活体肝移植22例临床分析

目的 总结开展活体肝移植的临床经验,探讨进一步提高活体肝移植疗效的措施.方法 回顾性分析我院22例活体肝移植供受体的临床资料,总结术前评估过程、手术方法和术后并发症的情况.结果 本组获取的供肝移植物包括左外叶2例、左半肝6例、扩大左半肝1例、右半肝5例和扩大右半肝8例.所有供体术后恢复顺利,未出现严重并发症.22例受体中成年患者13例,儿童患者9例.围手术期发生并发症8例,包括严重腹腔感染1例,肝功能恢复不良合并伤口感染1例,腹腔内出血继发肝动脉血栓形成1例,此3例患者最终均因多器官功能衰竭死亡.1例肝功能衰竭的患儿术后因心肺功能衰竭死亡.另外发生胆漏2例,顽固性腹水1例,右下肢深静脉血栓形成1例,均通过保守疗法治愈.18例受体病愈出院.手术后期发生胆道吻合口狭窄3例,行PTCD并留置支撑管治疗,Oddi括约肌失迟缓引起的梗阻性黄疸1例,行内镜下十二指肠乳头括约肌切开术治疗.此4例患者病情稳定,肝功能均已恢复正常.结论 选择合适的供体、掌握关键的手术技术,才能使供受体都获得良好的预后.     

补救性肝移植19例手术体会

目的探讨采用补救性肝移植(salvage liver transplantation,SLT)治疗原发性肝细胞癌(肝癌)切除术后肝内复发或肝功能衰竭的疗效及手术体会。方法肝癌切除术后肝内复发16例,肝癌切除术后肝功能衰竭3例,其中合并肾功能异常2例,均接受SLT。术前充分评估病情。手术方式采用附加腔静脉整形的改良背驮式原位肝移植,其中肾功能异常的2例采用股静脉-颈内静脉转流术。肝动脉的重建采用供肝腹腔干动脉与受者肝固有动脉行端端吻合17例,采用供肝腹腔干动脉通过供者髂动脉间置搭桥与受者腹主动脉行端侧吻合2例。胆道的重建全部采用胆道端端吻合。术程始终遵循精细的无瘤操作,术后常规抗排斥和抗感染治疗,并对患者进行了长期随访。结果围手术期19例SLT患者无死亡。术后1、3、5年累积生存率分别为100%、84%、84%;1、3、5年无瘤生存率分别为100%、89%、89%。结论采用SLT治疗肝癌切除术后肝内复发或肝功能衰竭患者的疗效较好。采用腔静脉整形的改良背驮式肝移植术式、充分的术前评估以及遵循精细的无瘤操作是手术成功的关键。     

肝移植术后肝动脉和门静脉并发血栓形成两例

2001年11月至2009年12月间,我中心共行尸体肝移植3100余例次.其中2例患者肝移植术后,肝动脉和门静脉同时发生血栓形成,现报告如下. 病例资料 例1男性,38岁,因"慢性重型乙型肝炎"行原位肝移植.肝移植术后2个月,因胆道并发症(胆道感染、胆道坏死而至胆道铸型)而行二次肝移植.二次肝移植术中,采用5-0 prolene线端端连续吻合供、受者门静脉;供者端以腹腔动脉袢,受者端以肝总动脉与胃十二指肠形成动脉袢,采用6-0 prolene线行间断端端吻合.     

肝移植术后再次手术14例临床分析

目的 探讨肝移植术后并发症的再次手术治疗.方法 对2002年6月至2007年3月肝移植病例中14例肝移植术后患者的17例次再次手术的临床资料进行回顾性分析.结果 17次再次手术治疗手术成功率100%,1例因腹腔内出血于术后第10天死于肾功能衰竭并发ARDS.1例因胸穿后血胸于术后第20天死于严重的腹腔和肺部感染,1例因左肝内胆管结石伴胆道感染于术后第33天因多器官功能衰竭死亡,1例因肿瘤复发转移于再次术后25天死亡,其余10例成活至今且肝功能良好,生存率71.4%(10/14).结论 正确把握肝移植术后再次手术的适应证和手术时机,充分的手术前准备,术中精细操作,加强围手术期严密监测和正确处理是肝移植术后再次手术成功的关键.     

