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Technical Choices in Pediatric Living Donor Liver Transplantation: The Path to Reduce Vascular Complications and
João Seda Neto1,2,3, Eduardo A Fonseca1,2,3, Rodrigo Vincenzi1,2,3
1Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil.
Insights
Technical advancements in pediatric living donor liver transplantation (PLDLT) significantly reduced complications like hepatic artery thrombosis and portal vein thrombosis, improving patient and graft survival rates.
Area of Science:
- Hepatology
- Pediatric Surgery
- Transplantation Medicine
Background:
- Pediatric living donor liver transplantation (PLDLT) is a vital treatment for pediatric liver disease.
- Early PLDLT outcomes spurred the development of technical refinements to enhance success.
Purpose of the Study:
- To evaluate the outcomes of 975 primary PLDLTs performed across three distinct practice periods.
- To assess the impact of technical advancements on complication rates and survival in PLDLT.
Main Methods:
- Retrospective analysis of 975 primary PLDLTs divided into three periods: 1995-1999, 2000-2009, and 2010-2019.
- Identification and implementation of specific technical refinements in the third period, including hyperreduced grafts and double arterial anastomoses.
Main Results:
- Significant reductions in hepatic artery thrombosis (HAT), early portal vein thrombosis (EPVT), and retransplantation rates were observed in the third period.
- Improved patient and graft survival rates were documented in the third period compared to earlier periods.
- HAT, EPVT, and higher Pediatric End-Stage Liver Disease (PELD) scores were independently associated with worse 90-day patient survival.
Conclusions:
- Technical refinements, coupled with enhanced patient care, led to decreased EPVT, HAT, and retransplantation in PLDLT.
- These improvements resulted in increased patient and graft survival across all studied time points.
- PLDLT remains a successful therapeutic option for children, with ongoing advancements continually improving outcomes.
Abstract:
Pediatric living donor liver transplantation (PLDLT) is a successful therapeutic option for children with chronic and acute liver disease. After early transplant results, many technical advancements were introduced in the field to reduce the rate of complications and improve survival. The aim of this study is to present the outcomes of 975 primary PLDLTs in 3 periods: initial practice (period 1, 29 patients, January 1995 to December 1999), second period (period 2, 331 patients, January 2000 to December 2009), and third period (period 3 [P3], 615 patients, January 2010 to September 2019). Among the technical refinements introduced in P3 are the use of hyperreduced left lateral segment grafts, abdominal wall prosthetic mesh closure, double hepatic artery anastomosis, and increased use of vascular grafts for portal vein reconstruction. The outcomes included significant reductions of hepatic artery thrombosis (HAT), early portal vein thrombosis (EPVT), and retransplantation, with better patient and graft survival in P3. Additional analyses showed that the factors independently associated with worse 90-day patient survival were HAT, EPVT, and increasing Pediatric End-Stage Liver Disease score. In conclusion, the introduction of technical refinements in P3, in addition to improvements in patient care, determined a reduction in EPVT, HAT, and retransplantation. Consequently, patient and graft survival rates increased in all time points studied.
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