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Technique of Porcine Liver Procurement and Orthotopic Transplantation using an Active Porto-Caval Shunt
Published on: May 7, 2015
Mild to Moderate Intrapulmonary Shunting in Pediatric Liver Transplantation: Is Screening Necessary?
V P Mali1, A Fukuda2, T Shigeta2
1Department of Paediatric Surgery, National University Hospital, Singapore; Organ Transplantation Centre, National Centre for Child Health and Development, Tokyo, Japan.
Insights
Screening for intrapulmonary vascular shunting (IPVS) before and after pediatric liver transplantation (LT) is crucial. Mild to moderate IPVS did not significantly impact transplant outcomes, suggesting LT is viable in these cases.
Area of Science:
- Hepatology
- Pediatric Gastroenterology
- Cardiopulmonary Medicine
Background:
- Intrapulmonary vascular shunting (IPVS) is linked to poor outcomes in pediatric liver transplantation (LT).
- Current guidelines for screening IPVS in pediatric LT are lacking.
- This study investigates IPVS prevalence and impact in pediatric LT recipients.
Purpose of the Study:
- To evaluate intrapulmonary vascular shunting (IPVS) before and after pediatric liver transplantation (LT).
- To assess the relationship between IPVS severity and post-transplant outcomes.
- To determine if LT is feasible in children with mild to moderate IPVS.
Main Methods:
- Retrospective review of 370 pediatric LT cases (2005-2015).
- Included children with cirrhosis and suspected IPVS, excluding cardiac/pulmonary conditions.
- Utilized 99mTechnetium labelled macroaggregated albumin (99mTcMAA) scans to grade IPVS severity via shunt ratios.
Main Results:
- Twenty-four children met inclusion criteria; all had mild to moderate IPVS.
- Mean shunt ratio decreased post-LT (20.69% to 15.1%, P=.06).
- No significant difference in mortality, PVT, biliary strictures, or graft loss compared to controls. Hepatopulmonary syndrome (HPS) observed in 2/24 children.
Conclusions:
- Hepatopulmonary syndrome (HPS) is less common with mild to moderate IPVS.
- Pediatric liver transplantation (LT) can yield comparable results even with mild to moderate intrapulmonary vascular shunting (IPVS).
- Further research may inform screening guidelines for IPVS in pediatric LT.
Background:
Despite reported associations between intrapulmonary vascular shunting (IPVS) and morbidity and mortality in pediatric liver transplantation (LT), there are no guidelines for screening.
Objective:
To investigate IPVS before and after pediatric LT.
Methods:
Retrospective records review of all pediatric LT (n = 370) from 2005 to 2015 at a single institute in Japan. All children with cirrhosis and clinical suspicion of IPVS without cardiac or pulmonary conditions were included. 99mTechnetium labelled macroaggregated albumin (99mTcMAA) scans were performed before and after LT. The severity of IPVS was graded using shunt ratios.
Results:
Twenty-four children fulfilled inclusion criteria and underwent Tc99MAA scans. All revealed mild (<20%) to moderate (20%-40%) grades of IPVS. Following LT, the mean shunt ratio regressed from 20.69 ± 6.26% to 15.1 ± 3.4% (P = .06). The median (range) follow-up was 17 (4-85) months. Mortality was zero. The incidence of portal vein thrombosis (4.2%) biliary strictures (12.5%) and graft loss (4.1%) in the study group was not statistically significant compared to the remainder of the 370 transplants (3.2%, 9.4% and 3%, respectively). Sub-group analysis revealed hepatopulmonary syndrome (HPS) in 2 out of 24 children. The mean shunt ratios before and after LT were 39.2 ± 0.77% and 16.2 ± 8.5%, respectively (P = .08). There was 1 complication (intra-abdominal abscess).
Conclusions:
HPS is less likely in mild to moderate IPVS. LT may achieve comparable results when performed in the presence of mild to moderate IPVS.
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