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Liver transplantation in children from living related donors
INTERNATIONAL ABSTRACTS
ers years 1959 to 1988. During this time a total of 165 intussusceptions were treated in 153 patients, with 1 death. The peak incidence for age was characteristic, and, as expected, the study showed a gradual increase in the number of hydrostatic reductions. Eight patients had a lead point. In four hydrostatic reduction failed (Meckel's diverticulum 3, Henoch-Schfnlein purpura 1) and in four a laparotomy was performed without attempted hydrostatic reduction (Meckel's diverticulum 3, lymphoma 1). The authors advocate ultrasonography as a screening procedure in cases of suspected intussusception (53 uttrasounds performed, 44 negative results, 9 positive results of whom one proved negative on barium enema examination).--Patricia Davidson One-Drug Versus Two-Drug Antibiotic Therapy in Pediatric Perforated Appendicitis: A Prospective Randomized Study. J.L. Meller, H.M. Reyes, D.S. Loeff, et al. Surgery 110:764-768, (October), 1991. This is a prospective randomized study to compare the use of gentamicin and clindamycin to a single antibiotic, cefoxitin, in the treatment of perforated appendicitis in pediatric patients. Fifty-six patients with perforated appendicitis were randomized. Twentynine received cefoxitin and 27 received gentamicin and clindamycin. Antibiotics were started before operation and continued for a minimum 6 days after operation. Wounds were left open and closed secondarily after day 3 if they appeared to be clean. The most common organisms cultured were Escherichia eoli (62%) and Bacteroides (46%). No difference was noted in infectious complications between the two groups nor in the length of hospital stay. There was one pelvic abscess and three subfascial abscesses in the group with gentamicin and clindamycin versus one wound infection with cefoxitin alone. The hospital cost for a 5-day course of cefoxitin was $106, whereas the cost for a 5-day course of gentamicin and clindomycin was $68. The authors state that based on this study cefoxitin as a single drug is a good alternative to the traditional dual combination.--Thomas F. Tracy, Jr Adenocarcinomas of the Colon and Rectum in Persons Under 40 Years Old. P.M. Griffin, J.M. Lift, R.S. Greenberg, et al. Gastroenterology 100:1033-1040, (April), 1991. A population-based study was done to characterize the epidemiology of noncarcinoid adenocarcinomas of the colon and rectum in persons under 40 years old between 1973 and 1984 (n = 1,736). These were compared with those in persons 40 years and older (n = 106,760). The median age at diagnosis was 35 years; the youngest age at diagnosis was 4 years, and only 29 patients (1.7%) were under 20 years of age. There was a higher incidence in blacks than in whites, and there was a higher proportion of mueinous and signet ring histological types than in the older aged group. The proportion of tumors classified as mucinous decreased with age, from 28% among those aged 0 to 19 years to 5% among those 40 years and older. The adenocarcinomas were often advanced in the persons under 40 years old: 30% were localized, 44% were regional, and 26% had metastasized at the time of diagnosis. A significantly higher proportion of tumors were localized in the persons over 40 years of age.--Richard R. Ricketts ABDOMEN
A Valved Hepatic Portoduodenal Intestinal Conduit for Biliary Atresia, K. Tanaka, I. Shirahase, H. Utsunomiya, et al. Ann Surg 213:230-235, (March), 1991. Technical details for the construction of a unique intussuscepted muscular valve for portoduodenal intestinal conduit are presented.
