Surgical complications after living donor liver transplantation in patients with biliary atresia: a relatively high incidence of portal vein complications

Modified patch-conduit venoplasty for portal vein hypoplasia in pediatric liver transplantation

Background

Portal vein (PV) interposition can induce various PV-related complications, making more reliable techniques necessary. The present study describes the development of a modified patch venoplasty technique, combining the native PV wall and a vein homograft conduit, called modified patch-conduit venoplasty (MPCV).

Methods

The surgical technique for MPCV was optimized by simulation and applied to seven pediatric patients undergoing liver transplantation (LT) for biliary atresia combined with PV hypoplasia.

Results

The simulation study revealed that inserting the whole-length native PV wall as a longitudinal rectangular patch was more effective in preventing PV conduit stenosis than the conventional technique using triangular partial insertion. These findings were used to develop the MPCV technique, in which the native PV wall was converted into a long rectangular patch, acting as a backbone for PV reconstruction. A longitudinal incision on the vein conduit converted the cylindrical vein into a large vein patch. The wall of the native PV was fully preserved as the posterior wall of the PV conduit, thus preventing longitudinal redundancy and unwanted rotation of the reconstructed PV. This technique was applied to seven patients with biliary atresia undergoing living-donor and deceased-donor split LT. None of these patients has experienced PV complications for up to 12 months after transplantation.

Conclusions

This newly devised MCPV technique can replace conventional PV interposition. MCPV may be a surgical option for reliable PV reconstruction using fresh or cryopreserved vein homografts during pediatric LT.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

INTRODUCTION

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

METHODS

Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

RESULTS

Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

CONCLUSIONS

The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Pediatric Liver Transplantation

Liver transplantation (LT) for children results in excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and select genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, appropriate patient selection and evaluation, allocation of organs, transplant surgery including the use of variant grafts, posttransplant care including immunosuppression management, prognosis, and transition of care.

Portal vein reconstruction with cryopreserved vascular grafts: A two-edged sword

BACKGROUND

Portal vein anastomotic complications related to size discrepancy are important causes of morbidity and mortality in pediatric liver transplantation. Interposed vascular grafts in portal vein anastomosis can solve this problem. The aim of this study is to evaluate the results of pediatric liver transplantations performed using cryopreserved interposed vascular grafts between graft portal vein and superior mesenteric vein (SMV)-splenic vein (SpV) confluence.

METHODS

Twenty-nine pediatric patients received liver transplantation using cryopreserved venous grafts in our Liver Transplant Institute between 2013 and 2020 were included in this study. Demographic, clinical, and operative characteristics and postoperative follow-up were analyzed.

RESULTS

Sixteen patients (55.2%) had portal hypoplasia and five patients (17.2%) had portal vein thrombosis. In total, six patients (20.6%) suffered portal vein thrombosis in the early postoperative period. Three patients (10.3%) experienced portal vein thrombosis in the late postoperative period. Late portal vein thrombosis rate was significantly higher in patients with early portal vein thrombosis (3/6 patients [50%] versus 0/23 patients [0%]; p = .034). Lack of portal flow was significantly higher in patients with both early (50% versus 0%; p = .002) and late portal vein thrombosis (66.7% versus 6.7%; p = .03).

CONCLUSION

Preoperative portal vein thrombosis and insufficient flow are important factors affecting success of liver transplant in children. The use of interposed vein grafts in problematic portal anastomoses can overcome portal flow problems.

Technical Aspects and Considerations of Meso-Rex Bypass Following Liver Transplantation With Left Lateral Segment Grafts: Case Report and Review of the Literature

In pediatric patients with extrahepatic portal vein obstruction and complications of portal hypertension, but with normal liver function, a meso-Rex bypass (MRB) connecting the superior mesenteric vein to the intrahepatic left portal is the favored surgical management. Pediatric patients with a history of a partial liver transplant (LT), especially living donors, are at greater risk for portal vein complications. Hence, an adequate knowledge of this technique and its additional challenges in the post-LT patient setting is crucial. We provide an overview of the available literature on technical aspects for an MRB post-LT. Preoperative considerations are highlighted, along with intraoperative considerations and postoperative management. Special attention is given to the even-more-demanding aspect of performing an MRB post-liver transplantation with a left lateral segment. Surgical alternatives are also discussed. In addition, we report here a unique case in which this surgical technique was performed on a complex pediatric patient with a history of a living-donor LT with a left lateral segment graft over a decade ago.

