Planned exploration of pediatric liver transplant recipients reduces posttransplant morbidity and lowers length of hospitalization

J. F. Renz, P. Rosenthal, J. P. Roberts, N. L. Ascher and J. C. Emond
Department of Surgery, University of California-San Francisco, USA.

BACKGROUND: Pediatric liver transplantation (eg, orthotopic liver transplantation) has been associated with decreased graft survival compared with adult transplantation; this has been attributed to the increased difficulty of the procedure in small children and the increased number of technical variants that have been used to increase the supply of small livers. OBJECTIVES: To adopt a policy of planned exploration (PLANEX) of children on the seventh day after orthotopic liver transplantation, to obtain a liver biopsy specimen, to identify and treat potential technical problems at that time, and to evaluate the effect of this strategy on the length of hospitalization and morbidity rate in 60 children who underwent orthotopic liver transplantation. DESIGN: The PLANEX was adopted progressively during a 3-year period. A retrospective study was conducted that compared outcomes between patients who did and did not undergo PLANEX. Data were collected from chart review with a complete follow-up of patients. SETTING: A university medical center at which 130 liver transplantations are performed annually in adults and children. PATIENTS: Sixty children who received primary transplants between October 1992 and December 1996 were studied. INTERVENTIONS: Standard, partial, and living-donor transplantations were performed. Routine procedures performed at PLANEX included hematoma evacuation, tissue culture, inspection of all anastomoses, intraoperative ultrasonographic verification of vessel patency, open liver biopsy, and definitive abdominal closure. MAIN OUTCOME MEASURES: The duration of the primary hospitalization was the main outcome measure. Surgical complications and graft and patient survival rates were also analyzed. RESULTS: The mean +/- SD length of hospitalization for 24 recipients who underwent PLANEX was 16.5 +/- 5.7 days compared with 19.2 +/- 4.7 days for 6 patients (25%) who had significant findings at exploration (P = .34). In the 36 patients who did not undergo PLANEX, 10 patients (28%) required unplanned explorations (on median posttransplant day 13) that identified the following 13 complications: biliary (n = 4), undiscovered enterotomy (n = 6), hemoperitoneum (n = 2), and partial vascular thrombosis (n = 1). The mean length of hospitalization for recipients who did not require exploration was 19.3 +/- 3.9 days (PLANEX, P = .28); however, in patients who required unplanned exploration, the mean length of hospitalization increased to 41.2 +/- 15.5 days (median, 43 days). The mean length of hospitalization of recipients who underwent unplanned exploration was significantly increased compared with recipients who underwent PLANEX with significant intraoperative findings (P = .02). CONCLUSIONS: In this series, early identification and repair of surgical problems in asymptomatic patients on day 7 significantly decreased the hospital stay and morbid consequences of surgical problems. This aggressive approach may improve overall graft and patient survival.