787
The intussuscepted segment is first devitalized, and then the seromuscular coat is circumferentially removed prior to intussusception. Construction of a portoduodenal conduit preserves normal bile physiology. In a series of 46 patients, 23% developed cholangitis as compared with 68% to 100% in other reported reconstructions. The 5-year jaundice-flee survival of 64% is attributed to the decreased incidence of cholangitis with this new t e c h n i q u e . Edward G. Ford
Liver Transplantation in Children. R.W. Busuttil, P. Seu, M. Millis, et al. Ann Surg 213:48-57, (January), 1991. The cases of 103 liver transplant patients (OLT) under 18 years of age are reviewed to emphasize factors important to a favorable outcome. Two hundred and twenty-five children were initially evaluated, 154 of which (68%) were considered candidates for OLT. One hundred twenty-three OLTs were performed in 103 patients (mean age, 5.2 years). Indications for OLT included biliary atresia (47%) and less than 10% each for metabolic disease, hepatic failure, tumors, biliary hypoplasia, and familial cholestasis. Ten percent of active waiting list patients died (50% for lack of suitable donors, 50% from progression of disease). Immunosuppression was maintained with CsA and Azathioprine. Clinical suspicion of rejection was confirmed by percutaneous liver biopsy and treated with methylprednisolone pulse. Standard rejection treatment failures were treated with antithymocyte globulin or OKT3. Eighty percent of patients are long-term survivors. The best prognosis occurred in patients with cq-antitrypsin deficiency (5-year survival 95%), and the worst in patients with biliary atresia and tumors (5-year survival 71%). Four of 21 deaths occurred within 10 days of OLT (brainstem herniation [2], bleeding and hepatic failure [1], pulmonary hemorrhage [1]). Significant survival advantage (96%) occurred in 82 patients with identical blood-type matching. Retransplantation was performed 21 times in 19 patients with a survival of 58%. OLT is the treatment of choice for children with end-stage liver failure. The technique can be performed with acceptable morbidity and mortality, and an excellent quality of life is expected in most eases.--Edwai-d G. Ford
Liver Transplantation in Children From Living Related Donors. C. Broelsch, P. Whitington, J. Emond, et al. Ann Surg 214:428439, (October), 1991. Orthotopic liver transplantation (OLT) in children is difficult because of the availability of few appropriate sized donors. Technical and social advances now allow the use of reduced-sized grafts (RLT) from living-related donors (LRT). This report details experience in LRT in 20 infants, mean age 15.5 months and mean weight 8.4 kg. The authors detail donor and recipient selection, donor and recipient surgical procedures, and postoperative care. Indications for LRT were biliary atresia (16), cq-antitrypsin deficiency (2), cytomegalovirus hepatitis (1), and neonatal hepatitis (1). Donors ranged in age from 21 to 41 years and included 12 mothers, 7 fathers, and one grandmother. Seventeen recipients are alive 3 to 18 months after LRT, and 15 are home with normal liver function. Biliary complications occurred in 7 of 20 (3 leaks and 5 anastomotic breakdowns associated with arterial thrombosis). The overall incidence of graft rejection was 35%. There were no losses of primary LRT grafts from rejection. The discussion includes a historical update of LRT, as well as considerations for re-transplantation. Vascular complications are also discussed.--Edward G. Ford
ers years 1959 to 1988. During this time a total of 165 intussusceptions were treated in 153 patients, with 1 death. The peak incidence for age was characteristic, and, as expected, the study showed a gradual increase in the number of hydrostatic reductions. Eight patients had a lead point. In four hydrostatic reduction failed (Meckel's diverticulum 3, Henoch-Schfnlein purpura 1) and in four a laparotomy was performed without attempted hydrostatic reduction (Meckel's diverticulum 3, lymphoma 1). The authors advocate ultrasonography as a screening procedure in cases of suspected intussusception (53 uttrasounds performed, 44 negative results, 9 positive results of whom one proved negative on barium enema examination).--Patricia Davidson One-Drug Versus Two-Drug Antibiotic Therapy in Pediatric Perforated Appendicitis: A Prospective Randomized Study. J.L. Meller, H.M. Reyes, D.S. Loeff, et al. Surgery 110:764-768, (October), 1991. This is a prospective randomized study to compare the use of gentamicin and clindamycin to a single antibiotic, cefoxitin, in the treatment of perforated appendicitis in pediatric patients. Fifty-six patients with perforated appendicitis were randomized. Twentynine received cefoxitin and 27 received gentamicin and clindamycin. Antibiotics were started before operation and continued for a minimum 6 days after operation. Wounds were left open and closed secondarily after day 3 if they appeared to be clean. The most common organisms cultured were Escherichia eoli (62%) and Bacteroides (46%). No difference was noted in infectious complications between the two groups nor in the length of hospital stay. There was one pelvic abscess and three subfascial abscesses in the group with gentamicin and clindamycin versus one wound infection with cefoxitin alone. The hospital cost for a 5-day course of cefoxitin was $106, whereas the cost for a 5-day course of gentamicin and clindomycin was $68. The authors state that based on this study cefoxitin as a single drug is a good alternative to the traditional dual combination.--Thomas F. Tracy, Jr Adenocarcinomas of the Colon and Rectum in Persons Under 40 Years Old. P.M. Griffin, J.M. Lift, R.S. Greenberg, et al. Gastroenterology 100:1033-1040, (April), 1991. A population-based study was done to characterize the epidemiology of noncarcinoid adenocarcinomas of the colon and rectum in persons under 40 years old between 1973 and 1984 (n = 1,736). These were compared with those in persons 40 years and older (n = 106,760). The median age at diagnosis was 35 years; the youngest age at diagnosis was 4 years, and only 29 patients (1.7%) were under 20 years of age. There was a higher incidence in blacks than in whites, and there was a higher proportion of mueinous and signet ring histological types than in the older aged group. The proportion of tumors classified as mucinous decreased with age, from 28% among those aged 0 to 19 years to 5% among those 40 years and older. The adenocarcinomas were often advanced in the persons under 40 years old: 30% were localized, 44% were regional, and 26% had metastasized at the time of diagnosis. A significantly higher proportion of tumors were localized in the persons over 40 years of age.--Richard R. Ricketts ABDOMEN
A Valved Hepatic Portoduodenal Intestinal Conduit for Biliary Atresia, K. Tanaka, I. Shirahase, H. Utsunomiya, et al. Ann Surg 213:230-235, (March), 1991. Technical details for the construction of a unique intussuscepted muscular valve for portoduodenal intestinal conduit are presented.
