title: Pediatric recipients of three or more hepatic allografts: results and technical challenges.
abstract: OBJECTIVE
  Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties.
  
  
  METHODS
  Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively.
  
  
  RESULTS
  A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.).
  
  
  CONCLUSIONS
  The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.
authors.affiliation: Department of Pediatric Surgery, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA.
authors.forename: D T
authors.initials: DT
authors.lastname: Schindel
authors.forename: S P
authors.initials: SP
authors.lastname: Dunn
authors.forename: A T
authors.initials: AT
authors.lastname: Casas
authors.forename: K
authors.initials: K
authors.lastname: Falkenstein
authors.forename: D F
authors.initials: DF
authors.lastname: Billmire
authors.forename: C D
authors.initials: CD
authors.lastname: Vinocur
authors.forename: W H
authors.initials: WH
authors.lastname: Weintraub
mesh_terms: D000293:Adolescent; D001656:Biliary Atresia / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D002779:Cholestasis / Q000601:surgery; D005260:Female; D006084:Graft Rejection; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D020176:Tyrosinemias / Q000097:blood