再次肝移植28例经验总结

目的 总结再次肝移植的临床经验.方法 回顾性分析本研究所1996年5月至2009年8月实施的28次再次肝移植病例资料,并结合文献进行讨论.结果 在连续880例次同种异体原位肝移植中,有24例病人共接受28次再次肝移植术,再次移植率为3.18%.再次移植的指征分别为胆道并发症16例次(57.1%),原发病(肿瘤)复发6例次(21.4%),肝动脉血栓形成4例次(14.3%),慢性排斥反应(3.6%)和原发性移植肝无功能各1例次(3.6%).再次肝移植13例(17次手术)术后恢复顺利痊愈出院,随访至今已经存活51 d至67个月;11例于1～489 d病死.病死原因是:3例术后失血性休克,2例肝癌复发,2例心血管并发症,2例感染性休克,1例神经系统并发症,1例肝动脉血栓形成.病死率为39.3%.结论 再次肝移植能有效挽救移植肝失功病人的生命,再移植指征的掌握、手术时机的选择、手术技巧的提高和围手术期的正确处理是提高再次移植成功率的关键.     

再次肝移植132例的临床分析

目的 探讨再次肝移植的比率、原因及术后存活时间.方法 回顾性分析1998至2007年间2833例次肝移植术后患者的资料.比较1998至2003年(手术技术初期)和2004至2007年(手术技术相对成熟期)两个阶段中,再次肝移植的比率、原因及术后患者的存活时间.结果 共对132例患者进行了再次肝移植,再次肝移植率为4.66%(132/2833).1998至2003年行首次肝移植的患者中有67例进行了再次肝移植,再次肝移植率为10.84%(67/618),2004至2007年行首次肝移植的患者中有65例进行了再次肝移植,再次肝移植率为3.12%(65/2083),两者再次肝移植率的比较,差异有统计学意义(P<0.01).132例患者再次肝移植的原因包括:胆道并发症6H4例、原发病复发24例、排斥反应14例、移植肝功能不良13例、肝动脉血栓形成12例、腹腔感染2例、门静脉血栓形成2例及其他原因1例.手术技术初期再次肝移植的主要原因为胆道并发症、排斥反应、移植物功能不良及乙型肝炎复发;手术技术相对成熟期则以胆道并发症、肝动脉血栓形成、排斥反应及移植物功能不良为主.首次肝移植术后6个月之内和之后行再次肝移植的患者分别为42和90例,其中位存活时间分别为570和1202 d(P<0.05).结论 随着肝移植手术技术的进步,再次肝移植率下降.再次肝移植成为治疗首次肝移植术后朋道并发症、原发病复发、排斥反应、移植物功能不良等的有效方法 .再次肝移植的手术时机最好在首次肝移植术后6个月之后.     

肝移植胆道重建的手术技巧

目的探讨原位肝移植手术中胆道重建的手术技巧。方法回顾性分析132例原位肝移植患者的临床资料,总结胆道重建的手术技巧。结果132例患者的手术成功率为93.94%,术后出现胆道并发症者12例(9.85%),其中胆管狭窄6例,胆泥淤积或结石3例,肝断面胆漏者2例(劈离式肝移植患者),T管拔除后胆瘘1例。除1例胆道狭窄者行再次肝移植,因发生严重感染导致肝功能衰竭死亡外,其余患者获得满意的效果。结论胆道并发症是肝移植术后的常见并发症,而良好的胆道重建技术是预防肝移植术后胆道并发症的重要保证。     

原位肝移植术后并发症的诊治体会(附16例报告)

目的 探讨原位肝移植术后并发症的诊治经验。方法 回顾性分析我院16例肝病患者行17例次肝移植术后各种并发症的诊断及治疗方法。结果 全组手术成功12例次，围手术期死亡5例，死亡原因：脑出血1例，急性呼吸窘迫综合征(ARDS)1例，急性肾功能衰竭1例，肝动脉血栓1例，急性排斥反应1例。现存活6例，其中1例存活已超过3年。术后并发腹腔内出血3例，脑血管病变2例，ARDS2例，血管并发症2例，胆道并发症3例，急、慢性排斥反应各2例，急性肾功能衰竭2例。结论 肝移植围手术期采取合理的防治措施能有效地减少肝移植术后并发症的发生，对肝移植术后并发症的及时诊断和有效治疗是提高肝移植术后成功率的关键．     