787
The intussuscepted segment is first devitalized, and then the seromuscular coat is circumferentially removed prior to intussusception. Construction of a portoduodenal conduit preserves normal bile physiology. In a series of 46 patients, 23% developed cholangitis as compared with 68% to 100% in other reported reconstructions. The 5-year jaundice-flee survival of 64% is attributed to the decreased incidence of cholangitis with this new t e c h n i q u e . Edward G. Ford
Liver Transplantation in Children. R.W. Busuttil, P. Seu, M. Millis, et al. Ann Surg 213:48-57, (January), 1991. The cases of 103 liver transplant patients (OLT) under 18 years of age are reviewed to emphasize factors important to a favorable outcome. Two hundred and twenty-five children were initially evaluated, 154 of which (68%) were considered candidates for OLT. One hundred twenty-three OLTs were performed in 103 patients (mean age, 5.2 years). Indications for OLT included biliary atresia (47%) and less than 10% each for metabolic disease, hepatic failure, tumors, biliary hypoplasia, and familial cholestasis. Ten percent of active waiting list patients died (50% for lack of suitable donors, 50% from progression of disease). Immunosuppression was maintained with CsA and Azathioprine. Clinical suspicion of rejection was confirmed by percutaneous liver biopsy and treated with methylprednisolone pulse. Standard rejection treatment failures were treated with antithymocyte globulin or OKT3. Eighty percent of patients are long-term survivors. The best prognosis occurred in patients with cq-antitrypsin deficiency (5-year survival 95%), and the worst in patients with biliary atresia and tumors (5-year survival 71%). Four of 21 deaths occurred within 10 days of OLT (brainstem herniation [2], bleeding and hepatic failure [1], pulmonary hemorrhage [1]). Significant survival advantage (96%) occurred in 82 patients with identical blood-type matching. Retransplantation was performed 21 times in 19 patients with a survival of 58%. OLT is the treatment of choice for children with end-stage liver failure. The technique can be performed with acceptable morbidity and mortality, and an excellent quality of life is expected in most eases.--Edwai-d G. Ford
Liver Transplantation in Children From Living Related Donors. C. Broelsch, P. Whitington, J. Emond, et al. Ann Surg 214:428439, (October), 1991. Orthotopic liver transplantation (OLT) in children is difficult because of the availability of few appropriate sized donors. Technical and social advances now allow the use of reduced-sized grafts (RLT) from living-related donors (LRT). This report details experience in LRT in 20 infants, mean age 15.5 months and mean weight 8.4 kg. The authors detail donor and recipient selection, donor and recipient surgical procedures, and postoperative care. Indications for LRT were biliary atresia (16), cq-antitrypsin deficiency (2), cytomegalovirus hepatitis (1), and neonatal hepatitis (1). Donors ranged in age from 21 to 41 years and included 12 mothers, 7 fathers, and one grandmother. Seventeen recipients are alive 3 to 18 months after LRT, and 15 are home with normal liver function. Biliary complications occurred in 7 of 20 (3 leaks and 5 anastomotic breakdowns associated with arterial thrombosis). The overall incidence of graft rejection was 35%. There were no losses of primary LRT grafts from rejection. The discussion includes a historical update of LRT, as well as considerations for re-transplantation. Vascular complications are also discussed.--Edward G. Ford