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Kumaran V, Kapoor S, Sable S, Nath B, Varma V. The "W" Technique: A Safe and Reproducible Technique for Hepatic Artery Reconstruction in Living Donor Liver Transplantation. Ann Transplant 2021; 26:e926979. [PMID: 33510125 PMCID: PMC7852041 DOI: 10.12659/aot.926979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Reconstruction of the hepatic arterial inflow can be technically demanding in living donor liver transplantation, and thrombosis can result in graft loss and mortality. We describe the safe and reproducible “W” technique to reconstruct the hepatic artery and outcomes before and after adoption of the technique in a consecutive series of liver transplants at 2 high-volume living donor liver transplant centers. Material/Methods Prospectively collected data were analyzed to compare the outcomes before and after introduction of a standardized “W” technique for reconstruction of the hepatic artery in 2 high-volume living donor liver transplant programs. Results In a consecutive series of 675 liver transplants, of which 27 were deceased donor transplants and 648 were living donor transplants, 443 transplants were performed with a standard interrupted reconstruction of the hepatic artery under loupes. These transplants were performed by a single surgeon, with an incidence of hepatic artery thrombosis of 2%. After introduction of the “W” technique, despite the arterial reconstruction being done by several surgeons in the early part of their learning curve, the incidence of hepatic artery thrombosis decreased to 0.86% in the next 232 transplants. Conclusions The “W” technique is a simple, easy to learn and teach technique for reconstruction of the hepatic artery without the use of the operating microscope in living donor liver transplantation.
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Affiliation(s)
- Vinay Kumaran
- Department of Surgery (Transplant), Hume Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Sorabh Kapoor
- Department of Surgical Gastroenterology and Liver Transplant, Zydus Hospital, Ahmedabad, India
| | - Shailesh Sable
- Department of Liver Transplant and Hepatobiliary Surgery, Sahyadri Hospital, Pune, India
| | - Barun Nath
- Department of Liver Transplant and Hepatobiliary Surgery, Apollo Gleneagles Hospital, Kolkata, India
| | - Vibha Varma
- Department of Liver Transplant and Hepatobiliary Surgery, Max Hospitals, New Delhi, India
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Pandey Y, Varma S, Chikkala BR, Acharya R, Verma S, Balradja I, Das D, Dey R, Agarwal S, Gupta S. Outcome of Pediatric Liver Transplants in Patients With Less Than 10 kg of Body Weight Is Not Worse. EXP CLIN TRANSPLANT 2020; 18:707-711. [PMID: 33187463 DOI: 10.6002/ect.2020.0308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Liver transplant in pediatric patients with body weight < 10 kg poses a challenge to the entire liver transplant team. Many reports have considered 10 kg to be a cutoff pointfor body weightforfavorable posttransplant outcomes. With evolving surgical techniques and postoperative management, there is potential to improve outcomes in this subset of recipients. We compared the outcomes in pediatric patients with body weight < 10 kg with those > 10 kg; also, we studied the factors of influence. MATERIALS AND METHODS We performed a retrospective analysis to evaluate the outcomes of liver transplants in pediatric patients with < 10 kg body weight. The cohort consisted of 90 children subdivided into the following 2 subgroups: group A (n = 35) with > 10 kg body weight at liver transplant and group B (n = 55) with < 10 kg body weight at liver transplant. We compared the following pretransplant characteristics between the groups: graft weight, graft-to-recipient weightratio, cold ischemia time, warm ischemia times, and liver transplant outcomes. RESULTS Pediatric End-stage Liver Disease score was significantly higher in group B (score of 24) versus group A (score of 18). Group B had significantly higher graft-to-recipient weight ratio (2.8 in group B vs 1.7 in group A). Graft function showed no significant difference between the 2 groups. Portal vein thrombosis was seen only in group B, whereas biliary leaks were observed among 5 patients in group B and 1 patientin group A. Patient survivalrate was higherin group B (86%) than in group A (77%). CONCLUSIONS Pediatric patients weighing < 10 kg have similarif not better survivalrates after liver transplant compared with patients > 10 kg. Advancements in surgical techniques and a careful monitoring for complications and timely intervention are important to facilitate these outcomes.