Portal vein reconstruction using side-to-side unification technique for infant-to-infant deceased donor whole liver transplantation

Backgrounds/Aims

Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. We analyze clinical sequences of our 7 cases of I2I-WLT and present evolution of surgical techniques to prevent PV stenosis.

Methods

A total of 7 cases of I2I-WLT were performed at our institution during last 13 years, which represented 0.1% of our LT volume. Patient perioperative profiles and clinical sequences were analyzed with focusing on portal vein (PV) complications.

Results

Donor ages were 6-17 months and graft weights were 140-525 g. Recipient ages were 7-16 months and body weights were 6-10.1 kg and Primary diagnoses were biliary atresia in 6 and progressive familial intrahepatic cholestasis in 1. The first case underwent PV stenting 2 months after I2I-WLT, and underwent retransplantation 6 years later. The second case underwent intraoperative PV stenting, but died 32 days later. The third case underwent repeated PV dilatation. The fourth, fifth and seventh cases experienced no surgical complications, and PV reconstruction was performed using a side-to-side unification venoplasty technique. The sixth case had poor development of the PV system, so customized PV venoplasty was performed, but PV occlusion requiring PV stenting occurred. Early retransplantation was performed, but scanty PV flow was detected despite no obvious PV stenosis, resulting in graft failure. Serious PV complications developed in 4, but none experienced after adoption of side-to-side unification venoplasty.

Conclusions

As PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty.

Side-to-side portal vein reconstruction for infant-to-infant deceased donor whole liver transplantation: Report of 2 cases with video

Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. Unlike living donor liver transplantation or split liver transplantation, the donor graft portal vein (PV) in I2I-WLT is very small in diameter, so risk of PV complications increases significantly. We present two cases of I2I-WLT with application of side-to-side unification venoplasty for secure PV reconstruction. The first case recipient was a 10-month-old female baby who weighed 6.0 kg. She was diagnosed with progressive familial intrahepatic cholestasis. The deceased donor was a 12-month-old boy. The graft weight was 245 g, so the graft-recipient weight ratio (GRWR) was 4.1%. PV was reconstructed using side-to-side unification venoplasty. The function of graft liver recovered uneventfully and there was no evidence of PV complications. She is currently doing well for 4 years. The second case recipient was a 10-month-old female baby who weighed 8.8 kg. She had also undergone Kasai operation for biliary atresia. GRWR was 6.0%. Because the graft liver was much larger than the native liver, we designed the length of the extrahepatic PV more redundant than the precedent cases to avoid extrinsic compression by the large-sized caudate lobe. The PV was reconstructed using side-to-side unification venoplasty. The function of the graft liver recovered uneventfully. There was no evidence of PV complications. She is currently doing well for 2 years. As the PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty. Three supplementary video clips are provided.

Efficacy of Prophylactic Negative Pressure Wound Therapy After Pediatric Liver Transplant

OBJECTIVES

Wound dehiscence is a common surgical complication, especially among pediatric liver transplant recipients in our center. In 2013, we introduced negative pressure wound therapy as a preventive treatment. We herein report the clinical outcomes of this intervention.

MATERIALS AND METHODS

We conducted a retrospective review of the 26 pediatric liver transplant recipients in our center since 2011. We excluded 1 girl whose wound could not be closed due to bowel edema. The first 13 of the 25 remaining patients were treated with conventional wound management (conventional group). The latter 12 were treated with prophylactic negative pressure wound therapy (prophylactic group). Incidences of surgical complications and patient characteristics were compared between groups.

RESULTS

Wound dehiscence occurred in 7 of the 13 patients in the conventional group and 3 of the 12 patients in the prophylactic group. When restricted to dehiscence that required surgical debridement, there were 6 cases in the conventional group and no cases in the prophylactic group. Although background data showed that liver insufficiency in the prophylactic group was more severe, this group had a lower incidence of wound dehiscence (P = .015).