肝移植术后肝动脉并发症的治疗

目的 探讨肝移植术后肝动脉并发症治疗方式与时机的选择.方法 总结2003年10月至2007年3月中山大学附属第三医院肝脏移植中心25例肝移植术后肝动脉并发症的临床资料,分析介入溶栓、经皮腔内血管成形(PTA)、支架植入和再次肝移植对肝动脉并发症预后的影响.结果 本组患者肝移植术后肝动脉血栓形成(hepatic artery thrombosis,HAT)5例,2例患者因肝功能衰竭行再移植治疗,术后均存活;3例接受介入溶栓治疗后,1例肝功能恢复正常,1例死亡,1例再次出现HAT,并再次移植术后因多器官功能衰竭死亡.术后1个月内出现肝动脉狭窄(hepatic arterystenosis,HAS)者12例,因肝功能衰竭行再移植2例;支架植入10例(治疗后因胆道缺血性改变行再移植4例);6例再移植患者存活4例,因颅内出血和感染死亡2例.术后1个月后出现HAS者8例,行肝动脉支架植入5例,肝功能好转.因胆道缺血性改变接受再移植1例.另外2例行保守治疗,情况稳定未作处理.结论 肝移植术后肝动脉并发症的治疗应根据并发症采用个体化的治疗方案.HAT的治疗以再次肝移植为主,HAS以介入治疗为主,一旦出现胆道缺血性改变,应及时行再次肝移植.     

再次肝移植五例报告

目的　总结再次肝移植的临床经验。方法　对 5例男性患者施行再次肝移植 ,再次肝移植的原因分别为原发性移植肝无功能 (1例 )、急性排斥反应 (1例 )、慢性排斥反应并胆道感染 (1例 )以及胆道缺血并感染 (2例 )。供肝植入均采用改良背驮式原位肝移植术。术后免疫抑制治疗采用达利珠单抗、甲泼尼龙及他克莫司联合用药 ,必要时加用霉酚酸酯。结果　 3例治愈 ,已分别存活11个月、5个月和 1个月 ,2例分别于术后第 8d、第 10d死亡 ,1例死于多器官感染及功能衰竭 ,1例死于心力衰竭。术后并发症有腹腔出血、多器官感染、胆道感染及切口感染等。结论　再次肝移植是移植肝功能衰竭的有效治疗方法 ,适应证及手术时机的正确把握、围手术期的严密监测和正确处理是提高再次肝移植患者存活率的关键。     

Pediatric living donor liver transplantation

AIM: The aim of this study was to analyze the results of living donor in a pediatric liver transplantation program. PATIENTS: Twenty-six living donor liver transplantations were performed in children from 0.5 to 14.8 years of age. The main indication was biliary atresia (72%) followed by tumors (2 hepatoblastomas and 1 hepatocarcinoma). Left lateral segments were used in 23 (1 transformed into a monosegment), 1 left lobe was used in 1, and right lobes were used in 2. Arterial reconstruction employed saphenous venous grafts in the first 3 cases and end-to-end anastomoses with a microsurgical technique in the following 22 cases. RESULTS: There has been no major morbidity in the donors, with a median hospitalization of 6 days. Four grafts have been lost; 2 in the first 3 cases. In only 1 case, the graft loss was related to the procedure saphenous venous graft thrombosis). Early biliary complications were frequent (23%). Six month, 1 year, and 5 year graft and patient survival rates were 91%, 85%, and 85% and 100%, 96%, and 96%, respectively. CONCLUSIONS: Living donor liver transplantation is an excellent option for transplantation in children.     

