Reducing Pediatric Liver Transplant Complications: A Potential Roadmap for Transplant Quality Improvement Initiatives Within North America

Abstract

Though robust clinical data is available within transplantation, these data are not used for broad-based, multicentered quality improvement initiates. This article describes a targeted quality improvement initiative within the Studies of Pediatric Liver Transplantation (SPLIT) Registry. Using standard statistical techniques and clinical expertise to adjust for data and statistical reliability, we identified the pediatric liver transplant centers in North America with the lowest hepatic artery thrombosis rate and biliary complication rates. A survey was completed to establish current practices within the entire SPLIT group. Surgeons from the highest performing centers presented a detailed, technically oriented overview of their current practices. The presentations and discussion that followed were recorded and form the basis of the best practices described herein. We frame this work as a unique six-step approach roadmap that may serve as an efficient and cost effective model for novel broad-based quality improvement initiatives within transplantation.

Combined liver and kidney transplantation in children

“…Gastrointestinal hemorrhage [7]. Little published data are available on surgical problems after CLKT, but after isolated pediatric LT the frequency of bleeding, thrombotic, and biliary complications varies between 5 and 18 %, 3 and 20 %, and 3 and 35 %, respectively [8,9]. Surgical complications of the renal graft are less common and include lymphocele and leakage or stenosis of the vesical implantation site or the ureter.…”

Paediatric liver transplantation in Johannesburg revisited: 59 transplants and challenges met

“…[11] These are reported to occur in 3 -35% of paediatric liver transplants. [3,14] Our current incidence for the entire series is 24%, falling well within this range. Attention to detail during the LDLT harvest, the back table split of a deceased donor whole liver and reconstruction of the bile duct during the implant procedure, as well as meticulous arterial reconstruction, all contribute to minimising the incidence of this complication.…”

“…Attention to detail during the LDLT harvest, the back table split of a deceased donor whole liver and reconstruction of the bile duct during the implant procedure, as well as meticulous arterial reconstruction, all contribute to minimising the incidence of this complication. [14] As alluded to in the discussion of our LDLT programme, our unit' s current numbers of paediatric transplants per annum compare favourably with other centres in the Western world. [12] Looking at the expected number of transplants per population, there is room to grow this significantly.…”

The role of interventional radiology in complications after paediatric liver transplantation

“…The reported incidence of HAT is highly variable, but is ~5% in high-performing transplant centres. [8] Doppler US is sensitive in detecting HAT (92%), with non-visualisation of the artery and loss of arterial Doppler signal along the anticipated course of the hepatic artery. [9] Surgical treatment options include thrombectomy with revascularisation (if diagnosed early) and repeat transplantation.…”