LIVER TRANSPLANTATION IN CHILDREN WEIGHTING LESS THAN 6 KG. THE BERGAMO EXPERIENCE.

Abstract

O159 Aims: Liver transplantation (OLTX) remains a major medical and surgical challenge in paediatric patients weighting less than 6 Kg. Methods: From October 1997 through February 2004, 13 babies less than 6.0 Kg.underwent OLTX at the Ospedali Riuniti di Bergamo. They represent 6 % of 217 paediatric candidates for OLTX at our institution. Median age was 5 months (range=1-8); median weight was 5.2 Kg (range, 2.2 to 5.8). The indications were biliary atresia (n=8), neonatal haemochromatosis (n=2), unknown fulminant hepatic failure (n=1), cryptogenic cirrhosis (n=1), haemangio-endothelioma (n=1). Of these 13 patients, 4 were in UNOS status 1, 3 in status 2A and 6 in status 3. One child in UNOS status 1 underwent retransplantation for chronic rejection. One whole, 2 reduced and 11 split liver grafts (left lateral segments) were used. The median donors age and weight were 11 years (range= 0.5-62) and 40 kg (range=7-60) respectively. Donor to recipient median weight ratio (D/R) was 9.2 Kg (range=5.5-17) and median graft-to-recipient weight ratio (GRWR) was 6% (range=3.2-9.3). Results: Surgical complications included biliary strictures (n=3), bile leak (n=1), bowel perforations (n=2), wound dehiscence (n=1) and early portal vein thrombosis (n=1). Biliary anastomotic strictures were successfully treated in 2 cases by percutaneous balloon dilatation and temporary stenting while in one case by surgical redo. The bile leak was managed by percutaneous drainage. Early relaparatomy was necessary to repair bowel perforations (n=2), to achieve abdominal closure (n=1) and to perform portal vein thrombectomy with vascular reconstruction(n=1). Ten children (77%) are alive with a good graft function after a median follow up of 37 months (range=12-69). Three patients died on day 285 (brain death), 17 (multiorgan failure) and 229 (cardiovascular failure) post transplant respectively. In particular the last one died during the retransplant operation and the second received a large graft (D/R =17; GRWR = 8.2). All these patients were in UNOS status 1 at transplantation. Actuarial survival at 5 years is 77%. All the patients who were transplanted in UNOS status 2 or 3 are alive (patient and graft survival=100%) at a median follow up of 41 months (range=12-69). Currently only one of the children who were in UNOS status 1 is alive (patient survival=33%). During the same period one patient died on the waiting list. She was a premature neonate (Kg.1,8) with a fulminant hepatic failure caused by neonatal haemochromatosis in UNOS status 1. Conclusions: Our data confirm that the extensive use of the split liver technique from small adult or pediatric donors can offer the benefits of liver transplantation to very small paediatric candidates with excellent results in elective cases. In our experience patient’s clinical condition (UNOS status 1) and large-for-size grafts (GRWR > 8) are associated with lower survival rate.