P1.15: Paediatric domino liver transplant following multivisceral transplant (liver-inclusive) with splenic preservation – A case report

Abstract

Introduction:A multivisceral transplant followed by domino implantation of the resected liver to another patient was first reported by Tzakis in 1999. Since then there has not been much development in this technique and its implications for both recipients. We present a paediatric multivisceral transplantation with native spleen preservation followed by the use of the recipient’s liver as a domino graft for another child. Patients and Methods:Multivisceral donor: 3 year old boy with hypoxic brain damage, blood group O+, weight 14kg. Multivisceral recipient: 7 year old boy, blood group A+, weight 24 kg, with severe intestinal failure (Neuropathic intestinal dysmotility). No enteral feed and 24-h PN, with persistent central line infections. Listed for multivisceral transplant seeking immunological advantage. At transplant, normal native liver (mild portal fibrosis at biopsy) preserved for domino transplant. Splenic artery and left gastric artery were preserved. Pancreas removed leaving splenic vein. Spleno-caval shunt performed preserving native spleen. Native liver perfused with UW solution and stored. Multiorgan graft implanted (liver, stomach, duodenum, pancreas, small bowel and right haemicolon). CIT: 10h. Domino liver recipient: 3 year old boy, blood group: A+, weight 12 kg, with cholestatic liver disease. Domino liver transplant (graft weight: 484 g, CIT: 10h, duct-to-duct anastomosis). Results:Multivisceral recipient had bowel obstruction (day 3 post-transplant) that required laparotomy. No acute cellular rejection and no serious infections post-operatively. Stoma reversed at 5 m. He remains on enteral feeding and PN support due to rapid bowel transit. The domino liver recipient had acute cellular rejection (day 8 post-transplant). Anastomotic biliary stricture corrected with biliary reconstruction (6 m post-transplant). Conclusion:A liver-inclusive intestinal transplant seems to give an immunological advantage to the recipient by decreasing rejection episodes but make them vulnerable to lethal infections (Wu & Cruz, 2018), which is maybe worsened by native splenectomy at transplantation. Preserving the native spleen may reduce the incidence of PTLD, GVHD and risk of infections. The above case could be a better option than a modified multivisceral transplantation and using the multivisceral recipient’s liver as a domino graft will decrease the impact on the donor pool. More cases are required to establish the advantages of these surgical techniques.