Composite liver-small bowel allografts with preservation of donor duodenumand hepatic biliary system in children

Background/Purpose: Liver and intestinal transplantation is commonly requir ed for children with intestinal failure who suffer concomitant total parent eral nutrition (TPN)-induced liver failure. Retrieval of such composite all ografts using previously described "standard techniques" mandates reconstru ction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications hav e been associated with significant morbidity and mortality. Also, size matc hing has limited the pool of donor organs for this patient population. To i mprove outcome and increase the donor pool the authors have utilized a duod enal-sparing composite liver small bowel allograft technique (DLSBTx) by pr eserving the head of the pancreas and the pancreatic-duodenal arteries. Thi s precludes a biliary drainage procedure. Methods: Nine children (5 girls, 4 boys), with a mean age of 1.4 years (ran ge, 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 t ime of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age an d mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 k g (range, 4 to 70 kg), respectively. All transplants were performed under t acrolimus 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 underwe nt a combined retransplantation with the standard technique 31 days after t he primary allograft was destroyed by a native pancreatic fistula. Currentl y, all surviving recipients are at home and off TPN. DLSBTx allowed the exp ansion of the donor pool by transplanting 6 patients with donor to recipien t weight ratio greater than or equal to 1 and utilizing 2 less than 5-kg do nors, including a neonatal donor. In 55% of the patients, chemical pancreat itis was observed during the early postoperative period. None of the duoden al allografts experienced signs of ischemia or leak. Conclusions: The technical advantages of this procedure include avoidance o f a biliary reconstruction and simplification of the operative procedure. T his, together with the feasibility of split or reduced liver grafting promi ses to increase the donor pool from neonates to adults. J Pediatr Surg 36:2 91-296 Copyright (C) 2000 by W.B. Saunders Company.