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Biliary strictures affect 4%−12% of pediatric liver transplantations. Biliary strictures can contribute to graft loss if left untreated; however, there remains no consensus on the best course of treatment. Study objectives included analyses of outcomes associated with biliary stricture management strategies via percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), or surgery. We identified pediatric liver transplantation recipients (2011–2016) with biliary strictures from the Society of Pediatric Liver Transplantation (SPLIT) registry and retrieved imaging, procedural, and operative reports from individual centers. Subanalyses were performed to specifically evaluate PTC and ERCP for “optimal biliary outcome” (OBO), defined as graft survival with stricture resolution and without recurrence or surgery. A total of 113 children with a median follow-up of 3.9 years had strictures diagnosed 100 days (interquartile range, 30–290) after liver transplantation; 81% were isolated anastomotic strictures. Stricture resolution was achieved in 92% within 101 days, more frequently with isolated anastomotic strictures (96%). 20% of strictures recurred, more commonly in association with hepatic artery thrombosis (32%). Patient and graft survival at 1 and 3 years were 99% and 98% and 94% and 92%, respectively. In a subgroup analysis of 79 patients with extrahepatic strictures managed by PTC/ERCP, 59% achieved OBO following a median of 4 PTC, and 75% following a median of 3 ERCP (P < 0.001). Among patients with OBO, those with ERCP had longer time intervals between successive procedures (41, 47, 54, 62, 71 days) than for PTC (27, 31, 36, 41, 48 days; P < 0.001). Allograft salvage was successful across all interventions. Stricture resolution was achieved in 92%, with 20% risk of recurrence. Resolution without recurrence was highest in patients with isolated anastomotic strictures and without hepatic artery thrombosis.

Background Post-operative biliary complications have been reported to occur in 10-33% of pediatric liver transplantation (LTx) recipients. (2-10) Percutaneous intervention has become the primary treatment method for these complications; however, efficacy and outcomes of these patients have not been well studied. Methods Institutional pediatric LTx from 1998 to 2019 were retrospectively reviewed to determine the patients referred for percutaneous treatment of post-LTx biliary strictures. Clinical parameters, percutaneous transhepatic biliary cholangiograms (PTC), biliary catheter placement, cholangioplasty, and long-term outcomes were analyzed. Results Of the 396 consecutive pediatric LTx recipients during our study period, 50 (12.6%) were diagnosed with biliary strictures on PTC. LTx biliary reconstruction was Roux-en-Y hepaticojejunostomy (HJ) in 28 (56%), choledochojejunostomy (CJ) in 11 (22%), and choledochocholedochostomy (CC) in 11 (22%). Median age at LTx was 23.2 months (IQR, 10.9-90.6) and 14 (28%) patients developed hepatic artery thrombosis. Forty-four (88%) patients were treated with internal/external biliary catheters, of whom 38 (76%) underwent balloon cholangioplasty. By 12 months, 84% of patients had complete stricture resolution and catheter removal. Median total duration of catheter drainage was 152 days (IQR, 76-308). Eight patients required additional surgery (biliary reconstruction or re-LTx) or died with drainage catheter in place from complications unrelated to PTC intervention. Amongst the six (12%) treated with unilateral external biliary drainage catheters, two had catheters removed for inadequate drainage but then had spontaneous biliary obstruction resolution, one underwent duct reconstruction, and three required long-term catheterization. Conclusions Biliary strictures following pediatric LTx can be successfully treated with internal/external biliary drainage catheters and cholangioplasty if the stricture can be crossed. However, patients with isolated strictured ducts may require long-term external catheter drainage until re-LTx or percutaneous obliteration of isolated ducts.