CONCLUSIONS

Prophylactic negative pressure wound therapy is thought to be effective for preventing wound dehiscence among pediatric liver transplant recipients.

Liver Transplantation in Children

Liver transplantation (LT) for children has excellent short- and long-term patient and graft survival. LT is a lifesaving procedure in children with acute or chronic liver disease, hepatic tumors, and a few genetic metabolic diseases in which it can significantly improve quality of life. In this article, the authors discuss the unique aspects of pediatric LT, including the indications, patient selection and evaluation, allocation, transplant surgery and organ selection, posttransplant care, prognosis, adherence, and transition of care.

Thrombosis after liver transplantation for hepatocellular carcinoma

The influence of thrombosis on the prognosis of patients with hepatocellular carcinoma (HCC) after liver transplantation (LT) and the role of the commonest inherited thrombophilia abnormalities factor V Leiden and prothrombin G20210A in the development of thrombosis are unknown. We investigated a cohort of patients who underwent LT for HCC with the aim to estimate the incidence rate (IR) of thrombosis, its influence on mortality and re-transplantation rates and, in the frame of a nested case-control study, the role of thrombophilia in donors and recipients for the development of thrombosis. Four-hundred and thirty patients underwent LT and were followed for a median of 7.2 years. Twenty-six recipients (6%) developed thrombosis (IR 1.06 [95%CI: 0.71–1.53] per 100 pts-yr). Mortality rate after LT was 3.95 (95%CI: 3.22–4.79) per 100 pts-yr and was not influenced by thrombosis. Re-transplantation was planned for 33 patients and was more common in patients with thrombosis than in those without (HR 2.50 [95%CI: 0.87–7.17]). The risk of thrombosis was 4 times higher in recipients with thrombophilia than in those without (OR 4.23 [95%CI: 0.99–18.04]) and 6 times higher when the analysis was restricted to venous thrombosis (OR 6.26 [95%CI: 1.19–32.85]). The presence of inherited thrombophilia in the donors did not increase the risk of thrombosis of the recipient. In conclusion, thrombosis is a complication of 6% of patients transplanted for HCC and increases the risk of re-transplantation but not of mortality. The risk of thrombosis, particularly venous, is increased in the presence of thrombophilia abnormalities in the recipients.

Case report of a modified Meso-Rex bypass as a treatment technique for late-onset portal vein cavernous transformation with portal hypertension after adult deceased-donor liver transplantation

RATIONALE

Portal vein thrombosis is a complication after liver transplantation and cavernous transformation of the portal vein (CTPV) is a result of portal vein thrombosis, with symptoms of portal hypertension revealed by an enhanced CT scan. Meso-Rex bypass is an artificial shunt connecting the left portal vein to the superior mesenteric vein and is mainly used for idiopathic cavernomas. This technique is also used for post-transplant portal vein thrombosis in pediatric patients thereby bypassing obstructed sites of the extrahepatic portal vein. Here we report about an adult patient who was treated by connecting the cystic part of the portal vein to the splenic vein instead of the superior mesenteric vein.

PATIENTS CONCERN

An adult male patient with post-liver transplantation portal vein cavernous transformation suffered from hypersplenism and elevated hepatic enzymes.

DIAGNOSIS

The last follow up revealed irregular and obvious hypersplenism, and splenomegaly had occurred, while an enhanced CT scan revealed serious esophagogastric varices and CTPV in addition to occluded right and common PV trunks.

INTERVENTION

The patient was treated by connecting the cystic part of the portal vein to the splenic vein instead of the superior mesenteric vein.

OUTCOME

After the operation, a satisfactory velocity was confirmed 1 month postoperatively and the shunt still remained patent at the 6-month postoperation follow-up.

LESSONS

A Meso-Rex bypass intervention connecting the left portal vein to the splenic vein instead of the superior mesenteric vein after liver transplantation in an adult patient with right and common portal vein occlusions has been successfully performed as an alternative approach.