Combined liver and kidney transplantation: analysis of Padova experience

BACKGROUND/AIM: The main indications for combined liver and kidney transplantation (CLKT) are as follows: (1) cirrhosis with renal damage dependent or not upon liver disease, (2) renal failure with dialysis and concomitant liver end-stage disease, (3) congenital diseases, and (4) enzymatic liver deficiency with concomitant renal failure. The aim of this study was to evaluate our results with CLKT both in adult and pediatric patients. METHODS: From September 1995 to September 2006, 15 CLKT (2.8%) among 541 liver transplantations included 4 pediatric patients (27%). The main indications for CLKT were hepatitis C virus (HCV) and polycystic diseases in adult patients, and primary hyperoxaluria in pediatric patients. RESULTS: The double transplantation was performed from the same donor in all cases. All adult patients received whole liver grafts, whereas 3 split transplants and 1 whole liver graft were transplanted in the pediatric patients. Median liver and kidney cold ischemia times were 468 and 675 minutes, respectively. After a median follow-up of 36 months (range, 1-125), the overall survival rate was 80%. Five-year patient and graft survival rates were 100% for adult CLKT, whereas they were 50% for pediatric patients. We observed only 2 cases (18%) of delayed renal function, requiring temporary hemodialysis with progressive graft improvement. There was only 1 case of kidney retransplantation due to early graft nonfunction in a pediatric patient. CONCLUSION: Although CLKT is related to major surgical risks, results after transplantation are satisfactory with an evident immunological advantage.     

Pediatric liver transplantation: the Montreal experience

The introduction of cyclosporine A in 1980 greatly improved the survival of children with end-stage liver disease undergoing orthotopic liver transplantation. The average 1-year survival rate following hepatic transplantation increased from 30% in 1963 to 70% in 1980. This report summarizes the initial experience of two pediatric hospitals in Montreal--H?pital Ste-Justine and Montreal Children's Hospital. Since December 1985, 13 orthotopic liver transplantations have been performed in 11 patients: six females and five males. The median age was 18 months (range, 13 months to 17 years) and the median weight was 10 kg (range, 8.5 to 38 kg). The indications for transplantation were biliary atresia (5 patients), tyrosinemia (2 patients), biliary hypoplasia (1 patient), Amerindian cirrhosis (1 patient), Crigler-Najjar syndrome, type I (1 patient), and fulminant non-A, non-B hepatitis with grade IV encephalopathy (1 patient). Immunosuppression was ensured by cyclosporine A, azathioprine, and steroids. The function of 11 grafts was immediate following revascularization of the grafts. One graft had delayed function due to preservation injury, and one had primary nonfunction. Surgical complications included bile peritonitis (1), ruptured aneurysm of an aortic conduit (1), and thrombosis of the hepatic artery necessitating retransplantation (2). Three of our patients died, one from postoperative cerebral edema, one of primary nonfunction of the graft, and one of ruptured aneurysm of an aortic conduit. Our overall survival rate was 72% with a follow-up of 3 to 32 months. Pediatric liver transplantation can now provide successful treatment and cure of liver diseases considered, until recently, dismal and hopeless.     

Pediatric liver retransplantation: indications and outcome

INTRODUCTION: Liver transplantation is the only treatment for end-stage liver disease. Not all patients have a favorable outcome. Graft failure secondary to primary nonfunction, vascular complications, or chronic rejection among other problems may lead to retransplantation. Retransplantation represents 8% to 29% of liver transplantations in the pediatric population. The aim of this study was to present our experience with retransplanted children by analyzing the indications and the results. METHODS: All patients were prospectively included in our database, including 125 children. We included the indications for retransplantation, complications, and mortality. Kaplan-Meier curves were used for survival analysis. RESULTS: Since 1994, 125 patients were transplanted and 25 were retransplanted (20%), including 5 who received a third graft. Primary nonfunction represented 30% of the indications for retransplantation and hepatic artery thrombosis, 20%. Six of 25 patients who received a first retransplantation and 2 of 5 who received a second retransplantation died. The most frequent cause of death was multiorgans failure. The survivals at 1 and 5 years were 82% and 76% for children receiving a first retransplantation, and 60% at 1 and 5 years for those who received a second retransplantation. CONCLUSIONS: Organ failure after liver transplantation was a common event in pediatric transplantation. Survival was similar between patients transplanted once and those who received one retransplantation. Survival decreased among patients who received a third graft but was maintained at 60%, which is better than most published results for first retransplanted patients. Retransplantation is a valid option with good results for selected pediatric cases.     

