Search

Liver transplantation has improved the survival of children with end-stage liver disease, and is frequently the only curative treatment for these patients. More infants are being given liver transplants because of success with older children, but many transplant centers do not accept infants, even if they have life-threatening liver disease. The outcomes of liver transplantation in 17 infants under one year of age are reported. Of the 17 patients, 5 received more than one graft and a total of 26 liver transplantations were performed. Eleven patients survived to be discharged from the hospital, and 10 survived a year or more after hospital discharge. Four of the six patients who died following transplantation had required hospitalization prior to surgery. Surgical complications included blood clots in the hepatic artery (of the liver). Bacterial infections were common; two patients died as a result of complications associated with viral infections. Eleven patients experienced 18 episodes of graft rejection. One patient with rejection required a second transplant, but nine responded successfully to medical treatment. Although several patients had impaired kidney function following surgery, it was similar to their pretransplant status. Liver function is normal in all, but two of the surviving patients. Three of the older survivors have entered primary school and have no known deficits, while a fourth is developmentally delayed. The findings suggest that liver transplantation is a feasible treatment for children under one year of age, but should only be performed in medical facilities which are capable of managing these patients. The 64.7 percent survival rate of these infants, while not out of line, is less than the 75.8 percent survival of all 139 children who received liver transplants at this facility during a 5-year period. Careful selection of candidates and preoperative nutritional boosting are highly desirable. Further studies are needed to determine the risk factors of liver transplantation, which are specific to infants. (Consumer Summary produced by Reliance Medical Information, Inc.)

A major drawback in pediatric liver transplantation is the severe shortage of appropriately sized livers. Between 25 and 30 percent of children waiting for liver transplants die before an appropriate donor organ can be found. When liver transplantation possible, it offers the hope of long-term survival. A report is presented of 141 transplantations performed on 117 children using 54 reduced-size grafts. Ten children were under one year of age; 63 were between l and 3 years old; 21 were between 3 and 6; and, 23 were between 6 and 14 years old. The most common indication for transplant was biliary atresia, a congenital absence of one or more of the biliary structures, which affected 86 patients. Reduced-size livers were used in both urgent and elective cases. There were 83 full-size livers and 54 reduced-size livers transplanted; 4 were considered other technical variants. The one-year survival rate for the entire group was 77 percent; for the full-size liver recipients it was 82 percent, and for the reduced-size liver recipients it was 68 percent. Graft loss occurred with 26 (31 percent) of the full-size livers, and 24 (44 percent) of the reduced-size livers. Of the 74 children who had functioning livers six months after transplant, 67 percent had completely normal liver function tests, and 14 percent had only slightly abnormal liver tests. Use of this technique has reduced the mortality of children on the waiting list to 14 percent. It is concluded that the technique of reduced-size liver transplantation is safe and reliable and is recommended for treatment in urgent and elective cases. (Consumer Summary produced by Reliance Medical Information, Inc.)

Background. Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported. Methods. Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included indiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm. Results. Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 80% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2. Conclusions. Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.