Background: The reconstruction of hepatic artery (HA) is most complex step in living donor liver transplantation (LDLT) due to smaller diameter of the artery and increased risk of HA related complications. Due to smaller diameter of the HA, many centres use microsurgical technique with interrupted sutures for arterial anastomosis. Aim of our study was to retrospectively investigate the outcomes after HA reconstruction performed under magnifying loupes using “parachute technique”. Materials and Methods: From August 2002 to 31st August 2016, LDLT was performed in 766 recipients. HA reconstruction for initial 25 LDLT surgeries was performed using microsurgery technique (Era I). From May 2007 till date, HA reconstruction was performed in 741 recipients by a “parachute technique” under surgical loupes (Era II). Results: HA reconstruction was performed using surgical loupes in 737 adults (Male:Female, 526:211) and 4 pediatric patients (Male:Female, 3:1). Average diameter of the donor graft HA was 2.8 mm (range,1 to 6.5 mm). The most notable factor in this era was quick HA anastomosis procedure with a mean time of 10 ± 5 minutes (range, 5-30 minutes). In Era II, nine patients (1.21%) developed hepatic artery thrombosis (HAT) whereas 2 patients developed non-thrombotic HA related complications. Extra-anatomic HA reconstruction was performed in 14 patients due to either primary HA anastomosis failure or poor caliber recipient HA. Conclusions: Use of magnifying surgical loupes to perform HA reconstruction is safe, feasible, and yields low incidence of HA related complications. The “Parachute Technique” for HA reconstruction can achieve a speedy reconstruction without increasing risk of HAT. This article is protected by copyright. All rights reserved.

Although there is an agreement that liver grafts from pediatric donors (PDs) should ideally be used for pediatric patients, there remain situations when these grafts are turned down for pediatric recipients and are then offered to adult recipients. The present study aimed to investigate the outcomes of using these grafts for liver transplantation (LT) in adult patients. Data from all patients undergoing LT between 2002 and 2014 were obtained from the United Network for Organ Sharing Standard Analysis and Research file. Adult recipients undergoing LT were divided into 2 groups: those receiving a pediatric liver graft (pediatric-to-adult group) and those receiving a liver graft from adult donors (adult-to-adult group). A separate subgroup analysis comparing the PDs used for adult recipients and those used for pediatric recipients was also performed. Patient and graft survival were not significantly different between pediatric-to-adult and adult-to-adult groups (P = 0.08 and P = 0.21, respectively). Hepatic artery thrombosis as the cause for graft loss was higher in the pediatric-to-adult group (3.6%) than the adult-to-adult group (1.9%; P

In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing ≤6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing ≤6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing ≤6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates.

Hepatic artery thrombosis (HAT) after liver transplantation (LT) increases patient morbidity and mortality. Early HAT is considered to occur within the first month after LT, whereas late HAT occurs after the first month. Few studies have addressed late HAT after LT, especially in pediatric patients. Between 1987 and 2007, 99 patients (age

Indocyanine green clearance (Cl-ICG) has been used to assess liver function and hepatic blood flow mainly before and after hepatic surgery. Cl-ICG (invasive method) has been reported to be a good marker of early graft function after liver transplantation (LT). The goal of this study was to determine if the indocyanine green plasma disappearance rate (PDR-ICG), measured by a noninvasive technique (LiMON, Impulse Medical System, Munich, Germany), is predictive of complications and graft outcome after LT. From September 2005 to June 2006, 72 LT recipients were included in the study. PDR-ICG was measured daily (from day 0 to day 5 after LT) with a digital sensor after patients were injected with 0.25 mg/kg indocyanine green. A PDR-ICG cutoff level of 12.85%/minute was predictive of the development of a serious postoperative complication. The sequential changes of PDR-ICG enabled us to differentiate 2 groups: (1) patients with early severe complications (hepatic artery thrombosis, primary graft nonfunction, or sepsis) who had a low value of PDR-ICG during the first 5 posttransplantation days (average, 8.8 +/- 4.5%/minute) and (2) patients who developed acute rejection and who had a progressive reduction of PDR-ICG between days 0 and 5 (from 25.5 +/- 4.8 to 10.3 +/- 2.5%/minute; P < 0.002). In conclusion, after LT, PDR-ICG (a noninvasive technique), measured regularly during the first 5 postoperative days, is a safe technique that can predict early postoperative complications.

