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In liver transplant recipients, new onset of diabetes mellitus (posttransplant diabetes mellitus or PTDM) is estimated to occur in 9% to 21% of recipients. The limited published data on survival and posttransplant complications in liver transplant recipients who develop PTDM show conflicting results. The objective of our study was to compare the morbidity and mortality of 46 patients who developed PTDM with 92 age- and sex-matched patients without pretransplant or posttransplant diabetes mellitus (DM). The demographics of both groups were similar except that there were more blacks with PTDM. The incidence of following complications was higher in the PTDM group compared with the control group: cardiac (48% v 24%; P =.005), major infections (41% v 25%; P =.07), minor infections (28% v 5%; P =.001), neurologic (22% v 9%; P =.05), and neuropsychiatric (22% v 6%; P =.009). Acute rejection was seen more commonly in the PTDM group (50% v 30%; P =.03). The duration of hospital stay, cost of hospitalization, retransplantation rate, and graft survival were similar in both groups. Patient survival also was similar in the PTDM and control groups at 1 year (93.5% v 83.5%), two years (88.1% v 77.9%), and 5 years (75% v 77.2%); Kaplan-Meier survival analysis also did not show survival difference. In conclusion, PTDM was associated with significant morbidity, and our findings suggest that patients with PTDM should be monitored very closely to improve long-term outcome.

Background: Children with small or hypoplastic portal veins represent a challenge for liver transplantation. Graft loss of up to 70% has been reported in these patients in the past. A variety of techniques has been used in both cadaveric and living related transplants in an effort to overcome this problem. Variability arises as to whether to use a vascular graft and where on the portal system to attach the graft., Method: We present our usage of a simple and straightforward interposition iliac vein allograft fashioned in a manner to achieve large anastomotic cross-sectional area on the confluence of the superior mesenteric/splenic veins. The procedure also overcomes problems of graft vein/portal vein size mismatch in the cases where liver and vein grafts are procured from much larger donors., Results: A total of 14 children presented with hypoplastic portal vein (diameter<5 mm), of a total of 30 consecutive patients requiring cadaveric liver transplants, and benefited from this technique. Median recipient age was 10.5 months. Revascularization times ranged from 22 to 43 min with a mean of 33 min. All patients are alive and well at a mean follow-up of 329 days (10 months). All liver grafts are well and functioning. No portal vein problem was detected., Conclusion: Results from this technique are clearly encouraging. Because portal vein hypoplasia is a common problem in pediatric transplant candidates, we believe this alternative technique is of interest and should be added to the transplant surgeon's armamentarium.

The influence of preexisting diabetes mellitus (DM) on outcome after orthotopic liver transplantation (OLT) has not been well defined. The objective of our study was to compare the morbidity and mortality after OLT in 57 patients with preexisting DM (3 type I, 54 type II) with 114 age-, sex-, and race-matched patients without DM (case controls). The demographics were similar in both groups. Pretransplantation serum creatinine was significantly higher in the diabetic group compared with case controls. The incidence of the following complications was significantly higher in the diabetic group after OLT: cardiovascular (61.4% vs. 21.9%, P <.001), major (54.4% vs. 29.8%, P =.002) and minor infections (29.8% vs. 7.9%, P <.0001), renal (59.7% vs. 20.2%, P <.001), ophthalmologic (10.5% vs. 0.9%, P =.01), respiratory (24.6% vs. 7.0%, P =.001), neurologic (31.6% vs. 7.0%, P <.001), hematologic (19.3% vss 2.6%, P =.001), musculoskeletal (24.6% vs. 5.3%, P =.001), and malignancy (22.8% vs. 10.5%, P =.03). The duration of hospital stay, cost of hospitalization, retransplantation, and overall graft survival were similar. Acute rejection was seen in 50.9% of diabetics compared with 25.4% in controls (P =.0009). One-year (87% vs. 77%) and 2-year (81.6% vs. 70.1%) patient survival was similar, but 5-year survival was lower in the DM group (34.4% vs. 67.7%, P =.002). In conclusion, preexisting diabetes is associated with a significant post-OLT morbidity and mortality, and our observations suggest that patients with DM warrant more rigorous pre- and post-OLT evaluation.

