Pediatric Liver Transplantation Information for Healthcare Professionals

Chapter 7: Types Of Liver Transplantation

Historically, a whole liver graft was the only option available for infants and small children waiting for liver transplantation.  In this option, the whole liver of a donor, (usually a child donor,) is used to replace the whole liver of the recipient.  Children had to wait a long time for a size-matched organ.  Since the late 1980’s, several new options have become available because of improved surgical techniques: reduced size liver transplant, split liver transplant and living-related liver transplantation.  These options have shortened waiting times for the smallest recipients.

Reduced Size Live Transplantation

When an organ is available, the liver transplant team recovers the liver as a whole organ. Small infants will require an organ that is reduced in size, a segment of the whole liver.  This procedure is performed by the surgical team just prior to the transplantation.  A new preservation solution, developed by the University of Wisconsin, is used to preserve the donated liver for up to 24 hours.  This solution allows transplant surgeons the opportunity to extend the time needed to reduce the size of the donated organ.  With reduced size liver transplantation, the weight of the donor can be as much as 10 times that of the recipient.  This has significantly lessened the waiting time for small children and infants and has reduced the mortality rate of those on the waiting list to nearly zero.

Studies have shown that children do just as well with a reduced size liver as with a whole liver.  If you have questions about the procedure, your transplant surgeon will be happy to discuss them with you.

Split Liver Transplantation

Another option to meet the needs of pediatric liver transplant recipients is the use of the split liver transplantation in which the liver tissue, vasculature and biliary structures are divided to obtain viable grafts for use in two patients.  The liver is transplanted in the usual position after careful inspection of all structures.  The advantage for this procedure is that two recipients in urgent need of a liver graft can be successfully transplanted.  It can also be safely used for an elective procedure.  The portion of the liver used for each recipient is determined by the size and shape of the donor organ and the respective weights of the recipients.  Potential complications include a vascular thrombosis or a biliary leak, similar to the complications found in other pediatric transplant procedures.

Living-Related Liver Transplantation

The concept of living-related transplantation grew from surgical experience with segmental liver transplantations and experience gained from the resection of a portion of the liver in patients with a liver tumor.  Surgeons have been able to safely resect a portion (either the left lateral segment, left lobe or right lobe) of the liver without any harm to the donor.  The advantage of this technique is the ability to provide a donor for every needy recipient and the improved quality of the graft from a healthy living donor.  The relief for the family providing a donor for their child rather than the anxiety of waiting an undetermined period of time must be balanced against having two loved ones undergo major surgical procedures simultaneously.  The risk to the donor is minimal, however, it is important to remember that the donor is undergoing a major surgical procedure.  A six to eight day hospitalization is planned; expected length of recovery for the donor is eight weeks.

The donor evaluation involves a variety of blood tests (the donor and recipient must be a blood type match), a volumetric computed tomography (CT) scan of the liver (measuring the volume of the segment to be donation), a physical examination, a psychiatric examination and finally an arteriogram of the liver to assess the veins and arteries of the liver.  Once the donor is deemed a “good match,” the surgical procedures are scheduled.

On the morning of surgery the “parent donor” will be taken to the surgical suites to harvest the liver segment.  Several hours later your child will be taken to an adjoining operating room.  This procedure is described in detail in the section “Transplanation and the Immediate Post-Operative Period.”  At the completion of the donor’s surgery, the parent is taken to the post anesthesia recovery room (PACU) for close observation overnight and is transferred to a postoperative surgical unit the next morning.  After surgery, the parent donor will have a nasogastric tube inserted from his nose to his stomach and one large abdominal drain.  A large surgical dressing will cover the abdominal incision.  Pain medication will be provided via intravenous as patient controlled analgesia (PCA); in other words, a button can be pushed to administer prescribed doses of pain medication.  Once the donor has active bowel sounds, a diet can be resumed.  Most parents feel well enough to visit their child in the PICU on post operative day 2.