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short communication

Indian Pediatr 2009;46: 1088-1090

Early Postoperative Complications of Pediatric Liver Transplantation


Mohammad Hadi Imanieh*†, Asma Erjaee†, Seyed Mohsen Dehghani*†, Ali Bahador* and
Seyed Ali Malek-Hosseini*

From *Shiraz Transplant Research Center, and †Gastroenterohepatology Research Center, Department of Pediatric Gastroenterology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.

Correspondence to: Dr Seyed Mohsen Dehghani, Shiraz Transplant Research Center, Gastroenterohepatology Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz 7193711351, Iran.
Email: [email protected]

Received: June 25, 2007;
Initial review: September 21, 2007;
Accepted: September 11, 2008.
Published online 2009 April 1

PII: S0974757900413-2

Abstract

We reviewed records of 35 pediatric liver transplant recipients who were operated at the Shiraz Organ Transplant Center between April 1998 and April 2005 to gather demographic data, primary diagnosis, duration of hospital stay, source of graft, mortality, and surgical (vascular, biliary, fluid collection) and medical (infection, respiratory, neurological, cardiovascular, and gastrointestinal) complications. Among 23 male and 12 female pediatric liver transplant recipients (mean age: 11.8±4.9 years) with a mean hospital stay duration of 23.3±20.3 days, the postoperative complications included biliary leakage (7.20%), biliary stricture (3.10%), biliary obstruction (3.10%), pleural effusion (9.26%), lung collapse (n=1) pulmonary hemorrhage (n=1), and vascular complications of portal and hepatic vasculature (n=10, 28.6%); and infections of the peritoneum, lung, wound site, and urinary tract (n=10; 28.6%). Acute cellular rejection was documented in 6 (17.1%) recipients. Overall, 13 (37.1%) children died.

Key words: Children, Complication, Iran, Liver transplant.


O
rthotopic liver transplantation (OLT) is the treatment of choice for all types of end-stage liver diseases in both children and adults(1-3); it was first used as a treatment for pediatric chronic liver disease in 1998 at our center. Despite the improvement in survival due to advances in organ preservation, improved immunosuppressive agents, and refinement of surgical techniques, there are still significant complications and mortality associated with pediatric OLT(3,4). The aim of this study was to determine the type and frequency of early postoperative complications that occurred among our pediatric liver transplant recipients.

Methods

We reviewed the records of 35 pediatric patients (less than 18 years old) who underwent first OLT at Shiraz Organ Transplant Center between April 1998 and April 2005. The operative procedure was preformed in a standard manner, using duct-to-duct anastomosis in 68% of cases and piggy-back technique was utilized in 90% and venovenous bypass in the rest. Immunosuppressive regimen included mycophenolate mofetil, cyclosporine, tacrolimus and prednisolone. Data including demographic characteristics, primary diagnosis, duration of hospital stay, source of graft, mortality, and early postoperative complications were gathered. Early postoperative complications were considered as any surgical or medical complication that occurred any time during the patient’s hospital stay following transplantation.

Results

Twenty- three of the 35 pediatric liver transplant recipients were male and 12 were female. The mean age of the recipients was 11.8±4.9 years (range, 11 mo-18 yr). 77% of the patients used organs from deceased donors and 22.9% from living sources. The primary diagnoses for these patients included cryptogenic cirrhosis (n=17, 48.6%), autoimmune cirrhosis (n=7, 20%), biliary atresia (n=5, 14.3%), Wilson disease (n=4, 11.4%) and neonatal hepatitis (n=2, 5.7%). The mean duration of hospital stay was 23.3±20.3 days. The complications are listed in Table I. Pleural effusion (n=9) was the most common respiratory complication. There was one case each of lung collapse and pulmonary hemorrhage. In all cases, the right hemithorax was affected. Re-laparatomy was needed in 11 (31.4%) cases due to complications. Outcome did not vary with the kind of complication and the need for re-laparatomy.

