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We aimed to assess the incidence of HAT over three eras following implementation of microvascular techniques and a customized anticoagulation protocol in a predominantly cadaveric split liver transplant program. We retrospectively reviewed pediatric liver transplants performed between April 1986 and 2016 and analyzed the incidence HAT over three eras. In E1, 1986-2008, each patient received a standard dose of 5 U/kg/h of heparin and coagulation profiles normalized passively. In E2, 2008-2012, microvascular techniques were introduced. In E3, 2012-2016, in addition, a customized anticoagulation protocol was introduced which included replacement of antithrombin 3, protein C and S, and early heparinization. A total of 317 liver transplants were completed during the study period, with a median age of 31.7 months. In E1, 22% of grafts were cadaveric in situ split grafts, while the second and third eras used split grafts in 59.0% and 64.9% of cases, respectively. HAT occurred in 9.5% in the first era, 11.5% ( P=.661) in the second, and dropped to 1.8% in the third era ( P=.043). A routine anticoagulation protocol has significantly reduced the incidence of HAT post-liver transplantation in children in a predominantly cadaveric in situ split liver transplant program. [ABSTRACT FROM AUTHOR]

Citation counts can identify landmark papers. The aim of this study was to identify and characterize the top-cited articles in the pediatric liver transplantation literature. A search strategy for the Scopus® database was designed for pediatric liver transplantation publications from 1945 to 2014. The 50 top-cited articles were analyzed. Author co-citation analysis was performed using VOSviewer techniques. There were 2896 articles published between 1969 and 2015. The mean citation count of the top 50 cited articles was 166 (range 95-635). There were three case reports in this top-cited list. There were 15 collaborations in this top-cited list with nine being international. The top-cited publications originated in 12 countries, with the USA and the UK contributing 31 and seven articles, respectively. There were 14 authors with four or more publications in this list. There was a single author with nine publications in the top-cited list. These top-cited papers were found in 16 journals, with three journals collectively publishing over 50% of these publications. Pediatric liver transplantation research is an evolving entity. Surgical techniques and case reports are influential articles. Collaborations at a national and international level produce highly cited articles, which are found in influential journals. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to analyze the general surgical complications in pediatric liver transplant recipients and the safety of delayed primary closure at a single tertiary center. Methods A retrospective review of all liver transplant recipients between April 1986 and May 2014 was performed. All general and gastrointestinal complications were recorded and analyzed. The incidence and risk of these complications were compared between children who had a primary versus those who had a delayed closure, with or without the use of Surgisis®, of their abdomen. Results 242 patients underwent 281 liver transplants. The median age of the children was 31 months. Whole (77), reduced size (91), split (96), and living related grafts (17) were used. General surgical complications were observed in 33 cases (11.7%). 135 cases underwent delayed primary closure (DPC) of their abdomen, 35 with Surgisis®. Patients with biliary atresia had a higher rate (4.6%) of bowel perforation (p = 0.013). The majority of complications occurred within 3 months of transplantation. Conclusion General surgical complications postpediatric liver transplantation were common but usually not life threatening. Delayed primary closure was safe, had no significant long-term issues, and was not associated with higher incidence of wound related complications. [ABSTRACT FROM AUTHOR]

HBS is used in the management of liver transplantation, a significant complication of which is biliary stricture. Strictures may be intraparenchymal within segments and main duct (non-anastomotic) or at the biliary-enteric anastomosis (anastomotic). Strictures are definitively diagnosed, and often managed, by PTC. This is invasive, technically challenging, and requires general anesthesia in young children. HBS may allow early detection of these complications and is non-invasive. The aim of this study was to review the scintigraphic pattern of biliary strictures using 99mTcDISIDA HBS following pediatric orthotopic liver transplantation, and to assess its role in the diagnostic algorithm of suspected biliary strictures. All available hepatobiliary studies performed post-transplant in 101 episodes of liver transplantation in 92 pediatric patients were reviewed. Twenty-three (23%) patients had known biliary strictures. Twenty-two patients had adequate studies available for review; five had intrahepatic (non-anastomotic) strictures alone, nine had a stricture of the anastomosis alone, and eight had both intrahepatic and anastomotic strictures. HBS patterns (either segmental or global changes) correlated very highly with clinically significant biliary strictures. All patients with known strictures had abnormal HBS; hence, in patients with abnormal liver function tests post-liver transplant, a normal HBS makes strictures very unlikely. We propose that HBS can thus be used to determine if further investigation is required. [ABSTRACT FROM AUTHOR]