Pediatric Thromboembolism in Japan

OBJECTIVES

To investigate the clinical and epidemiologic characteristics of thromboembolism in Japanese children.

METHODS

Clinical data of 77 patients with thromboembolism from a national tertiary pediatric care center were reviewed.

RESULTS

Incidence of thromboembolism was calculated to be 15 per 10,000 hospital admissions. Infants younger than one year of age made up the largest age group (25 patients, including nine neonates younger than 30 d). The occurrence of thromboembolism increased over the years in the index population. Thromboembolism was diagnosed as follows: portal vein thrombosis (n = 15), obstruction of central venous catheter (n = 13) and cerebral infarction (n = 9). Among the 77 patients, there were eight mortalities and six significant sequelae.

CONCLUSIONS

In pediatric care, especially in intensive care, we should pay more attention to thromboembolism in order to detect it promptly.

Living donor liver transplantation in Brazil-current state

Currently in Brazil, living donor liver transplantation (LDLT) represents 8.5% of liver transplantation (LT), being the majority pediatric one. Up to now, according to Brazilian Organ Transplantation Association (ABTO) annual report, 2,086 procedures have been done nationwide, most of them in southeast and south regions. Based on national centers reports, biliary complication is the most common recipient postoperative complication (14.5-20.6%), followed by hepatic artery thrombosis (3.1-10.7%) and portal vein thrombosis (2.3-9.1%). Patient and graft overall 5-y survival correspond to 76% and 74%, respectively. Regarding the donor, morbidity rate ranges from 12.4% to 28.3%, with a national mortality rate of 0.14%. In conclusion, Brazilian LDLT programs enhance international experience that this is a feasible and safe procedure, as well as an excellent alternative strategy to overcome organs shortage.

Current state of the art in management of vascular complications after pediatric liver transplantation

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threatening consequences after pediatric liver transplantation. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in management of vascular complications after pediatric liver transplantation.

Calcification of Cryopreserved Arterial Graft Causing Delayed Obstruction of Portal Vein Flow After Liver Transplant

In patients with biliary atresia, portal vein problems may cause challenges for liver transplant. Interposition grafts have been used for vascular anastomoses in transplant recipients with varied success. A cryopreserved iliac artery graft was used for the reconstruction of the portal vein in a 29-month-old infant with biliary atresia. At 17 months after transplant, she developed upper gastrointestinal bleeding that was caused by portal vein occlusion because of vascular calcifications in the graft. Upper gastrointestinal endoscopy showed esophageal varices with fresh bleeding, and the varices were band ligated. At 3 months after the bleeding episode, the patient was asymptomatic and biochemical tests were normal. In summary, liver transplant with cryopreserved iliac artery graft may be complicated by calcifications and portal vein occlusion, and caution is advised in using this graft material for portal vein anastomoses.

Frequency of and factors associated with vascular complications after pediatric liver transplantation

OBJECTIVE

to evaluate the frequency and factors associated with vascular complications after pediatric liver transplantation.

METHOD

risk factors were evaluated in 99 patients under 18 years of age with chronic liver disease who underwent deceased donor liver transplantation (DDLT) between March of 1995 and November of 2009 at the Hospital de Clínicas de Porto Alegre, Brazil. The variables analyzed included donor and recipient age, gender, and weight; indication for transplant; PELD/MELD scores; technical aspects; postoperative vascular complications; and survival.

RESULTS

vascular complications occurred in 19 patients (19%). Arterial events were most common, occurred earlier in the postoperative period, and were associated with high graft loss and mortality rates. In the multivariate analysis, the following factors were identified: portal vein diameter ≤ 3mm, donor-to-recipient body weight ratio (DRWR), prolonged ischemic time, and use of arterial grafts.

CONCLUSION

the choice of treatment depends on the timing of diagnosis; however, in this study, surgical revision or correction produced worse outcomes than percutaneous angioplasty. The reduction of risk factors and early detection of vascular complications are key elements to a successful transplantation.

