Reconstruction In Pediatric Liver Transplantation Research Articles

223.5: Biodegradable stent for biliary reconstruction in pediatric liver transplantation, surgical approach.

223.5: Biodegradable stent for biliary reconstruction in pediatric liver transplantation, surgical approach.

Systematic Review and Meta-Analysis of the Outcomes After Hepatic Artery Reconstruction in Pediatric Liver Transplantation Using a Microscope Versus Surgical Loupe

BackgroundTo review the impact of the operating microscope (OM) for reconstruction of the hepatic artery (HA) by comparing the outcomes with standard loupe reconstruction (SL) in pediatric liver transplantation (LT). MethodsStudies comparing the application of OM and SL for the reconstruction of the HA in primary pediatric LT were included from a systematic search of MEDLINE, Cochrane Library and EMBASE from inception to June 2022. Re-transplantation, dual grafts and auxiliary transplants were excluded. Primary outcome was the rate of HA thrombosis (HAT). Secondary outcomes were graft loss and mortality. ResultsThere were 1261 liver recipients from 9 included studies published until June 2022. There were 484 patients in the OM group and 777 patients in the SL group. HAT incidence with OM was significantly lower with OR = 0.18 (95% CI: 0.07-0.48). The 1-year graft survival was significantly better in the OM group with OR = 2.77 (95% CI: 1.13-6.80). 1-year overall mortality was also significantly lower with OM with OR = 0.39 (0.18-0.86). The use of OM did not significantly impact the incidence of HAT in the living donor liver transplant subgroup. Differences in time for hepatic HA reconstruction, total operating time and length of hospital stay did not reach statistical significance. ConclusionThe use of OM has reduced the risk of HAT, graft loss and mortality in pediatric liver transplantation. Adoption of microsurgical principles in general may have contributed to the improved outcomes with SL reconstruction of HA in pediatric LT.

Comment on The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation

Comment on The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report

Portal vein reconstruction in pediatric liver transplantation using end-to-side jump graft: A case report

End-to-side jump graft from superior mesenteric vein for portal vein reconstruction in pediatric liver transplantation: a case report

Jaewon Lee, Nam-Joon Yi, Jiyoung Kim, Hyun Hwa Choi, Sola Lee, Su Young Hong, Suk Kyun Hong, YoungRok Choi, Kwang-Woong Lee, Kyung-Suk Suh. Korean J Transplant 2022;36:295. https://doi.org/10.4285/ATW2022.F-4352

312.3: Outcomes of Duct-To-Duct Biliary Anastomosis in Pediatric Liver Transplantation Using Left Sided Graft

Background: Roux-en-Y hepaticojejunostomy(HJ) is the standard-of-care for biliary reconstruction in pediatric liver transplantation(LT), especially in left sided grafts. This study aimed to investigate the learning curve and the risk of biliary complication of duct-to-duct biliary anastomosis(DDA) in pediatric LT using left sided grafts. Method: This was a retrospective study from a surgical unit of a university-affiliated center. From 2017-2020, DDA was performed in pediatric LT with a high hilar dissection and patch anastomosis technique under a prospective protocol.(Figure 1) The exclusion criteria were: 1) disease mandated HJ, 2) widely separated graft bile ducts that ductoplasty was infeasible, 3) native biliary anatomical factors that rendered a patch infeasible. Size discrepancy was not a contraindication. The primary endpoint was the risk of biliary complication at 1-year after LT. Results: During study period, 137 pediatric recipients fulfilled inclusion and were considered eligible for DDA, 110 (80.3%) patients had DDA. The pre-transplant characteristics were listed in table 1. The first 40 patients belonged to learning curve period and after that, more patients were eligible for DDA (7.2% vs. 15.1%, P<0.001). The overall risk of biliary complication at 1-year was 2.9% (4/137) and it was higher in the learning phase (9.1% vs 1.3%, P=0.045). Of the 4 biliary complications: 1 had bile leakage and stricture and required endoscopic stenting; 3 had biliary stricture with 2 required conversion to HJ and 1 had endoscopic stenting. All 4 patients have normal graft function at time of analysis. There was only one hospital mortality (1/137, 0.7%) and was due to post-operative bleeding and was unrelated to biliary complication. Graft survival rates at 1-and 3-year after DDA were 98.2% and 96.8% respectively. Conclusion: DDA was safe and feasible with excellent perioperative and long-term outcomes and should be considered the primary choice for biliary reconstruction in eligible pediatric transplant patients.

The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation.