Infants with end-stage liver disease represent a treatment challenge. Living donor liver transplantation (LDLT) is the only option for timely liver transplantation in many areas of the world, adding to the technical difficulties of the procedure. Factors that affect morbidity and mortality can now be determined, which opens a new era for improvement. We have accumulated an 11-year experience with LDLT for children weighing10 kg. From October 1995 to October 2006, a total of 222 LDLT in patients18 years of age were performed; 129 primary LDLT and 7 retransplants (4 LDLT and 3 deceased donor grafts) were performed in 129 infants weighing10 kg. Forty-seven patients received grafts with graft-to-recipient weight ratio (GRWR) of4%. Two patients received monosegmental grafts, and 2 patients underwent delayed abdominal wall closure. Portal vein thrombosis occurred in 5.4% of the patients, hepatic artery thrombosis in 3.1%, and both in 1.5%. Among several variables studied, only the bilirubin level at the time of transplantation was associated with increased risk of death (P=0.009). Grafts with GRWR4% had no negative effect on patient survival. There were 7 retransplants, and 4 patients received a second parental LDLT. Patient survival rates at 1, 3, and 10 years after transplantation were 88.8%, 84.7%, and 82% for all children, and 87.5%, 84.9%, and 84.9% for infants weighing10 kg. LDLT has results comparable to other modalities of liver transplantation in infants. Monosegment grafts were rarely required in this series, although they may be necessary in patients with lower body weight.

1. Historical perspective of donor allocation to patients with fulminant hepatic failure (FHF). 2. Predicting prognosis in patients with FHF using the London and Clichy criteria. 3. Model for end-stage liver disease (MELD) is a predictor of mortality in patients with FHF. 4. Outcomes of adults listed as Status 1 in the United States. 5. Outcomes of pediatric candidates listed as Status 1 in the United States. 6. Proposed redefinition for Status 1 in adult and pediatric candidates.

The success of adult right-lobe living donor liver transplants (RLDLT) would not have been possible without the experience of the early pioneers of pediatric living donor liver transplants (LDLT). Our experience with 95 RLDLTs from July, 2000 to May, 2002 at a single institution is reported with specific emphasis on arterial reconstruction. The evolution of technique using the autogenous Y extension graft and the reverse extension bifurcated graft for arterial revascularization, which we believe has reduced the incidence of hepatic artery thrombosis, is described. Outcome and the incidence of hepatic artery thrombosis are reported.

Sirolimus is a new immunosuppressive agent increasingly being used in liver transplant recipients. There is concern that sirolimus may be associated with wound complications and hepatic artery thrombosis (HAT). We have used sirolimus as primary immunosuppression in 170 liver transplant recipients and therefore reviewed our experience with wound complications and HAT in our cohort of patients. Records of all 170 patients administered sirolimus as primary immunosuppression and 180 historic controls were reviewed. Numbers of wound and hepatic artery complications were recorded, as well as the prevalence of obesity, reoperation, diabetes, and OKT3 use, all of which are risk factors for wound complications. The prevalence of wound complications was 12.4% in sirolimus-treated patients compared with 13.9% in historic controls (P = not significant [NS]). The prevalence of hepatic artery complications was 5.3% in sirolimus-treated patients compared with 8.3% in historic controls (P = NS). The prevalence of obesity and OKT3 administration was significantly lower in sirolimus-treated patients. Multivariate analysis failed to show an association between sirolimus therapy and hepatic artery or wound complications. The prevalence of wound and hepatic artery complications is not different in liver transplant recipients administered sirolimus as part of a primary immunosuppressive regimen compared with historic controls.

Key Points 1. Living donor liver transplantation (LDLT) is currently performed at about 30 centers in the United States. 2. Careful and critical evaluation of donor and recipient is required for optimal outcome. 3. Right lobe donation is preferred over left lobe donation in adult LDLT. 4. There has been 1 donor death (