Related Experiment Videos
Composite liver--small bowel allografts with preservation of donor duodenum and hepatic biliary system in children
J Bueno1, K Abu-Elmagd, G Mazariegos
1Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Children's Hospital of Pittsburgh, PA 15213, USA.
Insights
The duodenal-sparing liver small bowel transplant technique (DLSBTx) simplifies surgery and avoids biliary reconstruction. This innovative approach expands the donor pool for pediatric patients needing liver and intestinal transplants.
Area of Science:
- Hepatology
- Transplantation Surgery
- Pediatric Surgery
Background:
- Children with intestinal failure and total parenteral nutrition-induced liver failure often require liver and intestinal transplants.
- Standard transplant techniques necessitate biliary reconstruction, which can lead to complications and limit donor organ availability.
- Donor organ size matching is a significant challenge in pediatric liver and intestinal transplantation.
Purpose of the Study:
- To introduce and evaluate the duodenal-sparing liver small bowel allograft technique (DLSBTx) for pediatric liver and intestinal transplantation.
- To improve patient outcomes by simplifying the surgical procedure and reducing post-transplant complications.
- To expand the donor pool by enabling the use of size-mismatched and reduced-size allografts.
Main Methods:
- Nine children underwent DLSBTx, with some receiving reduced livers or whole pancreases.
- Transplants were performed using tacrolimus and steroid immunosuppression.
- Donor and recipient characteristics, including weight and age, were recorded.
Main Results:
- The DLSBTx procedure demonstrated patient and graft survival rates of 78% and 67%, respectively, at a mean follow-up of 419 days.
- This technique expanded the donor pool, allowing transplantation of 6 patients with donor-to-recipient weight ratios >=1 and utilizing small donors, including a neonatal donor.
- No duodenal allografts showed signs of ischemia or leak, although 55% experienced early postoperative chemical pancreatitis.
Conclusions:
- DLSBTx offers technical advantages by avoiding biliary reconstruction and simplifying the operative procedure.
- The technique's feasibility with split or reduced liver grafts enhances the potential to increase the donor pool across all age groups, from neonates to adults.
- This approach holds promise for improving outcomes in pediatric liver and intestinal transplantation.
Background/Purpose:
Liver and intestinal transplantation is commonly required for children with intestinal failure who suffer concomitant total parenteral nutrition (TPN)-induced liver failure. Retrieval of such composite allografts using previously described "standard techniques" mandates reconstruction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications have been associated with significant morbidity and mortality. Also, size matching has limited the pool of donor organs for this patient population. To improve outcome and increase the donor pool the authors have utilized a duodenal-sparing composite liver small bowel allograft technique (DLSBTx) by preserving the head of the pancreas and the pancreatic-duodenal arteries. This precludes a biliary drainage procedure.
Methods:
Nine children (5 girls, 4 boys), with a mean age of 1.4 years (range, 1 to 17.4 years) received a DLSBTx. In 2 patients the liver was reduced; 1 patient received the whole pancreas. The mean recipient weight at the time of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age and mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 kg (range, 4 to 70 kg), respectively. All transplants were performed under tacrolimus and steroid immunosuppression.
Results:
With a mean follow-up of 419 days (range, 5 to 795 days), patient and graft survival rates are 78% and 67%, respectively. One patient underwent a combined retransplantation with the standard technique 31 days after the primary allograft was destroyed by a native pancreatic fistula. Currently, all surviving recipients are at home and off TPN. DLSBTx allowed the expansion of the donor pool by transplanting 6 patients with donor to recipient weight ratio > or =1 and utilizing 2 less than 5-kg donors, including a neonatal donor. In 55% of the patients, chemical pancreatitis was observed during the early postoperative period. None of the duodenal allografts experienced signs of ischemia or leak.
Conclusions:
The technical advantages of this procedure include avoidance of a biliary reconstruction and simplification of the operative procedure. This, together with the feasibility of split or reduced liver grafting promises to increase the donor pool from neonates to adults.