Hepatic artery thrombosis represents a potentially fatal complication following liver transplantation. Rates of hepatic artery thrombosis are significantly higher in children, with mortality reported up to 80 percent. Microsurgical anastomosis has been shown to decrease the rate of hepatic artery thrombosis and now represents the standard of care at the authors' institution. In this article, the authors present the largest study of its type directly comparing rates of hepatic artery thrombosis with and without microsurgical reconstruction of the hepatic artery. All pediatric patients who underwent primary orthotopic liver transplantation between 1989 and 2018 were included. Patients were divided into two cohorts: standard anastomosis with loupes, and microsurgical anastomosis under the operating microscope. The authors' primary outcome was the rate of hepatic artery thrombosis. Secondary outcomes were graft survival, patient survival, retransplantation rate, requirement for intraoperative blood products, and length of stay. Two hundred thirty-one children met criteria for inclusion. One hundred eighty cases were performed with loupe magnification and 51 cases were performed under the microscope. The hepatic artery thrombosis rate was lower, but not significantly so (p = 0.114), in the microsurgical group [n = 1 (2.0 percent)] compared with the standard cohort [n = 15 (8.3 percent)]. Survival analysis revealed a significant increase in graft survival with microsurgical anastomosis (p = 0.020), but not patient survival (p = 0.196). The retransplantation rate was significantly lower with microsurgical anastomosis (p = 0.021). Microsurgical anastomosis was associated with a clinically important decrease in hepatic artery thrombosis compared with standard loupe anastomosis. The graft survival rate was significantly higher in the microsurgical cohort, with a reduced retransplantation rate at 1 year. On this basis, the authors recommend microsurgical hepatic artery anastomosis in cases of pediatric liver transplantation. . Therapeutic, III.

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

Hepatic artery reconstruction in pediatric liver transplantation: Experience from a single group

BackgroundThe reconstruction of hepatic artery is a challenging part of the pediatric liver transplantation procedure. Hepatic artery thrombosis (HAT) and stenosis are complications which may result in ischemic biliary injury, causing early graft lost and even death. MethodsTwo hundred and fifty-nine patients underwent liver transplantation in 2017 in a single liver transplantation group. Among them, 225 patients were living donor liver transplantation (LDLT) and 34 deceased donor liver transplantation (DDLT). ResultsIn LDLT all reconstructions of hepatic artery were microsurgical, while in DDLT either microsurgical reconstruction or traditional continuous suture technique was done depending on different conditions. There were five (1.9%) HATs: four (4/34, 11.8%) in DDLT (all whole liver grafts) and one (1/225, 0.4%) in LDLT (P = 0.001). Four HATs were managed conservatively using anticoagulation, and 1 accepted salvage surgery with re-anastomosis. Until now, 3 HAT patients remain in good condition, whereas two developed biliary complications. One of them needed to be re-transplanted, and the other patient died due to biliary complications. ConclusionsMicrosurgical technique significantly improves the reconstruction of hepatic artery in pediatric liver transplantation. The risk for arterial complications is higher in DDLT. Conservative therapy can achieve good outcome in selected HAT cases.

Outcomes after discontinuation of routine use of transanastomotic biliary stents in pediatric liver transplantation at a single site.

Routine use of transanastomotic biliary stents (RTBS) for biliary reconstruction in liver transplantation (LT) is controversial, with conflicting outcomes in adult randomized trials. Pediatric literature contains limited data. This study is a retrospective review of 99 patients who underwent first LT (2005-2014). In 2011, RTBS was discontinued at our center. This study describes biliary complications following LT with and without RTBS. 56 (56%) patients had RTBS. Median age at LT was 1.9 yr (IQR 0.7, 8.6); 55% were female. Most common indication for LT was biliary atresia (36%). Most common biliary reconstruction was Roux-en-Y choledochojejunostomy (75% with RTBS, 58% without RTBS, p = 0.09). Biliary complications (strictures, bile leaks, surgical revision) occurred in 23% without significant difference between groups (20% with RTBS, 28% without RTBS, p = 0.33). Patients with RTBS had routine cholangiography via the tube at 6-8 wk; thus, significantly more patients with RTBS had cholangiograms (91% vs. 19%, p < 0.0001). There was no difference in the number of patients who required therapeutic intervention via endoscopic or percutaneous transhepatic cholangiography (11% with RTBS, 19% no RTBS, p = 0.26). Routine use of RTBS for biliary reconstruction in pediatric LT may not be necessary, and possibly associated with need for costlier, invasive imaging without improvement in outcomes.

A novel classification of arterial reconstruction in pediatric liver transplantation and its relation with arterial thrombosis

A novel classification of arterial reconstruction in pediatric liver transplantation and its relation with arterial thrombosis

Biliary Reconstruction in Pediatric Liver Transplantation: A Case Report of Biliary Complications and Review of the Literature

With the advent of segmental liver allografts from liver donors, reduced-size cadaveric allografts, and split cadaveric allografts, pediatric pre-transplantation patient mortality has reduced. However, this expansion of the donor pool for size-appropriate allografts for patients with end-stage liver disease has led to an increased incidence of biliary complications. We performed a retrospective review of our series of 242 pediatric patients who received a liver transplantation. Biliary complications at our institution are presented, with a review of the current literature identifying risk factors that predispose pediatric liver transplant patients to biliary complications. We present the protocol used at our institution to minimize risk of biliary complications in our pediatric post-operative patient population.

