Paediatric liver transplantation with a split graft: experience at Bicêtre.

UNLABELLED: This study evaluates the results of paediatric liver transplantation (PLT) with split liver grafts at Bicêtre hospital. PATIENTS AND METHODS: Between January 1, 1988 and December 31, 1995, 205 PLT were performed in 180 children. One auxiliary PLT was excluded from the study. The graft was a whole (WLG), reduced (RLG) and split liver graft (SLG) in 76, 112 and 16 cases respectively. The SLG consisted of segments II + III in 14 cases, and II + III + IV in 2 cases. Results of PLT with SLT, RLT and WLG were retrospectively compared. Minimal follow-up was 12 months. RESULTS: In elective PLT, actual 1 year patient (graft) survival were 93.3% (84.4%) with WLG (n = 64), 84.1% (76.4%) with RLG (n = 72), 81.8% (81.8%) with SLG (n = 11). In urgent LT, actual patient (graft) survival were 100% (83.3%) with WLG (n = 6), 58.6% (52.5%) with RLG (n = 40), 25% (20%) with SLG (n = 5). Specific complications of the splitting technique were: 2 Budd-Chiari syndromes in 2 early patients, without any new case after modification of the technique of left hepatic vein to inferior vena cava anastomosis; 4 bile leaks (25%) from the left hepatic duct to Roux-en-Y loop anastomosis. DISCUSSION: In our experience, the results of PLT with SLG were satisfactory in the elective situation, but disappointing in urgent cases. In the current context of liver graft shortage, appropriate use of this sophisticated and demanding technique depends on the experience of the team, recipient's condition, and logistic considerations.

Portal vein complications after liver transplantation for biliary atresia.

The objective of this report is to review portal complications (PC) after pediatric liver transplantation (LT) for biliary atresia (BA) in the Bicêtre surgical series. From January 1, 1988, to February 28, 1995, 96 children with BA underwent 115 LTs Portal anastomosis was done on either the recipient portal vein (n = 85) or superior mesenteric vein (n = 11). No antiaggregative agents were administered postoperatively. Median follow-up was 50 months (range, 12 to 97). Nineteen PC (16.5%) occurred in 17 recipients: 16 portal thrombosis (PT) and 3 portal stenosis (PS). Fifteen instances of early PT occurred between days 0 and 17 (median, day 2). Emergency thrombectomy was performed in 9 cases (successful in 5). Three children underwent a secondary portosystemic shunt (successful in 2). Three PS were cured by either surgery or balloon dilatation. Four children died, 3 are alive with portal hypertension (PHT), and 10 are alive without PHT. Three-year patient actuarial survival is 82.4% in PC cases and 82% in others (NS). Significant risk factors of PC are young age and weight at the time of LT, small portal vein, and emergency LT. Analysis of our own results and review of the literature suggest that prevention of PC depends primarily on appropriate surgical technique. Reduction of postoperative hypercoagulability may also play an important role: a meta-analysis of 1,257 published pediatric LT show an overall risk of PT of 2.2% in teams using aspirin with or without dipyridamole compared with 7.8% when no antiaggregative agents are given (P = .0001).

Determinants of life span after Kasai operation at the era of liver transplantation.

The aim of this work is to determine the influence of age, extrahepatic biliary lesions pattern (EHBP) and association to polysplenia syndrome (PS) on 10 years outcome of 164 patients with biliary atresia (BA) treated from 1984 to 1992 by initial Kasai operation (KO) and secondary liver transplantation (LT) when necessary. Actuarial crude survival without or after LT (CS), actuarial survival with native liver (NLS) and jaundice-free actuarial survival with native liver (JFS) were calculated from 1 to 10 years versus age (under/over 45 days), EHBP (favorable/ unfavorable) and PS (no/yes). Overall 10-year CS is 70%, overall 10-year NLS and JFS are 14%. In univariate analysis, age at KO under 46 days, favorable EHBP (BA with patent gallbladder, and/or cystic dilatation of extrahepatic bile duct, or BA restricted to choledocus), and absence of PS are significant determinants of a better outcome regarding CS, NLS and JFS. EHBP is more discriminant than age. Influence of PS in this series is redundant with that of EHBP since 11/11 patients with PS had unfavorable EHBP.

Urgent liver transplantation for biliary atresia: the experience in Bicêtre.