Management and long-term consequences of portal vein thrombosis after liver transplantation in children

Portal vein thrombosis (PVT) occurs in ≤12% of pediatric recipients of liver transplantation (LT). Known complications of PVT include portal hypertension, allograft loss, and mortality. The management of PVT is varied. A single-center, case-control study of pediatric LT recipients with portal vein (PV) changes after LT was performed. Cases were categorized as early PVT (if PVT was detected within 30 days of transplantation) or late PVT (if PVT was detected more than 30 days after transplantation or if early PVT persisted beyond 30 days). Two non-PVT control patients were matched on the basis of the recipient weight, transplant indication, and allograft type to each patient with PVT. Thirty-two of the 415 LT recipients (7.7%) received 37 allografts and developed PVT. In comparison with control patients, a higher proportion of patients with PVT had PVT present before LT (13.3% versus 0%, P = 0.01). Patients with early PVT usually returned to the operating room, and 9 of 15 patients (60%) had PV flow restored. Patients with late PVT had lower white blood cell (4.9 [1000/μL] versus 6.8 [1000/μL], P < 0.01) and platelet counts (140 [1000/μL] versus 259 [1000/μL], P < 0.01), an elevated international normalized ratio (1.2 versus 1.0, P < 0.001), and more gastrointestinal bleeding (25% versus 8.3%, P = 0.03) compared to controls. Patients with PVT were also less frequently at the expected grade level (52% versus 88%, P < 0.001). The patient survival rates were 84%, 78%, and 78% and 91%, 84%, and 79% for cases and controls at 1, 5, and 10 years, respectively. The allograft survival rates were 90%, 80%, and 80% for cases and 94%, 89%, and 87% for controls at 1, 5, and 10 years, respectively. In conclusion, patients with early and late PVT had preserved allograft function, and there was no impact on mortality. Patients diagnosed with early PVT often underwent operative interventions with successful restoration of flow. Patients diagnosed with late PVT experienced variceal bleeding, and some required portosystemic shunting procedures. Academic delays were also more common. In late PVT, the clinical presentation dictates care because the optimal management algorithm has not yet been determined. Multi-institutional studies are needed to confirm these findings and improve patient outcomes.

Meso-Rex bypass as an alternative technique for portal vein reconstruction at or after liver transplantation in children: review and perspectives

Direct portal revascularization can be achieved by interposing a vascular graft between the SMV and the Rex recessus (left portal vein system): the MRB. To review indications and results of the procedure in the setting of pediatric liver transplantation, reports were selected from the English literature. Previously reported series were updated to analyze long-term outcome. A new series was added and analyzed as a complementary set of cases. A total of 51 cases were analyzed. With a 96% overall patient survival rate and a 100% long-term patency rate when the IJV is used for the bypass, MRB achieves a very successful physiologic cure of chronic portal hypertension and restores the portal flow into and through the liver graft. It also has been used successfully for primary revascularization of liver grafts, as well as for managing early acute portal vein thrombosis episodes. The use of this procedure in conjunction with other strategies and techniques might be of interest for transplant surgeons, particularly those caring for children.

The pre-Kasai procedure in living donor liver transplantation for children with biliary atresia

BACKGROUND

Biliary atresia (BA) is a major cause of chronic cholestasis, a fatal disorder in infants. This study was undertaken to evaluate the safety and effectiveness of primary living donor liver transplantation (LDLT) in comparison with the traditional first-line treatment, the Kasai procedure.

METHODS

We assessed 28 children with BA at age of less than two years (3-21.3 months) who had undergone LDLT in two hospitals in Southwest China during the period of 2008-2011. Eighteen children who had had primary LDLT were included in a primary LDLT group, and ten children who had undergone the Kasai operation in a pre-Kasai group. All patients were followed up after discharge from the hospital. The records of the BA patients and donors were reviewed.

