Nacoti Mirco, Ruggeri Giulia Maria, Colombo Giovanna, Bonanomi Ezio, Lussana Federico
Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy.
Hematology and Bone Marrow Transplant Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy.
World J Hepatol. 2018 Oct 27;10(10):752-760. doi: 10.4254/wjh.v10.i10.752.
To review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.
Studies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.
Nine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.
Poor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.
鉴于血栓形成仍是小儿肝移植（PLT）的关键并发症，对当前小儿肝移植血栓预防的文献进行综述。
通过电子检索MEDLINE、EMBASE和Cochrane图书馆（CENTRAL）数据库，检索截至2018年3月的研究。通过人工查阅纳入研究的参考文献以及已发表的关于血栓形成和小儿肝移植的主要系统评价的参考文献来补充检索。本综述排除了病例报告、小病例系列、评论、会议摘要、每年描述小儿肝移植少于10例的论文以及1990年以前发表的文章。两名评审员独立进行研究筛选，如有分歧通过讨论解决，必要时由第三名评审员给出意见。
本综述纳入了9项回顾性研究。研究的总体质量较差。由于纳入研究的回顾性设计和异质性，无法对研究结果进行汇总分析。我们发现小儿活体肝移植（LDLT）中门静脉血栓形成（PVT）的发生率为2%至10%，小儿尸体肝移植（DDLT）中为4%至33%。肝动脉血栓形成（HAT）主要在LDLT和DDLT混合的小儿人群中观察到，发生率为0%至29%。在大多数研究中，多普勒超声被用作血栓形成的一线诊断筛查。报告了四种不同的门静脉吻合手术技术，在降低PVT方面疗效相似。减体积肝移植与PVT（发生率4%）和HAT（发生率0%，<0.05）的低风险相关。同样，无移植物植入的主动脉动脉吻合和显微外科肝动脉重建与HAT发生率显著降低相关（分别为6%和0%）。根据我们的纳入和排除标准未发现评估血栓形成药物预防的合格研究。
质量较差的回顾性研究表明，采用针对性的手术策略可能有助于降低小儿肝移植术后的HAT和PVT；迫切需要开展前瞻性研究。