According to French rules for cadaver organ sharing, children with biliary atresia (BA) complicated with acute necrosis (ALN) can be registered on the waiting list for liver transplantation (LT) in a special intermediate grade urgent code. Over a 7 years period, 100 children have been submitted to elective LT for BA and 15 to urgent LT. Urgent procedures accounted for 25% of LT for BA in patients aged 0-2 years and 67% (8/12) in patients under 1 year of age. Children actuarial survival at 1, 12 and 48 months was respectively 66%, 60% and 60% versus 92%, 86% and 85%, deaths occurring earlier in the urgent group. Graft actuarial survival at 1, 12 and 48 months were 60%, 53% and 53% versus 85%, 77% and 76% (p < 0.05), respectively. Outcome of children and grafts after LT is not significantly different in BA cases and in other urgent indications, excluding retransplantations. In a LT program based on cadaver organ donation, allocation of in an urgent registration code to children with BA and ALN offers them more than 50% chance to escape death and does not result in wasting of grafts.

[An unknown etiology of fetal ascites: acute intestinal intussusception]. / Une cause méconnue d'ascite foetal: l'invagination intestinale aiguë.

BACKGROUND: Intussusception is a frequent diagnosis during the first year of life. However, it is an uncommon and very rare pathology in neonates and premature infants. CASE REPORTS: Two full term neonates presented an antenatal intussusception associated with fetal ascites; another premature infant developed an intussusception at the age of 15 days. In the three cases the diagnosis of intussusception had only been established during the laparotomy. A recent review of the literature revealed 13 cases of antenatal intussusception, one of these being associated with fetal ascites. CONCLUSION: The differential diagnosis of fetal ascites should always include intussusception. Early recognition of this pathology and prompt surgical action would avoid fatalities.

Spontaneous perforation of the biliary tract in infancy: a series of 11 cases.

Eleven patients presenting with spontaneous perforation of the biliary tract were treated at Bicêtre Hospital between 1971 and 1993. Three groups were individualised, each with a different pattern of local presentation: generalised biliary peritonitis (n = 2), localised biliary peritonitis (n = 4), secondary biliary stenosis (n = 5). In each case, cholestatic jaundice developed after a postnatal symptom-free interval. Ten patients were operated on. Perforation was located in the cystic duct (n = 2), at the junction of the cystic and hepatic ducts (n = 4), in the common hepatic duct (n = 1) or common bile duct (n = 1). The site of perforation was no longer identifiable in two cases with stenosis. A cholecystectomy was performed in the 2 cases with cystic duct perforation; in the cases of lesions of the main duct, either simple external biliary drainage (n = 3) or biliary reconstruction (n = 5) was carried out. Postoperative complications included bile leak (n = 2), ascending cholangitis (n = 1), portal vein thrombosis (n = 2). Five patients were submitted to further surgery including biliary revision (n = 3), porto-systemic shunt (n = 1), and other procedures (n = 2). One infant died from postoperative sepsis; 2 were lost to follow-up, one of which probably did not survive; 4 are alive and well. Late sequelae are present in 4 children: portal hypertension (n = 1), mild residual bile duct dilatation without cholestasis (n = 1), and mild to moderate liver fibrosis (n = 2). Prompt diagnosis and appropriate treatment should improve the prognosis of this rare condition.

[Prenatal detection of a cyst in the liver hilum. Interpretation for an adequate treatment]. / Diagnosi ecografica prenatale di una immagine cistica a carico dell'ilo epatico. Interpretazione per un adeguato trattamento.

The diagnosis assigned to a cystic collection of liver hilum (CCLH) detected by means of prenatal ultrasonography is usually that of choledochal cyst (CC) thus carrying a good prognosis. The aim of this work is to state more precisely the significance of such CCLH, from a review of our experience. Files of children treated in our institution for either CC or biliary atresia (BA) with bile duct cysts have been screened for prenatal detection of CCLH. From 1985 to 1994, seven children have been referred to our institution, all after birth, all after prenatal detection of CCLH between 22 and 38 weeks of pregnancy (median = 33 weeks). Postnatal diagnosis, established by means of percutaneous cholangiography, was CC in 5 children without any evidence of cholestasis, and BA in 2 children with alcoholic stools and hepatomegaly. The 5 CC patients have been submitted to successful surgery at age 16 days to 10 months. The 2 BA patients have been operated at age 23 and 111 days, the latter unfortunately with gross cirrhosis and portal hypertension. An accurate prenatal diagnosis had been done by previous investigators only in 3 of the 7 cases, all 3 being CC cases. A review of the literature confirms that prenatal detection of a CCLH occurs mostly during the 3rd trimester of pregnancy and that of the postnatal diagnosis is almost always CC. Nevertheless the diagnosis of BA, requiring an early surgical procedure is also possible. We recommend that prenatal detection of a CCLH should result at least in referring the baby soon after birth to a team skilled in hepatobiliary pathology.