Combined liver and kidney transplantation in a multicenter transplantation program in Chile

INTRODUCTION: Combined liver and kidney transplantation (CLKT) is an exceptional therapeutic procedure limited to a few diseases with advanced compromise of these organs. Hyperoxaluria type I and polycystic disease are the most frequent indications. The aim of this article was to report our indications and results of CLKT in a multicenter transplantation program in Chile. MATERIAL AND METHODS: Our Excel database was reviewed to select patients who were treated with CLKT between 1993 and July 2004. RESULTS: Among 242 liver transplantations (LT) and 48 kidney transplantations (KT), 7 were CLKT, representing 2.8% of LT and 14.5% of KT. Four patients were women and 3 were male of average age 46.8 years. One patient was a child. Most frequent indications were chronic renal failure associated with terminal liver disease and polycystic disease. One patient needed liver retransplantation due to hepatic vein thrombosis. One patient had a biliary fistula and another had a urinary fistula, treated conservatively. Acute liver rejection took place in 3 cases, 1 of which required antibodies. Two patients died, 1 due to aspergillosis and the other due to vascular complications in the transplanted liver. Actuarial survival rates were 71.4% at 1 and 5 years. Chronic renal failure is not a contraindication to LT. CONCLUSION: CLKT is an acceptable option for these patients.     

Surgical complications and outcome of pediatric liver transplantation in Hong Kong

Purpose: The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention. Methods: The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed. Results: Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well. Conclusions: Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved.     

Living-related liver transplantation in pediatric patients

INTRODUCTION: Many developments in surgical technique, immunosuppression, and patient selection criteria have led to improved long-term patient and graft survival in pediatric patients receiving liver transplants. In this study, we examined the early results of 26 pediatric recipients who underwent 26 liver transplantations between January 2003 and December 2004 at our institution. MATERIALS AND METHODS: The most common indications for liver transplantation were cholestasis in 10 patients (38.5%) and Wilson's disease in 8 (30.8%). Other indications were fulminant hepatic failure (4 patients, 15.4%), tyrosinemia (2 patients, 7.7%), Caroli disease (1 patient, 3.8%), and cryptogenic cirrhosis (1 patient, 3.8%). One recipient with Byler disease and two with tyrosinemia also had incidental hepatocellular carcinoma. RESULTS: Of 26 patients, 24 (92.3%) underwent living-related liver transplantation and 2 (7.7%) underwent cadaveric transplantation. The medical records of all patients were retrospectively reviewed. Twenty-two of 26 survived with excellent graft function, showing 91.2%, 86.4%, and 81.6% at 3, 12, and 24 months graft and patient survival rates, respectively. Sixteen patients (61.5%) developed various morbidities with biliary and vascular complications being the most common. Four patients (15.3%) developed bile leaks. Four patients (15.3%) developed hepatic artery thromboses. Five patients (19.2%) developed life-threatening infections. Four patients (15.4%) died during the study period, three owing to infectious complications. The other patient died due to acute respiratory distress syndrome. CONCLUSION: Despite technical difficulties and a donor organ shortage, the results of liver transplantation in pediatric patients with end-stage liver disease have demonstrated promising results at our institution.     

