Brief History of Pediatric Liver Transplantation

The Piggyback Technique

To avoid caval occlusion and veno-venous bypass, Tzakis described the piggyback technique : the native liver is excised with preservation of the retrohepatic vena cava (VC); the suprahepatic VC of the donor graft is implanted on the enlarged orifices of the recipient suprahepatic veins. Lateral clamping of the VC avoids the need for decompression of the lower part of the body. Decompression of the splanchnic bed during the anhepatic phase is not needed in cirrhotic children with portal hypertension because of spontaneous portosystemic collaterals. When the liver to be removed has a normal vascular resistance, like in metabolic diseases and hepatoblastoma, a swift vascular reconstruction is required.

This technique has become standard also for implantation of a segmental graft, both from cadaveric and from living donors.

Portal Vein Reconstruction

In children with biliary atresia, which is the most frequent pediatric liver transplantation (LT) indication, the very frequent hypoplasia of the portal vein must be appropriately corrected by portoplasty to avoid post-operative thrombosis. My first trainee in liver transplantation, Jean de Ville de Goyet, described the meso-Rex shunt for bypassing the thrombosed portal vein ; this has become the standard in most centers. This technique could also be used after LT.

Biliary Drainage

Except in larger children where end-to-end biliary reconstruction is possible, the most reliable technique is an end-to-side anastomosis on a Roux-en-Y intestinal loop of sufficient length (50 cm) to prevent reflux.