Background: Small volumes of fluid in the pleural and peritoneal cavities are common after paediatric liver transplantation. Occasionally, larger fluid collections develop and need intervention by aspiration or insertion of a drain. Objective. To assess the incidence of moderate and large pleural and peritoneal fluid collections following paediatric liver transplantation, the need for intervention and the outcome following radiological and non-radiological treatment, with the ultimate objective of recommending a treatment protocol for such post-operative fluid collections., Materials and Methods: A total of 184 consecutive liver grafts in 164 children were reviewed., Results: Of 184 grafts, 31 (16.8%) developed excessive fluid collections requiring intervention (19 pleural effusions, 8 ascites and 4 effusions and ascites). The effusions were first diagnosed between days 1 and 44 after transplant and the ascites between days 1 and 14. The initial diagnosis was made radiologically in 21 (91%) of 23 pleural effusions and in 10 (83%) of 12 ascites. No identifiable cause or association was seen in 18 (58%) of 31 cases. The mean duration of the pleural effusions and ascites, from onset of treatment to resolution, ranged from 33 +/- 42 days (SD) to 35 +/- 48 days and from 36 +/- 47 days to 39 +/- 46 days respectively. Comparison of the modes of interventional treatment (i.e. unguided, radiological and surgical) showed no statistically significant difference in the outcome of the management., Conclusions: Post-transplantation pleural effusions and ascites requiring intervention are often without definite cause. They are more common with reduced grafts, but this cannot completely explain the occurrence or the protracted duration of accumulation in spite of combined interventional management. The outcome of treatment is not significantly influenced by the mode of intervention except in cases where surgical intervention is indicated. Patients could be managed effectively without resorting to chronic outpatient aspiration. US contributed significantly in the initial and follow-up evaluation of these patients, even in cases of pleural effusions, and we would recommend greater use of US in place of radiographs to reduce the radiation burden when fluid collections are protracted.

We describe a unique case of percutaneous retrieval of a broken guidewire in the biliary tree of a patient with a biliary stricture following liver transplantation with a reduced segment 2,3 graft using an Amplatz "goose-neck" snare.

Transjugular intrahepatic portosystemic shunt (TIPSS) is a new development in the management of severe variceal haemorrhage which has been established in adult patients. We have successfully adapted this technique for children and describe our initial experience in the case of a 9-year-old boy who presented with acute and chronic liver failure and uncontrollable life-threatening bleeding from oesophageal and gastric varices, despite intensive medical management including sclerotherapy. A 10-mm TIPSS was successfully placed with immediate reduction in portal pressure and cessation of variceal bleeding. The patient's condition stabilised sufficiently for him to undergo liver transplantation 2 days later, at which time the TIPSS was patent.

We report the placement of intrahepatic metallic, balloon-expandable stents in the biliary tree following liver transplantation in a 12-month-old infant who developed biliary strictures secondary to hepatic artery thrombosis. The use of such stents has not previously been reported following transplantation in an infant. Re-transplantation was undertaken 5 months after stenting because of chronic rejection and progressive obstructive jaundice.

Biliary complications (BC) are well recognised following paediatric liver transplantation. We reviewed retrospectively 169 consecutive liver transplants performed in 139 children. BC occurred in 36/169 grafts (21 %) in 35/139 patients (25 %). Biliary obstruction was present in 18/169 grafts (11 %), biliary leakage in 14/169 grafts (8 %) and a combination of obstruction and leakage was present in 4/169 (2 %) grafts. BC were as likely to present radiologically as they were with either clinical and/or biochemical abnormalities. Most BC (26/36, i. e. 72 %) occurred in the first 2 weeks following transplantation. Ultrasound and cholangiography were the principle imaging modalities used for detection of these complications. False negative ultrasound examinations occurred in three patients with biliary obstruction and in three patients with biliary leakage. False negative cholangiograms occurred in two patients with biliary leakage. Ultrasound is important in the post-operative surveillance of paediatric liver transplants, with cholangiography having a complementary role in those with BC.

This retrospective study documents the incidence and distribution of fractures in 117 children with end-stage liver disease who underwent orthotopic liver transplantation (OLT) over a 6-year period (1987-1993). Both the pre- and post-OLT phases were included. Nineteen children (16.2 %) sustained a total of 69 fractures. Age at time of fracture ranged from 3 months to 9 years 8 months (median 13.5 months). There was no documented trauma in 14/19 cases. Metabolic bone disease, assessed qualitatively on plain radiographs, was present in 17/19 children at the time of fracture. This took the form of rickets (n = 3), osteopenia (n = 12) and osteosclerosis (n = 2). Potential risk factors including pre-existing metabolic bone disease, drugs and immobilization were assessed. The findings emphasise the need for clinical and radiological awareness of the fracture risk, particularly during the peri-transplant period when this risk may be greatest.