One hundred in situ split-liver transplantations: a single-center experience

OBJECTIVE: To identify predictors of graft and recipient survival from a single-institution series of in situ split-liver transplantations and compare outcomes to living donor and whole organs for adults and children. SUMMARY BACKGROUND DATA: Split-liver transplantation is a surgical technique that creates 2 allografts from a single cadaver donor. We have applied split-liver transplantation to all indications and categories of medical urgency for initial as well as retransplantation to expand the current donor pool and decrease reliance upon living donation. METHODS: A retrospective analysis was conducted of 100 consecutive in situ split-liver transplantations yielding a left lateral segment and right trisegment graft that were performed at the University of California Los Angeles between 9/91 and 02/03. These 100 transplantations generated 190 allografts for transplantation into 105 children and 60 adults, with the sharing of 25 allografts among transplant centers across the United States. Outcomes and incidence of complications were compared with living donor and whole organ recipients receiving liver transplantation during the same time period with independent predictors of split-liver graft and recipient survival identified by multivariate analysis. RESULTS: The incidence of biliary and vascular complications observed in recipients of left lateral segment grafts created by split-liver transplantation was not statistically different from recipients of left lateral segment grafts created from living donation or children receiving whole-organ grafts from pediatric donors. Kaplan-Meier survival estimations of left lateral segment graft and recipient survival also demonstrated no statistical difference among split-liver, living donor, and whole-organ recipients. Right trisegment grafts from split-liver transplantation demonstrated a 10% incidence of biliary and 7% incidence of vascular complications. Long-term graft function was excellent with patient and graft survival equal to 1086 recipients of cadaver whole-organ grafts from donors ages 10-40 years who underwent transplant operations during the same time period. Predictors of split-liver transplantation graft and recipient survival included United Network for Organ Sharing status at transplantation, indication, occurrence of a complication, donor creatinine, and donor length of hospitalization. CONCLUSIONS: Split-liver transplantation is an effective mechanism for immediate expansion of the cadaver donor pool that can reduce dependence upon living donation in adults and children.     

Pediatric organ transplantation

Since we started our pediatric kidney transplant program in 1970, we advocate children's transplantation to be performed in pediatric surgery units. Recent progress in immuno-suppression with ciclosporine and in operative procedures lead us to extend the program to liver transplantations in 1986, then to heart and lung transplantations in 1988. The Pediatric Transplant Unit was designed to assume the pre-operative evaluation of the recipients and the post-operative course of transplanted patients, closely connected to all specialists dealing with medical and surgical diseases of children. 29 patients were transplanted (kidney: 8, liver: 14, heart: 1, lungs: 6) with a 83% overall survival rate. The goal of this paper is not to discuss and compare indications or results with others series. Through our experience of pediatric organ transplantation, we shall try to point out the main advantages of a Pediatric Transplantation Unit: it optimizes the management of the rare pediatric donnors, and allows better skill and efficiency of the numerous specialities concerned by organ transplantation, such as intensive care, infectiology, immunology, radiology... The common medical and para-medical staff, common operative theater, and common use of equipment in the same department for transplantation of different organs is also an important matter to be considered now in term of cost-effectiveness.     

Graft Loss After Pediatric Liver Transplantation

OBJECTIVE: To describe the epidemiology and causes of graft loss after pediatric liver transplantation and to identify risk factors. SUMMARY BACKGROUND DATA: Graft failure after transplantation remains an important problem. It results in patient death or retransplantation, resulting in lower survival rates. METHODS: A series of 157 transplantations in 120 children was analyzed. Graft loss was categorized as early (within 1 month) and late (after 1 month). Risk factors were identified by analyzing recipient, donor, and transplantation variables. RESULTS: Kaplan-Meier 1-month and 1-, 3-, and 5-year patient survival rates were 85%, 82%, 77%, and 71%, respectively. Graft survival rates were 71%, 64%, 59%, and 53%, respectively. Seventy-one of 157 grafts (45%) were lost: 18 (25%) by death of patients with functioning grafts and 53 (75%) by graft-related complications. Forty-five grafts (63%) were lost early after transplantation. Main causes of early loss were vascular complications, primary nonfunction, and patient death. Main cause of late graft loss was fibrosis/cirrhosis, mainly as a result of biliary complications or unknown causes. Child-Pugh score, anhepatic phase, and urgent transplantation were risk factors for early loss. Donor age, donor/recipient weight ratio, blood loss, and technical-variant liver grafts were risk factors for late loss. CONCLUSIONS: To prevent graft loss after pediatric liver transplantation, potential recipients should be referred early so they can be transplanted in an earlier phase of their disease. Technical-variant liver grafts are risk factors for graft survival. The logistics of the operation need to be optimized to minimize the length of the anhepatic phase.