RESULTS

The time of follow-up ranged 12-44.5 months with a median of 31 months. The 30-day and 1-year survival rates were 85.7% and 78.6%, respectively. There was no significant difference in the 30-day or 1-year survival between the two groups (83.3% vs 90% and 77.8% vs 80%, P>0.05). The main cause of death was hepatic artery thrombosis. There were more patients with complications who required intensive medical care or re-operation in the pre-Kasai group (8, 80%) than in the primary LDLT group (9, 50%) (P=0.226). But no significant differences were observed in operating time (9.3 vs 8.9 hours, P=0.77), intraoperative blood loss (208.6 vs 197.0 mL, P=0.84) and blood transfusion (105.6 vs 100.0 mL, P=0.91) between the two groups. The durations of ICU and hospital stay in the primary LDLT group and pre-Kasai group were 180.4 vs 157.7 hours (P=0.18) and 27 vs 29 days (P=0.29), respectively.

CONCLUSIONS

Primary LDLT is a safe and efficient management for young pediatric patients with BA. Compared with the outcome of LDLT for patients receiving a previous Kasai operation, a similar survival rate and a low rate of re-operation and intensive medical care for patients with BA can be obtained.

Meso-Rex shunt for immediate portal revascularization in pediatric liver transplantation: first report

We describe the case of a 13-month-old girl transplanted for biliary atresia with PV hypoplasia. She received the left liver lobe of her mother and presented intraoperative portal thrombosis. Because of technical reasons, the opportunity to have conventional PV reconstruction using the donor left PV stump was lost. Immediate conversion to a meso-Rex shunt, using the recipient jugular vein as a bridge between the superior mesenteric vein and the graft Rex recessus, allowed excellent portal revascularization of the transplant. We suggest that synchronous meso-Rex shunt may constitute a valid alternative to truncal PV anastomosis during pediatric LT.

Living donor liver transplantation in 43 children with biliary atresia: a single-center experience from the mainland of China

BACKGROUND

There is no large-cohort report on living donor liver transplantation (LDLT) for biliary atresia (BA) patients from the mainland of China. This single-center study describes our initial experience with 43 LDLTs for BA patients aged two years or younger.

METHODS

In this study, the eligibility criteria were BA as the primary diagnosis and two years of age or younger. From October 2006 to December 2010, the clinical data of 43 LDLTs, including pre-operative evaluations, surgical techniques, postoperative complications and outcomes of donors and recipients, were retrospectively analyzed.

RESULTS

Donor graft type was the left lateral segment with compatible ABO blood groups. Forty-three recipients were selected in this study. The median patient age at operation was 9 months (range 6-24), and the median body weight was 8 kg (range 5.7-12.5). Fourteen (32.6%) recipients received Kasai operations before liver transplantation. The overall one- and two-year cumulative survival rates for grafts and recipients were 81%, 81% and 76%, 76%, respectively. No donor mortality was encountered, with a minimal morbidity and no long-term sequelae. Nine out of 43 recipients died. Postoperative complications of recipients were biliary leakage and refluxing cholangitis (11/43, 25.6%), hepatic artery thrombosis (4, 9.3%), pulmonary infections (4, 9.3%), portal vein thrombosis (3, 7.0%), wound disruption (3, 7.0%), acute rejection (3, 7.0%), cytomegalovirus infection (2, 4.7%), and intra-abdominal bleeding (1, 2.3%).

CONCLUSION

Despite the relatively low survival rates due to lack of experience initially, LDLT still provides encouraging outcomes for pediatric recipients with BA, even small children under two years old.

Hemodynamics of portal venous stenosis before and after treatment in pediatric liver transplantation: evaluation with Doppler ultrasound

AIM

The aim of this study was to evaluate portal vein stenosis (PVS) in pediatric liver transplantation (PLT) using Doppler ultrasound (DUS) before and after interventional management for hemodynamic changes.

MATERIALS AND METHODS

From 2000 to 2010, we encountered 11 PVS cases among 180 PLT that were evaluated using DUS and computed tomography (CT) angiography (CTA); all underwent portal stenting. DUS was used to monitor portal hemodynamics. For the diagnosis of PVS, we investigated multiple parameters including stenotic size (SS), stenotic ratio (SR) (SR [%]=PRE-SS/PRE [PRE=stenotic size]), portal flow velocity ratio (VR) (VR=VS/PRE [PRE=velocity at prestenotic site; VS=peak velocity at stenotic site]), spleen size, and platelet count.

