SURGICAL PROBLEMS IN PEDIATRIC LIVER TRANSPLANTATION(International Symposium ,第29回日本小児外科学会総会)

抄録

Liver transplantation in children poses a variety of surgical problems which are distinct from those in adults. The topic of this presentation will be a review of the patterns of complications observed after liver transplantation in children. Although early reports of liver transplantation suggest that the great majority of candidates were older children, the epidemiology of liver disease and the experience of centers in the United States suggest that most patients who require liver transplantation do so before their second year. Therefore, the primary problem of pediatric liver tranpslantation is addressing the needs of these very small children. Common complications which are observerd in pediatric liver transplantation include hepatic artery thrombosis, which occurs between 5 and 25 percent of children in large series. Surgical management of this includes early diagnosis, thrombectomy and vascular reconstruction or liver replacement. While acute hepatic necrosis occasionally occurs, the most common presentation is due to fever and jaundice, biliary tract sepsis, common bile duct necrosis, or hepatic abscess. These lesions tend to be recognized late and are best managed with liver replacement. Primary non-function of a liver graft occurs in between 5 and 10 percent of transplants. It may be more common in small pediatric donors, since the donor selection criteria are often less rigorous because of the scarcity of small donors. While hypofunction can occasionally be managed expectantly with support of the prothrombin time, early retransplantation is usually the safest measure. Segmental liver transplants occasionally cause complications due to biliary leakage or necrosis along the cut section which requires reoperative therapy and drainage. Portal vein thrombosis is occasionally seen after liver transplantation in children. It never is a cause of graft failure and is usually managed readily by thrombectomy and release of tension on the portal vein. This occasionally requires interposition grafting. Biliary leaks occur after liver transplantation in children and are nearly always associated with hepatic antery thrombosis. If the hepatic artery is patent, revision of the hepatico jejunostomy over a stent affoeds a very high success rate. Ptients with biliary atresia may have extensive visceral adhensions and due to the extensive dissection required, have a 5 to 10 percent risk of intesitnal perforation. A readiness to re-explore children with fever and abdominal distension between seven and fourteen days after transplantation can prevent the severe complication of uncontrolled peritonitis. The prophylactic use of oral antibiotics to prevent abdominal infections has reduced the morbidity of these problems. Overall, surgical complications account for the majority of graft and patient loss in pediatric liver transplantation. Attention to detail and the use of good livers can reduce the incidence of these complications.