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Affiliation(s)
- Yuktansh Pandey
- From the Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Kutluturk K, Sahin TT, Karakas S, Unal B, Gozukara Bag HG, Akbulut S, Aydin C, Yilmaz S. Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation. Transplant Proc 2019; 51:1162-1168. [PMID: 31101192 DOI: 10.1016/j.transproceed.2019.01.104] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/21/2019] [Indexed: 02/07/2023]
Abstract
AIM Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation. METHODS A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined. RESULTS Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive. CONCLUSION The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.
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Affiliation(s)
- K Kutluturk
- Inonu University Institute of Liver Transplantation, Malatya, Turkey.
| | - T T Sahin
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - S Karakas
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - B Unal
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - H G Gozukara Bag
- Inonu University Faculty of Medicine Department of Biostatistics and Bioinformatics, Malatya, Turkey
| | - S Akbulut
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - C Aydin
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - S Yilmaz
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
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The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia. J Pediatr Surg 2018; 53:1516-1522. [PMID: 29861326 DOI: 10.1016/j.jpedsurg.2018.04.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/31/2018] [Accepted: 04/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. BASIC PROCEDURES Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. MAIN FINDINGS Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). PRINCIPAL CONCLUSION Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. TYPE OF SUBMISSION Original article, Case control study, Retrospective. EVIDENCE LEVEL III.
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Uribe M, Alba A, Hunter B, González G, Godoy J, Ferrario M, Buckel E, Cavallieri S, Heine C, Rebolledo R, Auad H, Acuña C. Liver transplantation in children weighing less than 10 kg: Chilean experience. Transplant Proc 2014; 45:3731-3. [PMID: 24315011 DOI: 10.1016/j.transproceed.2013.08.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. In small children (≤ 10 kg), this procedure is challenging and has special considerations. The aim of this study is to describe the experience of a Chilean liver transplantation program in this subgroup of patients. METHODS The liver transplant database of Hospital Luis Calvo Mackenna and Clinica Las Condes was reviewed. All children less than 10 kg undergoing liver transplantation between January 1994 and July 2011 were included. Patient and graft outcomes and main complications were analyzed. RESULTS We have performed 230 pediatric liver transplantations, 49 of them in 41 patients weighing less than 10 kg. The first indication for transplantation was biliary atresia in 25 patients (61%). A living related donor was used in 23 cases (51%). Actuarial survival was 75.7% at 1 year and 67.1% at 5 years. The main cause of death was infection, and the leading cause of graft loss was vascular complication. DISCUSSION Our transplant program includes 2 centers that perform more than 90% of pediatric liver transplantations in Chile, including public health pediatric patients from all around the country. Patients weighing less than 10 kg represent the most challenging group in pediatric liver transplantation due to higher rates of vascular and biliary complications and postoperative infections.
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Affiliation(s)
- M Uribe
- Hospital Luis Calvo Mackenna, Santiago, Chile.
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Arnon R, Annunziato R, Miloh T, Sogawa H, Nostrand KV, Florman S, Suchy F, Kerkar N. Liver transplantation in children weighing 5 kg or less: analysis of the UNOS database. Pediatr Transplant 2011; 15:650-8. [PMID: 21797956 DOI: 10.1111/j.1399-3046.2011.01549.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED LT is a major medical and surgical challenge in very small patients. Aim of the study is to determine the outcomes after LT in infants ≤ 5 kg at transplant in a large cohort of patients. METHODS Infants ≤ 5 kg who had LT between 10/1987 and 5/2008 were identified from the UNOS database. Risk factors for death and graft loss were analyzed by multivariate logistic regression. RESULTS Of 11,467 children, 570 (5%) were ≤ 5 kg at LT. Mean age and weight at LT were 0.11 ± 0.48 yr, 4.32 ± 0.74 kg, respectively. One- and five-yr patient and graft survival were 77.7%, 72.2% and 66.1%, 57.6%, respectively. The primary cause of death was infection (25.9%). Recipient age was a predictor of graft loss. Patient and graft survival have improved over time. Life support at transplant was identified as a risk factor for both death and graft loss (p < 0.02, p < 0.01, respectively). CONCLUSION LT recipients ≤5 kg have high mortality and graft loss. Over time, graft survival has improved, although it is still inferior to the overall reported outcomes of pediatric LT. Being on life support at transplant is a significant risk factor for death and graft loss in very small recipients.
