Variant Techniques for Liver Transplantation in Pediatric Programs

Abstract

Introduction: Several variant techniques have been developed as alternatives to whole liver transplantation to improve size matching, timing, or simply to increase the pool of donors. The aim of this study was to assess the requirements of these techniques and their outcomes in a pediatric transplant program. Patients and Method: A retrospective analysis of children on the waiting list in the last 4 years was carried out. Data of patients who died while on the waiting list (WL) were recorded. Transplanted patients were divided according to the type of graft: whole liver, split, living donor and reduced liver. The analyzed outcome variables were: age, weight, UNOS status, cause of liver failure, complications and graft and patient survival. Comparisons between types of graft were performed by using Kaplan-Meier, log-rank, chi² and Kruskal-Wallis tests. Results: During the period studied, 116 children were listed for liver transplantation. Of these 116 children, nine (7.7 %) died after a mean period of 40.5 (5–175) days waiting for a suitable graft. Their median age at inclusion was 214 (35–1607) days, and median weight was 7.2 (12.3–3.6) kg. The cause of liver failure in this group was: 1 hemochromatosis, 1 hepatoblastoma, 2 biliary atresia, 2 acute liver failure, 2 primary non-function (PNF) and 1 chronic rejection. Liver transplantation was performed in 103 children: 25 (24 %) whole livers, 17 (16.5 %) split, 29 (28 %) living donor, 32 (31 %) reduced and 4 remain on the waiting list. Recipient age and weight were significantly lower in those receiving split and living donor than in those who given whole livers. Patient and graft survival were similar in all groups although there was a trend to lower graft survival in patients receiving whole livers. More than 50 % of patients with UNOS status I received a split graft and 5/6 children with hepatoblastoma underwent living donor transplantation. There were no differences in the rate of acute vascular complications, but long-term biliary complications were more frequent in split and living donor grafts. Conclusions: As long as the goal of zero mortality for children on the waiting list is not achieved, variant techniques will be necessary in pediatric liver transplantation programs. Split and living donor were employed mostly to treat younger children and particularly those with a higher UNOS status. Children with tumors were treated mainly with living donor grafts. Variant techniques, which are absolutely necessary in a pediatric program, need to be improved in order to avoid long-term biliary complications.

Key words

liver transplantation - children - split - living donor - reduced graft

References

• 1 Bismuth H, Morino M, Castaing D, Gillon M C, Descorps Declere A, Saliba F. et al . Emergency orthotopic liver transplantation in two patients using one donor liver.  Br J Surg. 1989;  76 722-724
• 2 Broelsch C E, Emond J C, Whitington P F, Thistlethwaite J R, Baker A L, Lichtor J L. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts, and living related segmental transplants.  Ann Surg. 1990;  212 368-375
• 3 Otte J B. Paediatric liver transplantation – a review based on 20 years of personal experience.  Transpl Int. 2004;  17 562-573
• 4 Pichlmayr R, Ringe B, Gubernatis G, Hauss J, Bunzendahl H. [Transplantation of a donor liver to 2 recipients (splitting transplantation) – a new method in the further development of segmental liver transplantation].  Langenbecks Arch Chir. 1988;  373 127-130
• 5 Rogiers X, Malago M, Gawad K, Jauch K W, Olausson M, Knoefel W T. et al . In situ splitting of cadaveric livers. The ultimate expansion of a limited donor pool.  Ann Surg. 1996;  224 331-339
• 6 Tanaka K, Uemoto S, Tokunaga Y, Fujita S, Sano K, Nishizawa T. et al . Surgical techniques and innovations in living related liver transplantation.  Ann Surg. 1993;  217 82-91
• 7 Ueda M, Oike F, Ogura Y, Uryuhara K, Fujimoto Y, Kasahara M. et al . Long-term outcomes of 600 living donor liver transplants for pediatric patients at a single center.  Liver Transpl. 2006;  12 1326-1336