Prenatal ultrasonographic detection of abdominal and pelvic tumors: impact on management.

An abdominal or pelvic tumor in very seldom detected in a prenatal ultrasound examination. The most commonly detected tumors are, in order of decreasing frequency, sacrococcygeal teratomas, neuroblastomas and kidney tumors. According to the present state of the art, diagnosis of a sacrococcygeal teratoma only leads to specific monitoring of the pregnancy, because an early delivery or delivery by cesarean section will be necessary in some cases to improve the prognosis of child and/or mother. For other types of tumors investigations and actions should be delayed until after birth.

[Vascular complications of liver transplantation: surgical treatment]. / Complications vasculaires de la transplantation hépatique: traitement chirurgical.

Vascular complications constitute a major cause of morbidity and mortality after liver transplantation. They are dominated by arterial complications, the most frequent being hepatic artery thrombosis. Venous complications essentially consist of portal vein thrombosis. The preventive treatment of vascular complications is based on a better understanding of the risk factors. Close cooperation between surgeon, and radiologist is essential for effective surgical correction, which requires a rapid diagnosis and is designed to save not only the patient's life, but also, whenever possible, the liver transplant.

[Transplantation of reduced-size livers in children]. / Transplantation des foies réduits chez l'enfant.

Nowadays, liver reduction techniques make it possible to use livers obtained from adults or adolescents for implantation in children. These techniques have been evaluated by analysis of 100 liver transplantations performed between January 1988 and October 1991 in 85 children. Forty-six full-size grafts implanted in 38 children (group 1) were compared with 54 reduced-size grafts implanted in 47 children (group 2). The overall actuarial survival at 4 years was 86 percent. There was no statistical significant difference between the two groups as regards the rates of death (8 versus 19 percent), reoperation (54 versus 64 percent), retransplantation (15 versus 16 percent), hepatic artery thrombosis (13 versus 15 percent) and graft survival (82 versus 70 percent) respectively. Haemorrhage was significantly more frequent in group 1 than in group 2 (P = 0.04), irrespective of whether transplantation was performed urgently or electively. Using reduced-size livers considerably increases the number of liver grafts available to children. Apart from a greater risk of haemorrhage, the results obtained with reduced-size livers were identical with those obtained with full-size livers.

[Surgery of liver transplantation in children]. / Chirurgie de la transplantation hépatique chez l'enfant.

From 1988 until 1992, 94 children with end-stage liver disease were put forward for orthotopic liver transplantation (OLT) by the surgical and anesthesic teams of the Bicetre Hospital. Due to a majority of adult donors, and to the young age of the recipients (mean = 3 years 3 months), a reduced-size graft was prepared in 64 out of the 111 transplants performed (58%). A number of children (42) had to be reoperated on due to complications: hepatic artery thrombosis, one of the most severe complications following pediatric OLT, occurred in 14 cases, and was an indication for seven out of the 17 retransplantations in this series. The eight deaths which occurred in the early postoperative period were the toll of this particularly challenging surgery.

[Liver transplantation in children. New experience in a Pediatric Surgery unit. Evaluation of the first 18 months' experience]. / Transplantation hépatique chez l'enfant. Nouvelle activité d'un service de Chirurgie Pédiatrique. Evaluation après dix-huit mois.

The authors report an eighteen month experience with orthotopic liver transplantation (OLT) in children in the Pediatric Department of Hospital Bicêtre in Paris, from January 1988 until July 1989. Thirty-eight OLTs including 4 retransplant operations, were performed in 34 children, aged from 7 months to 13 years, 20 of them under the age of 3 years. Biliary atresia was the indication for 22 children. Twenty-eight donors were children. A reduced-size liver was used in 17 cases. The technique for OLT was based on the description by TE Starzl. Surgical complications led to reoperation in 15 cases, mostly in relation to hepatic artery thrombosis (HAT), which occurred in 7 cases: small donor liver was considered to be one of the causative factors. In all but one case of HAT a retransplant was considered; to date it is has been performed in 3 of these children. Thirty-one children have survived, with a mean follow-up of 8 months, all are at home, except for one child at the time of this report. Liver function tests are normal for 22, and moderately altered for 5. For the four remaining children, retransplant is planned for 3 cases and one child has just been retransplanted. The authors emphasise the fact that OLT in small children requires a specialised pediatric environment, particularly as regards intensive care and nursing.