Abdominal closure in children less than 10 kg following liver or kidney transplantation can be challenging. Excessive pressure attained from a tight closure can result in abdominal compartment syndrome, graft compromise and loss. Concerns over using prosthetic patches are that of infection and dehiscence. We report a series of definitive abdominal wall closure using a biodegradable membrane from porcine intestinal submucosa (Surgisis®; Cook Biotech Incorporated, West Lafayette, IN, USA). A prospective collection and follow up of liver and kidney transplant patients weighing less than 10 kg who required abdominal wall augmentation with Surgisis® in order to achieve satisfactory closure. There were 10 liver and two renal transplant patients. The average weight of the liver transplant patients was 6.6 kg (5.4–8.5 kg) and the renal 9.8 kg. The average area of Surgisis® used was 71.2 cm2 (25–160 cm2) and length of follow up was 15.3 months (1–27 months). Concomitant measures to aid abdominal closure included bilateral recipient nephrectomy for the renal patients and reduction by 33% of the lateral segmental grafts in two liver transplant patients. Delayed closure occurred in all patients except one and the average days to closure from the first surgery was 3.75 days (0–6 days). Following liver transplantation one patient died from multiple organ failure at one month secondary to hemophagocytosis from underlying combined immune deficiency syndrome and one patient with hepatic artery thrombosis was salvaged at re-exploration. There were two wound complications, one patient developed two small sinuses and some skin dehiscence which healed over four months and the second developed a skin sinus following trans-patch liver biopsy which healed in three wk. Both had positive microbial cultures but neither necessitated removal of the graft. There were no incisional hernias. Surgisis® is a safe method for facilitating abdominal closure in pediatric transplant patients. It appears to have long-term durability with no incisional hernias on short- and medium-term follow up, and is fairly resistant to infection. [ABSTRACT FROM AUTHOR]

Abstract: Background: Liver transplantation using split adult segmental grafts in infants can be a technical challenge because the small abdominal cavity cannot comfortably accommodate the graft, leading to compression. This size mismatch can be a particularly difficult problem when the anteroposterior diameter of the graft is greater than the infant''s available anteroposterior peritoneal space. We describe a simple and novel technique that may prevent this complication. Methods and Results: Two infants with biliary atresia weighing 5 kg each and aged 6 and 5 months, received split adult liver left lateral segment transplants from deceased donors weighing 55 and 65 kg, respectively. Congestion of the graft and inadequate perfusion were prevented by placing a sterilized ping-pong ball in the retrohepatic space to elevate the graft off the native hepatic fossa. The bilateral subcostal incision was required to be extended vertically in the midline up to the xiphisternum in both patients to enlarge the abdominal cavity. Delayed closure of the wound was performed after 5 days using Surgisis (porcine small intestine submucosa, Cook Surgical Inc, Bloomington, IN) when it was possible to remove the ping-pong ball in one of the patients. Both patients have recovered well from the transplant. A follow-up of 1 year in the patient with the in situ ping-pong ball shows it to be well anchored and causing no symptoms. Conclusions: In children undergoing large-for-size split liver grafts, delaying the closure of the abdominal wound along with elevation of the graft using a ping-pong ball can be a useful and simple adjunct to prevent the complications of graft compression. [Copyright &y& Elsevier]