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Affiliation(s)
- Ronen Arnon
- Department of Pediatrics, Mount Sinai School of Medicine, Mount Sinai Medical Center, NY, USA.
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Guo C, Zhang M. Successful Treatment of Biliary Atresia in Very Small Infants through Living Related Liver Transplantation. Case Rep Gastroenterol 2010; 4:158-167. [PMID: 20805938 PMCID: PMC2929409 DOI: 10.1159/000314195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Improving outcomes in very small children is a major goal of pediatric liver transplantation. This report describes our experience of living related liver transplantation in an infant weighing 3.98 kg. The recipient, a 80-day-old male infant with congenital biliary atresia, was treated with living donor liver transplantation and then followed up for 6 months. The left lateral segment (segment II, III) with reduced size from the donor, his 26-year-old mother, was used as the graft. The graft weighed 200 g. The graft weight to recipient body weight ratio was 5.025%. The donor regained her liver function within 3 days and was discharged on day 8. The patient showed good results. Liver function returned to normal 9 days after the operation with bilirubin level almost decreased to normal. Cyclosporin, mycophenolate mofetil and prednisone were used for postoperative immunosuppression. No bleeding, thrombosis, infection or bile leakage occurred. The patient had slight fever because of a little collection in the abdomen and recovered after paracentesis and drainage. He was discharged on day 16. The donor and recipient are in satisfactory condition at present. Improvement of technique in hepatic surgery, microsurgical technique in vascular surgery and postoperative intensive care are the keys to ensure the success of the procedure.
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Affiliation(s)
- Chunbao Guo
- Department of Hepatobiliary Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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Liver Transplantation in Infants with Body Mass Less than 6 KG. POLISH JOURNAL OF SURGERY 2009. [DOI: 10.2478/v10035-009-0010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Polak WG, Peeters PM, Miyamoto S, Sieders E, De Jong KP, Porte RJ, Bijleveld CM, Hendriks HG, TenVergert EM, Slooff MJ. The outcome of primary liver transplantation from deceased donors in children with body weight ≤10 kg. Clin Transplant 2007; 22:171-9. [DOI: 10.1111/j.1399-0012.2007.00762.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
Orthotopic liver transplantation remains a major medical and surgical challenge in small pediatric patients. From April 2003 to June 2006, 21 small babies (each of whom weighed less than 10 kg or was younger than 1 year of age) underwent orthotopic liver transplantation. Five were girls and 16 were boys with a mean age of 15.7 +/- 9.3 months (range, 2-24 months); their mean weight at the time of transplantation was 9.8 +/- 3.6 kg (range, 6-16 kg). All transplants were obtained from a living-related donor. Left lateral segment was used for all transplantations. The median graft-to-recipient weight ratio was 3.5% +/- 1.2% (range, 1.5%-6.1%). During the early postoperative period, hepatic arterial thrombosis was identified in 4 patients, and a biliary leak was detected in 2 patients. In 2 patients, portal vein stenosis was identified during the late postoperative period. At the time of this writing, the 17 alive patients (81%) exhibited good graft function at median follow-up of 14.8 +/- 10.9 months (range, 1-39 months). Four patients died during the follow-up. Histological examination revealed hepatocellular carcinoma in 2 patients, and Burkitt's lymphoma in 1 patient. In conclusion, our data confirmed that living-related donors, especially in this age group, provide a reliable source for the organ pool. Satisfactory results can be achieved despite the anatomic handicaps of this age group.
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Affiliation(s)
- H Karakayali
- Department of General Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
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