20% of all liver transplants (LT) in children 1 . Retransplants in children are technically challenging due to adhesions from previous technical variant grafts (split or living donor), in addition to size mismatches and smaller vessels 2,3 . We report a case wherein biliary reconstruction in a child's third liver transplant was complicated by on‐going problems with “short‐gut syndrome.” The innovative solution used was a gastric sleeve tubular graft as an “extra‐anatomical” Roux limb.…”