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Liver transplantation is a mature treatment for children with end-stage liver disease. With the development of surgical techniques, immunosuppressive therapy, and infection monitoring in recent years, there have been significant increases in the survival rates of patients and liver transplants, helping children to achieve long-term survival. Meanwhile, several issues have emerged, such as viral infection, complications, new-onset tumors, quality of life, and self-management. Therefore, this article reviews related issues in long-term survival in children after liver transplantation from the two aspects of medical treatment and nursing and provides several regimens for reference, so as to provide a basis for long-term high-quality survival in children after liver transplantation. Here, these issues are reviewed.
ABSTRACT
Objective To explore the diagnosis and treatment of parvovirus B19 infection-associated anemia after pediatric liver transplantation (LT) .Methods The clinical data were retrospectively reviewed for 2 children with severe anemia caused by parvovirus B19 infection after LT .Case 1 was a 2-year-old girl with a weight of 10 .7 kg .Classical orthotopic LT was performed due to ornithine carbamoyltransferase deficiency . Hemoglobin level began to progressively decline since Day 2 post-transplantation .And case 2 was a 5-month-old girl with an age of 5 months and a weight of 7 .2 kg .She underwent classic orthotopic LT for biliary atresia and decompensated liver cirrhosis .Hemoglobin level progressively declined at nearly 2 months post-transplantation . Results In case 1 ,bone marrow aspiration was performed at Day 54 post-transplantation .There was pure red cell aplasia and the detection of microvirus B19 nucleic acid was positive .Intravenous immunoglobulin was prescribed at a dose of 2 .5 g/day for 10 days ,tacrolimus was switched to cyclosporine and hemoglobin level spiked from 62 to 105 g/L after one-month treatment .In case 2 ,hemoglobin decreased to 44 g/L at 2 .5 months post-transplantation and the result of polymerase chain reaction of parvovirus B 19 was 9 .7 × 107 copies/ml .Then intravenous immunoglobulin was dosed at 2 .5 g/day for 10 days and hemoglobin level rose to 122 g/L at 25 days after treatment . Hemoglobin level decreased to 63 g/L again at 4 .5 months post-transplantation .Anemia was corrected by intravenous immunoglobulin injection plus a temporary discontinuation of tacrolimus and a reduced dose of tacrolimus .Conclusions Infection of parvovirus B19 can cause pure red cell aplasia after LT in children . Early diagnosis with intravenous immunoglobulin and modification of immunosuppressive regimen can obtain excellent therapeutic efficacies .
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Objective To explore the experience of infantile liver transplantation ,reconstructing portal vein (PV) and avoid the higher incidence of portal vein low flow and complications .Methods The clinical data were reviewed for 152 infantile liver transplantations performed by a single surgery group .And 114 cases with PV risk factors underwent customized PV reconstructions .All of them were diagnosed as cholestatic liver diseases and 106 (93％ ) belonged to biliary atresia .Forty-two cases (36％ ) had 2 or more risk factors .Results Most cases (n= 106 ,93％ ) underwent living donor transplantations using lateral left graft while another 8 cases had deceased donor transplantations . Four types of PV reconstructions were adopted based upon individual conditions :left/right branch of PV trunk (n= 103) ,autogenous patch PV venoplastic reconstruction (n= 3) ,duct-to-duct of PV trunk (n= 5) and donor PV duct-to-recipient confluence of SMV/CV and SV (n= 3) .Graft size reduction was performed when GRWR > 4 .5％ (n= 16) .During a median follow-up period of 6 .5 (1 .5-13) months ,there were 3 LPVF (2 .6％ ) ,2PVS (1 .7％ ) and 1 PVT (0 .8％ ) .Three LPVF cases was corrected by PV stenting ,two cases of PVS were stable after anticoagulation therapy while one PVT case undergoing thromboectomy plus PV stenting resumed a normal PV flow .Conclusions PV reconstruction of high-risk infants require comprehensive risk evaluations ,precise surgical skills and customized strategies .For PV complications ,stenting is both safe and feasible .
ABSTRACT
Objective Hepatic artery (HA) reconstruction is one challenging procedure in pediatric liver transplantation (PLT).Here we review the first 115 microsurgical reconstructions of HA in PLT performed by a single surgeon,aiming to demonstrate the learning curve and the problems encountered.Methods From July 2016 to January 2017,a series of 115 microsurgical reconstructions of HA in PLT for end-stage liver disease were finished by one single surgeon with 4-year liver surgery experience and 2-week microsurgical training.HA reconstruction was performed with an operating microscope (Carl-Zeiss S88).Reconstruction was completed with interrupted sutures with 8-0 or 9-0 Prolene using the double clip for fixation.The blood flow was examined by Doppler scan daily after PLTs in first week and then once in 2nd week and first month for patency.A total of 143 artery anastomoses were performed in 115 PLTs.The age ranged from 3 months to 9 years.Indications for PLT included biliary atresia (105/115),Alagille syndrome (5/115),PFIC (3/115),Caroli disease (1/115),methylmalonicacidemia (1/115) and glycogen storage disease (1/115).Most of the PLTs were living donor liver transplantation (107/115),along with OLT (5/115) and split LT (3/115).Results The diameter of the arteries was mostly less than 2 mm (98/115).Up to date,one HA thrombosis (HAT) occurred at D8 after LT and 4 cases suspected as temporal HA stenosis (HAS) around 2 weeks after LT,which manifested as low velocity (<20 cm/s) and resistance index (<0.50) by Doppler.The HAT case failed in emergent re-anastomosis,but had a spontaneous recanalization at 3 weeks and is now in good condition without biliary problem.All the HAS children recovered to normal flows at first month.All children with HA complications started warfarin upon detection,with a targeted INR between 1.5-2.0.There were 6 deaths in this series including 5 cases of infections and 1 case of graft failure.Learning curve suggested a two phases growth (first 44 cases practicing phase vs.next 71 cases mature phase),which can be attributed to experience accumulation in terms of precise of manipulation,choice of inflow arteries for better match and stronger pulsation,avoidance of length redundant,prevention of kink.All the HAT and HASs happened in practicing phase while outcomes were excellent in mature phase.Moreover,time for each anastomosis was significantly shortened in second phase from 45-70 min to 30-55 min.Conclusion Microsurgical technique is highly safe in pediatric HA reconstruction,especially for very tiny arteries.It is possible to achieve low risk of complications for a new surgeon with adequate experience in liver surgery and microsurgical training.However,more surveillance and timing anticoagulation therapy is required before the mature of microsurgical technique.