Composite liver--small bowel allografts with preservation of donor duodenum and hepatic biliary system in children.
OBJECTIVE
Liver and intestinal transplantation is commonly required for children with intestinal failure who suffer concomitant total parenteral nutrition (TPN)-induced liver failure. Retrieval of such composite allografts using previously described "standard techniques" mandates reconstruction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications have been associated with significant morbidity and mortality. Also, size matching has limited the pool of donor organs for this patient population. To improve outcome and increase the donor pool the authors have utilized a duodenal-sparing composite liver small bowel allograft technique (DLSBTx) by preserving the head of the pancreas and the pancreatic-duodenal arteries. This precludes a biliary drainage procedure.


METHODS
Nine children (5 girls, 4 boys), with a mean age of 1.4 years (range, 1 to 17.4 years) received a DLSBTx. In 2 patients the liver was reduced; 1 patient received the whole pancreas. The mean recipient weight at the time of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age and mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 kg (range, 4 to 70 kg), respectively. All transplants were performed under tacrolimus and steroid immunosuppression.


RESULTS
With a mean follow-up of 419 days (range, 5 to 795 days), patient and graft survival rates are 78% and 67%, respectively. One patient underwent a combined retransplantation with the standard technique 31 days after the primary allograft was destroyed by a native pancreatic fistula. Currently, all surviving recipients are at home and off TPN. DLSBTx allowed the expansion of the donor pool by transplanting 6 patients with donor to recipient weight ratio > or =1 and utilizing 2 less than 5-kg donors, including a neonatal donor. In 55% of the patients, chemical pancreatitis was observed during the early postoperative period. None of the duodenal allografts experienced signs of ischemia or leak.


CONCLUSIONS
The technical advantages of this procedure include avoidance of a biliary reconstruction and simplification of the operative procedure. This, together with the feasibility of split or reduced liver grafting promises to increase the donor pool from neonates to adults.
Bueno
J
J
Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Children's Hospital of Pittsburgh, PA 15213, USA.
Abu-Elmagd
K
K
Mazariegos
G
G
Madariaga
J
J
Fung
J
J
Reyes
J
J
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D020345:Enterocolitis, Necrotizing / Q000601:surgery*; D005260:Female; D020139:Gastroschisis / Q000601:surgery*; D006084:Graft Rejection; D006801:Humans; D007223:Infant; D007415:Intestinal Obstruction / Q000601:surgery*; D007421:Intestine, Small / Q000637:transplantation*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D010289:Parenteral Nutrition, Total; D014184:Transplantation, Homologous