Duct-to-Duct Biliary Reconstruction in Pediatric Liver Transplantation: One Center’s Results

In pediatric liver transplantation, both for cadaveric and living-related patients, the Roux-en-Y hepaticojejunostomy is often preferable to biliary reconstruction. Duct-to-duct biliary reconstruction in pediatric patients has been utilized only in a limited numbers of studies. Here, we retrospectively review our experience with duct-to-duct biliary reconstruction in pediatric liver transplantation patients. Since September 2001, 46 liver transplantations have been performed in 44 patients (29 boys and 15 girls of mean age, 8.4 ± 5.5 years). For the anastomoses, a corner-saving suture technique was used with 6-0 or 7-0 polypropylene monofilament nonabsorbable suture. A T tube was used in three patients, and in 11 patients, a straight feeding tube was inserted from the recipient common bile duct to the anastomotic site. A transhepatic biliary catheter insertion technique was used in 28 patients for external bile drainage; the remaining four patients had no tubes or stents. Four patients developed bile leakage in the early postoperative period. Three of these patients were treated with percutaneous drainage with excellent outcomes; the remaining patient required reoperation with a Roux-en-Y hepaticojejunostomy for bile leakage. Four biliary stenoses occurred in the late postoperative period. All biliary stenoses were successfully treated with balloon dilatation. There was no mortality or graft loss due to biliary complications. Of the 44 original patients, 36 (82%) are well at this time, with optimal liver function during follow-up (2–34 months). The remaining eight (18%) died during the study from acute respiratory distress syndrome ( n = 2), sepsis with multiorgan failure ( n = 5), and intracranial bleeding ( n = 1). Our results showed that duct-to-duct biliary reconstruction is a safe and easy technique for pediatric patients.

Innovative techniques for and results of portal vein reconstruction in living-related liver transplantation

Background: Portal vein reconstruction is a crucial factor affecting the outcome of a successful living-related liver transplantation. We describe here our experience with portal vein reconstruction in 314 cases of living-related liver transplantation with use of novel surgical modalities to enable the transplant surgeons to deal with any size mismatch between the donor's and recipient's portal veins. Methods: Portal vein reconstruction was classified into 2 major groups, anastomosis without and with a vein graft. When there was no stenosis of the recipient portal vein and the diameter was the same, the portal trunk was used for anastomosis. When the diameter mismatch was minimal, branch patch anastomosis was feasible. When the recipient portal vein was significantly stenotic and the portal vein of the graft was long enough, we removed the stenotic trunk and constructed an anastomosis between the graft portal vein and the confluence of the recipient portal vein. When the graft portal vein was short, a vein graft was interposed. The vein patch technique was preferable when the diameter of the graft vein was not large enough for the interposition technique. Results: Anastomosis without vein graft included trunk anastomosis (n = 156), branch patch anastomosis (n = 39), and confluence anastomosis (n = 22). Anastomosis with vein graft used the interposition technique (n = 77) and vein patch technique (n = 27). The origin of the grafts was mostly from the maternal left ovarian vein (70%) or the paternal inferior mesenteric vein (27%). Complications related to portal vein reconstruction occurred in 16 (5%) patients: portal vein thrombosis in 8, stenosis in 7, and fatal rupture in 1 patient. The incidence of complications was similar for all techniques except for confluence anastomosis. Conclusion: Our innovative techniques should be helpful for overcoming diameter or length mismatches in portal vein reconstruction in pediatric liver transplantation. (Surgery 1999;125:265-70.)

Donor vascular grafts for arterial reconstruction in pediatric liver transplantation

The authors compared the results of 48 orthotopic liver transplantations (OLT) in which revascularization was achieved with a conduit interposed between the receptor aorta and the graft (vascular graft [VG] group) with those obtained for 56 OLT performed during the same period (1991 to 1994) in which end-to-end anastomosis (EEA) of the hepatic arteries or celiac trunk was used (EEA group). In the VG group, the interposed conduits were the cadaveric iliac artery (37) the living-donor saphenous vein (3), or nonthrombosed conduits from previous transplants (8) (7 iliac arteries, 1 saphenous vein). There were significant differences between the two groups with respect to recipient age, recipient weight, the retransplant:first transplant ratio, the number of emergency transplantations, the use of reduced-size grafts, and intraoperative transfusion requirements. Twenty-nine grafts in the VG group (60.4%) and 43 in the EEA group (76.7%) currently are functioning. The actuarial 3-year graft survival rates are 60% and 71.5% for the VG and EEA groups ( P < .05), respectively. The rate of arterial thrombosis did not differ between the two groups. The authors conclude that, although EEA of the hepatic artery is still the perferred revascularization technique for OLT, revascularization of the liver graft by conduit interposition is safe when EEA is not possible. Reutilization of the interposed conduit during retransplantation proved to be safe in the absence of hepatic artery thrombosis.