Pediatric Liver transplant operation is as old as the Liver transplant itself. The first successful liver transplant operation was done in 1967 by Dr. Thomas Starzl on a child and the patient went on to live for 300 days after the surgery. It is indeed interesting to say that even after five decades, pediatric transplant continues to be a daunting endeavour.
Technically, this is an operation wherein the margin of error is very narrow. The surgery has to be performed meticulously with minimal blood loss. Some of the smaller patients who undergo a liver transplant, have total circulating blood volume of as less as 300-400ml, and the blood loss that might seem insignificant for an adult, may be enough to completely exsanguinate a small child. Additionally, all these children are at a higher risk of bleeding as they are started early on anticoagulation (blood thinners like heparin and aspirin). The vascular and biliary connections are very small, putting them at risk of thrombosis and leaks.
Also, there is a unique challenge, the “large for size” graft. Pediatric liver transplants are carried out using a small part of liver, most commonly from one of the parents. Less commonly, it is performed using a small part of the liver from a “cadaveric” donor (deceased donor split liver transplantation). However, even these partial liver grafts may be too big for the small recipients. The “large for size syndrome” can result in abdominal compartment syndrome, portal hypo-perfusion (Portal vein blood flow falling short of the blood required by the large graft) and problems with tissue oxygenation. This can result in dysfunction of the newly transplanted liver, vascular problems and re-explorations.
The post-operative period also poses immense challenges. The fluid balance has to be closely titrated as a little extra fluid can lead to pulmonary edema (lung congestion) and a little less can lead to low blood pressures and shock. Very small children cannot communicate effectively, and it requires very experienced pediatric intensive care nurses to pick up warning signs early. The need for feeding the children and maintaining adequate nutrition in the pre-operative as well as post-operative period cannot be overemphasized.
Shortage of donor organs, which is the bane of transplantation, is usually not so much of a problem in pediatric liver transplantation as one of the parents usually come up as willing and medically suitable donors. However, the socio-economic challenges associated with pediatric transplants in our country are no less. The primary caregivers of these patients are young parents and majority of them have additional responsibilities like caring for their other children. The young parents are still trying to find a sound footing with their careers and savings. These factors assume immense importance in a scenario where health insurance coverage is sparse and healthcare is largely funded by family savings. The pediatric liver transplant operations are commonly subsidized by the transplant programmes, and often they have to go a step further and liaison with social organizations and NGOs for gathering funds for the transplant surgery as well as long term post-operative care.
The Liver transplant programme at Apollo Hospitals, Jubilee Hills, Hyderabad has been doing pediatric liver transplant operations for chronic liver failure, acute liver failure and metabolic liver diseases for the last 3 years with excellent results. We have successfully performed liver transplantation in very small children and our smallest recipient was barely 6 months in age and 5 kilograms in weight. We are also the first centre in the world to have performed a combined open heart surgery and Living donor liver transplantation in a 5 year old child with Alagille syndrome. We have been at the forefront of pediatric transplantation in our country with pioneering techniques like composite Liver and Fascia allograft transplantation for difficult abdominal closures. Our multidisciplinary team consists of pediatric hepatologists, liver transplant surgeons, anesthetists, intensive care specialists, nephrologists, nutritionists, physiotherapists, and very experienced pediatric nursing staff. Our dedicated group of doctors, coordinators and social workers, ensure seamless follow-up care for endless years after liver transplantation. The state of the art infrastructure, most modern equipment and advanced blood bank and laboratory facilities help us deliver excellent outcomes, even in the most complex case scenarios.
The Pediatric Liver Transplant team at Apollo Hospitals, Jubilee Hills, Hyderabad, believes in bringing big smiles on the faces of our tiny patients and their families.
For all queries related to pediatric liver transplant operation, you can get in touch with Dr. Manish C Varma on Ask Apollo.