RESULTS

The incidence of PVS was 5.6% (11/180). The PV was 2.5 mm using DUS and 2.7 mm using CTA. The average SR was 65% fitting the criterion. Low prestenotic portal flow<12 cm/sec and high peak velocity in the stenotic segment (up to 147 cm/sec) were observed in 6 cases. The VR value was high at 7.5:1 and there was splenomegaly with thrombocytopenia. After portal vein stenting, hyperperfusion occurred might after reopening the stenosis: the flow increased to an average of 34 cm/sec and then flow decreased slowly to a stable level 2 weeks later. The size of the spleen decreased from 17 to 12 cm and the thrombocytopenia also improved with platelet counts increasing from 67×10(3) to 178×10(3)/μl at 2 months follow-up. The changes in portal flow, portal vein size, spleen size, and platelet count were significant (P<.05).

CONCLUSION

PVS is diagnosed using DUS by increased intrahepatic PV dilatation, peak flow at the stenotic site, discrepant VR. Early portal stenting showed a better prognosis. DUS is essential and effective for hemodynamic monitoring and management of PVS.

Pediatric liver transplantation: A report from a pediatric surgical unit

BACKGROUND

Liver transplantation is well established worldwide as an effective treatment for end-stage liver disease in children. Acceptance in India has been slow because of considerations of cost, infections, inability to support long-term care, and non-availability of expertise.

AIM

This study was designed to report our experience with pediatric liver transplantation.

MATERIALS AND METHODS

Twenty-eight children underwent liver transplantation.

RESULTS

Biliary atresia was the commonest indication (n = 15) followed by metabolic liver disease. Twenty-six children had living donor transplants, mothers being the donors in a majority of these. Common surgical complications included bile leaks (n = 3) and vascular problems (n = 6). Common medical complications included infections, acute rejection, and renal failure. Overall, patient survival was 71%, while that for the last 14 cases was 92%. All survivors are doing well, have caught up with physical and developmental milestones and are engaged in age appropriate activities.

CONCLUSIONS

The study demonstrates the feasibility of a successful pediatric liver transplant program in our country.

Portal vein obstruction after liver transplantation in children treated by simultaneous minilaparotomy and transhepatic approaches: initial experience

Portal vein thrombosis is a complication that occurs anytime after liver transplantation and can compromise the patient and graft survival. We describe a combined technique for PV recanalization in cases of PV obstruction after liver transplantation. Four children (1%), of 367 subjected to liver transplantation from June 1991 to December 2008, underwent PV recanalization through a combined approach (transhepatic and minilaparotomy). All children received left lateral hepatic segments, developed Portal vein thrombosis (n=3) and stenosis (n=1), and presented with symptoms of portal hypertension after transplantation. PV recanalization was tried by transhepatic retrograde access, and a minilaparotomy was performed when percutaneous recanalization was unsuccessful. Three patients underwent a successful portal recanalization and stent placement with the combined technique. In one patient, the recanalization was unsuccessful because of an extensive portomesenteric thrombosis. The other three children had the portal flow reestablished and followed with Doppler US studies. They received oral anticoagulation for three consecutive months after the procedure and the clinical symptoms subsided. In case of PV obstruction, the combined approach is technically feasible with good clinical and hemodynamic results. It' is a minimally invasive procedure and can be tried to avoid or delay surgical treatment or retransplantation.

Clinical practice: management of biliary atresia

Biliary atresia is a rare, serious and challenging disease in newborn children. Its aetiology remains unknown. Optimal management at specialist centres with resultant better overall outcomes is achieved through a multidisciplinary team approach. The Kasai portoenterostomy performed early in life remains the only surgical repair procedure. Two thirds of patients will clear their jaundice after a Kasai procedure, but only about one third will retain their livers after the first decade of life. Failure of this procedure leaves liver transplantation as the only chance for survival, and this disease is the commonest indication for liver transplantation in children. With modern medical care and refinements in surgical techniques, survival after either or both of these procedures is about 90%. Early referral to specialist centres and long-term specialist care remains the key to successful treatment of this condition.