Abdominal Closure in Oversized Pediatric Liver Transplantation - Description and Analysis of a Technique With Step Wise Reduced Patch.

Abstract

Introduction Based on a lack of size matched donors most children undergoing liver transplantation (LTX) receive a technical variant graft from adult donors, resulting in a large-for-size situation especially in smaller children. To avoid complications of further graft reduction (e.g. monosegmental LTX) or complications of an oversized liver graft (e.g. reduced graft perfusion, elevated intraabdominal pressure) we use an interim mesh. Here we describe our technique of step wise abdominal closure by a silastic mesh. Methods Retrospective analysis of our prospective LTX database with review of all surgical reports from 2003 - 2012. Transplantations were divided based on primary abdominal closure versus usage of a silastic mesh. Results Overall 298 pediatric LTX were performed, thereof 23 LTX were excluded from the study (1 intraoperative death; 22 combined liver-kidney transplantations). Primary closure was possible after 187/275(68%) LTX, whereas after 88/275(32%) LTX closure was performed using a patch. Decision about usage and size oft the patch (size trimmed) was guided by doppler ultrasound (DU) (single investigator; DU after reperfusion and abdominal closure, guided by systolic peak flow, resistance index, maximum portal flow). DU-guided operative reduction of the patch was performed every 3 to 4 days. Successful patch removal with definitive closure could be achieved in all children after a median of 2 revisions (range 1-14), after median 6 days (range 1-67 days) with no abdominal hernia development long-term (median follow-up 89mo). Children with patch were significantly younger 0.7(0-14.9) versus 2.8(0-15.9)years and lighter 7(2-35) versus 12(3-62)kg and had higher GRWR 4.4(1-12.5) versus 2.8(0.7-12)% compared to children with primary closure(all p<0.001). Comparing donor age, weight, height, graft weight or kind of graft there was no significant difference. There was no significant difference in the graft (1-/5-y 78.3/71.5% versus 86.2/68.4%) or patient survival (1-/5-y 94.6/90.5% versus 95.1/90%) between children with or without patch (p=0.449/1). Conclusion Successful abdominal closure in pediatric LTX using a silastic mesh with step-wise reduction could be achieved without further graft modifying surgery even in children with very large-for-size grafts.