Living-related liver transplantation in children: The 'Parisian' strategy to safely increase organ availability

Purpose: The aim of the authors was to report their experience with living related liver transplantation (LRLT) in children, particularly focusing on the safety of the two-center "Parisian" strategy. Methods:The records of donors a nd recipients of 26 pediatric living-relate d donor liver transplantations performed between November 1994 and March 19 98 were reviewed retrospectively. Donors were assessed 1 year after transpl antation for medical and overall status. Results: Indications for LRLT included biliary atresia (n = 18), Byler's di sease (n = 5), alpha-1-antitrypsin deficiency(n = 1), Alagille syndrome (n = 1), and undefined cirrhosis (n = 1). Liver harvesting consisted of either a complete left hepatectomy (n = 14) or left lateral hepatectomy (n = 12) without vascular clamping. The recipient procedure essentially was the same as in split liver transplantation. Mean overall cold ischemia time average d 140 minutes (range, 90 to 230 minutes). Twenty-four of 26 patients had en d-to-end vascular anastomoses without interposition. Biliary reconstruction consisted of a Roux-en-Y choledochojejunostomy in all patients. All recipi ents except one received cyclosporine A (CSA). Mean donor hospitalization w as 8 days (range, 6 to 13) with normalization of all liver function assays by the time of discharge. There were no donor deaths and two postoperative complications (perihepatic fluid collection and bleeding from the wound). O ne year after donation, the initial 19 donors had resumed their pretranspla nt status. Two of the children who underwent transplant died. Thirteen of t he recipients required reoperation for hepatic artery th rom basis (n = 2), portal vein thrombosis (n = 2), biliary complications (n = 6), fluid colle ction (n = 3), small bowel perforation (n = 1), and plication for diaphragm atic eventration (n = ?). With mean follow-up of 2 years, 24 of 26 patients are alive and well (patient and graft survival rate, 92%). Conclusions: LRLT is still controversial, even with minimal and decreasing donor risk. The "Parisian" strategy consists of harvesting the liver in an adult unit by an adult hepatic surgery team. The transplantation is then pe rformed in a pediatric hospital by the pediatric liver transplantation team . The two steps of the procedure allow units specialized in adult surgery, on one hand, and pediatric liver transplantation, an the other hand, to ded icate themselves completely to their respective procedures, improving the s afety of the harvest, and alleviating stress for both the medical staff and the families. Copyright (C) 1999 by W.B. Saunders Company.