Table I



Complications of Liver Transplant
  Total Living Cadaver
Surgical complications
  Hepatic artery thrombosis 3 (8.6%) 0 3 (11.1%)
  Portal vein thrombosis 4 (11.4%) 1 (12.5%) 3 (11.1%)
  Portal vein stenosis 1 (2.9%) 1 (12.5%)  0
  Hepatic artery stenosis 1 (2.9%) 1 (12.5%) 0
  Hepatic artery pseudoaneurysm 1 (2.9%) 1 (12.5%) 0
  Biliary leakage 7 (20.0%) 3 (37.5%) 4(14.8%)
  Biliary stricture 3 (8.6%) 1(12.5%) 2 (7.4%)
  Biliary obstruction 3 (8.6%) 1 (12.5%) 2 (7.4%)
  Liver ischemia 0% 0 0
  Liver infarction 0% 0 0
  Liver abscess 2 (5.7%) 2 (25.0%) 0
  Fluid collection 5 (14.3%) 1 (12.5%) 4 (14.8%)
  Hematomas 6 (17.1%) 0 6 (22.2%)
Medical complications
  Infection 10 (28.6%) 1 (12.5%) 9 (33.3%)
  Respiratory 11 (31.4%) 5 (62.5%) 6 (22.2%)  
  Neurological 6 (17.1%) 1 (12.5%) 5 (18.5%)
  Cardiovascular 3 (8.6%) 1 (12.5%) 2 (7.4%)
  Gastrointestinal bleeding 2 (5.7%) 1 (12.5%) 1 (3.7%)
  Rejection 6 (17.1%) 2 (25.0%) 4 (14.8%)
Others (alopeciaareata, hallucination) 4 (11.4%) 1 (12.5%) 3 (11.1%)
  

 

The infection sites included peritoneum (n=3), lungs (n=2), wounds (n=2) and the urinary system (n=1). Micro-organisms involved were fungal in 2 cases, viral (herpes and CMV) in 2 cases and bacterial in 6 others. Acute cellular rejection occurred in 6 (17.1%) cases; of these 4 died. All 10 cases with arterial and venous thrombosis also died. Overall mortality rate over one year was 37.1 % (n=13). The causes of death were rejection, vascular complications, hypoglycemia, gastrointestinal bleeding, and lymphoproliferative disorder.

Discussion

Liver transplant recipients are at risk for the same postoperative complications as any patient under-going a major intraabdominal operation, in addition to several complications specific to this pro-cedure(5). At least one early postoperative complication was seen in 27 pediatric OLT patients in our study. We observed that biliary and vascular complications were the most frequent early post-operative surgical complications while respiratory, infectious, and acute rejection complications were the most common medical problems in the early post surgical period. Similar complications have been reported by other authors (3,4,6-10).

We conclude that the liver transplant complications found in the pediatric age group at our center were very similar to that found in other transplant centers worldwide(4-7). However, considering the fact that our study had evaluated the outcome of liver transplantation in the first few years of pediatric liver transplant surgery, our overall mortality rate is higher compared to similar studies from the West.

Contributors: MHI: idea of research, data collection, drafting; AE; data collection and analysis, drafting; AB: data collection and drafting; SAM: data collection and critical revision. All authors approved the final paper.

Funding: Shiraz University of Medical Sciences.

Competing interests: None stated.


What This Study Adds?

• Overall mortality rate of liver transplant in children in Iran was 37.1% but the postoperative complications were similar to previous studies.
 

References

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2. Yamanaka J, Lynch SV, Ong TH, Fawcett J, Robinson HE, Beale K, et al. Surgical complications and long-term outcome in pediatric liver transplantation. Hepatogastroenterology 2000; 47: 1371-1374.

3. Araz C, Pirat A, Torgay A, Zeyneloglu P, Arslan G. Early postoperative complications of pediatric liver transplantation: experience at one center. Trans-plant Proc 2004; 36: 214-217.

4. Lin CC, Chuang FR, Wang CC, Chen YS, Chen CL, Liu YW, et al. Early postoperative complications in recipients of living donor liver transplantation. Transplant Proc 2004; 36: 2338-2341.

5. Ho MC, Wu YM, Hu RH, Ko WJ, Ni YH, Chang MH, et al. Surgical complications and outcome of living related liver transplantation. Transplant Proc 2004; 36: 2249-2251.

6. Saing H, Fan ST, Tam PK, Lo CM, Wei WI, Chan KL, et al. Surgical complications and outcome of pediatric liver transplantation in Hong Kong. Pediatr Surg 2002; 37: 1673-1677.

7. Shimizu T, Tajiri T, Akimaru K, Yoshida H, Yokomuro S, Mamada Y, et al. Postoperative management and complications in living-related liver transplantation. Nippon Med Sch 2003; 70: 522-527.

8. Egawa H, Uemoto S, Inomata Y, Shapiro AM, Asonuma K, Kiuchi T, et al. Biliary complications in pediatric living related liver transplantation. Surgery 1998; 124: 901-910.

9. Sieders E, Peeters PM, TenVergert EM, de Jong KP, Porte RJ, Zwaveling JH, et al. Early vascular complications after pediatric liver transplantation. Liver Transpl 2000; 6: 326-332.

10. Afessa B, Gay PC, Plevak DJ, Swensen SJ, Patel HG, Krowka MJ. Pulmonary complications of orthotopic liver transplantation. Mayo Clin Proc 1993; 68: 427-434.
 

 

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