Tanaka H, Verran D, Shun A, Dorney S, Stormon M, Fisher J, McCaughan G. Liver transplantation utilizing pediatric cadaver donor livers.Pediatr Transplantation 2005.© 2005 Blackwell MunksgaardThis is a review of a unit's experience with the use of pediatric (up to 15 yr of age), cadaver donor livers for orthotopic liver transplantation (OLTx). The records of 86 patients who underwent 90 OLTx with pediatric donor allografts from January 1986 to September 2002 were reviewed. A total of 69 of 90 (77%) allografts from pediatric donors were used for pediatric (P) recipients, and 21 of 90 (23%) for adult (A) recipients. Donor demographics were: mean donor age 8.5 (0–15) yr; donor sex 53 males/37 females; cause of death head injury 55/90 (61%), cerebral ischaemia 14 of 90 (15%), cerebrovascular 13 of 90 (15%), other eight of 90 (9%). Whole OLTx were performed in 44 of 69 (64%) P group and 20 of 21 (95%) A group. Reduced-size OLTx (13 left lateral lobe, 10 left lobe, one right lobe, one split left lateral lobe) were performed in 25 of 69 (36%) P group vs. in one of 21 (5%) A group, (right lobe split) (p < 0.005). The median follow up was 8.8 yr. The graft loss in the P recipients was 19 of 69 (27.5%) vs. eight of 21 (38.1%) in A recipients. Graft loss for reduced size P OLTx was nine of 25 (36%) vs. 10/44 (22.7%) for whole allograft P OLTx (p = NS). Underlying cause of P graft loss were: chronic rejection six (32%); patient mortality six (32%); vascular four (21%); other three (15%). Underlying cause of A graft loss were: patient mortality four (50%), acute rejection two (25%) and vascular two (25%). OLTx-utilizing pediatric cadaver donor allografts provides acceptable outcomes, including use of reduced-size grafts in pediatric recipients. Vascular complications and chronic rejection tend to be more common in pediatric recipients, whilst patient mortality and graft loss from acute rejection are more common in adult recipients. [ABSTRACT FROM AUTHOR]

Purpose The Bethesda classification for cytology is used to classify thyroid nodules into one of six categories, and for each category there is an implied cancer risk and also recommendation for management. Despite lack of data in children, the American thyroid association promotes the use of the same management guidelines as in adults. Our aim was to study the risk of malignancy for each Bethesda class in children with thyroid nodules. Methodology We included all patients ≤ 18 years of age that had underwent a thyroid fine needle aspiration (FNA) at one of two centers between January 1998 and July 2013. FNA results were reclassified according to the Bethesda criteria. Histological, repeat cytological, radiological and clinical follow-up were recorded. Results Fifty-six patients (66 nodules) underwent FNB. Mean age was 13.6 years. Numbers of nodules reported as BI-BVI were 7, 38, 11, 4, 3 and 3, respectively. Follow-up was achieved for 55 (83%) nodules. Twelve (18%) nodules were malignant by histology and revealed papillary (n = 7), follicular (n = 3) or insular thyroid cancer (n = 2), The proportion of nodules with malignancy for BI-BVI was: 0%, 0%, 18%, 100%, 100% and 100%. Conclusion The rate of malignancy in thyroid nodules in children seems to be higher than reported in adults. The Bethesda criteria seem to accurately identify benign nodules, but other categories have a very high rate of malignancy and BIII nodules pose a particular challenge. [ABSTRACT FROM AUTHOR]

Esophageal stricture is a well-known complication following caustic ingestion. Esophageal dilatation is the commonest approach to treat this complication. However, patients with a refractory esophageal stricture will require surgical interventions such as esophagectomy with gastric pull up or other forms of esophageal replacement with colonic or small intestinal interposition. We describe two patients with caustic-induced esophageal stricture managed successfully by using novel surgical strategies to preserve the native esophagus. One child underwent resection of the strictures and the subsequent esophageal gap was bridged by lengthening the esophagus using a Livaditis myotomy technique. The other had a fundoplication to manage her reflux which was complicating her clinical course, followed by subsequent myotomy to manage her residual upper esophageal stricture. Patients with short-segment, post-caustic esophageal stricture may be amenable to less drastic surgical procedures using myotomy, thereby preserving the native esophagus, instead of requiring esophageal replacement by another gastrointestinal conduit. [ABSTRACT FROM AUTHOR]