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Bleeding

Posttransplant bleeding, when it occurs, is usually slow but persistent. Bleeding into the abdomen occurs to some degree in most transplant patients and postoperative transfusion is often required. Blood is evacuated through the drains left in place at the time of the transplant, but blood and blood clots can occlude the drains and still accumulate in the abdomen resulting in progressive distension. A return to the OR is indicated when abdominal distension interferes with ventilation, renal perfusion and lower limb perfusion. Laparotomy results in the immediate improvement in renal perfusion and ventilation. The bleeding point, if found, will usually be a small arterial branch in the hilum of the liver or along the course of the hepatic artery. Bleeding is more frequent in reduced size or split liver transplants, but requires laparotomy in less than 10% of cases.

Nonfunction

Primary nonfunction occurs in less than 5% of cases, but requires urgent retransplantation when it is diagnosed. Reduced size and split liver transplantation may result in a higher incidence of nonfunction. Therefore, more stringent criteria are used for selection of livers to be reduced in size or split than for those used as whole organs. In general, organs intended for splitting or size reduction must be from donors less than 40 years of age, with near normal enzymes and less than 10% fat.

Vascular Thromboses

Early re-exploration of clotted arteries has not been reported to be as successful in children as in adults. Takedown of the arterial anastomosis, infusion of urokinase into the graft and trimming back both the donor and recipient ends of the artery can result in restoration of arterial flow on occasion and is probably worth doing in all cases when the thrombosis is detected early. Microvascular surgical techniques have resulted in a decrease in thrombotic complications in small children. When the artery does clot, however, the clinical course can be unpredictable. Retransplantation is always necessary if significant biliary damage has occurred. Some children, however, have acceptable liver function and heal any ischemic damage with few or no serious sequelae.

Portal Vein Occlusion

Unlike arterial thrombosis, portal vein occlusion can almost always be reversed when diagnosed early. Localized thrombus, kinking of the vein, or extrinsic compression can usually be reversed. Even if liver function is acceptable, the portal vein should be declotted to prevent the long-term problems of portal hypertension and cavernous transformation.

Biliary Problems

Choledochojejunostomies are the most common form of biliary hook up in children. Serious biliary leaks may signify arterial thrombosis, and in that setting, retransplantation may be the most practical option. Operation and evacuation of infected collections, attempted repair of biliary dehiscences and insertion of drains must be done in all cases of bile leaks associated with fever and a septic clinical state.21 Small leaks, which appear to be adequately drained, may be safely observed even if the artery is not open.

Bile leaks may also originate from secondary ducts that may not be visible at the time of the transplant. Although this may occur with whole liver transplantation, it is more common after living related or split liver transplantation when small segmental ducts at the liver parenchymal transection plane either at the cut surface or within the liver plate secrete bile into the abdominal cavity. Small ducts at the cut surface may safely be oversewn. Those at the plate may signify segmental ducts and should be anastomosed to the bowel with a separate choledo-chojejunostomy.

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