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Published on: April 8, 2018
The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation
Kevin J Nickel1, John Staples1, Glenda Meeberg1
1From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta.
Insights
Microsurgical hepatic artery anastomosis in pediatric liver transplants shows promise. This technique may reduce hepatic artery thrombosis and improve graft survival, leading to fewer retransplantations.
Area of Science:
- Transplantation Surgery
- Pediatric Surgery
- Vascular Surgery
Background:
- Hepatic artery thrombosis is a critical complication in liver transplantation, especially in children, with high mortality.
- Microsurgical anastomosis is increasingly adopted to mitigate this risk.
- This study compares microsurgical vs. standard anastomosis for hepatic artery reconstruction in pediatric liver recipients.
Purpose of the Study:
- To compare the incidence of hepatic artery thrombosis between microsurgical and standard anastomosis techniques.
- To evaluate the impact of microsurgical anastomosis on graft survival, patient survival, and retransplantation rates.
- To assess secondary outcomes including blood product usage and hospital length of stay.
Main Methods:
- Retrospective analysis of pediatric liver transplant recipients (1989-2018).
- Two cohorts: standard anastomosis (loupes) vs. microsurgical anastomosis (microscope).
- Primary outcome: hepatic artery thrombosis rate; secondary outcomes: graft/patient survival, retransplantation, blood products, length of stay.
Main Results:
- Lower, though not statistically significant, hepatic artery thrombosis rate in the microsurgical group (2.0% vs. 8.3%).
- Significantly higher graft survival (p=0.020) in the microsurgical cohort.
- Significantly lower retransplantation rate (p=0.021) with microsurgical anastomosis.
Conclusions:
- Microsurgical hepatic artery anastomosis is associated with a clinically meaningful reduction in hepatic artery thrombosis.
- This technique significantly improves graft survival and reduces retransplantation rates in pediatric liver transplantation.
- Microsurgical anastomosis is recommended for pediatric liver transplant recipients.
Background:
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.
Methods:
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.
Results:
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).
Conclusions:
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. .
Clinical Question/Level Of Evidence:
Therapeutic, III.
