Previously we reported the presence of portal fibrosis in 31% (n ‫؍‬ 84) of the grafts in protocol biopsies 1 year after pediatric liver transplantation (LTx). To assess the natural history of graft fibrosis after pediatric liver transplantation, we extended the analysis of graft histology in follow-up protocol biopsy specimens obtained 5 and 10 years after transplantation. We correlated histological results with clinical parameters at the time of LTx and during follow-up, to allow identification of risk factors for the development of fibrosis. From 1 year to 5 years after LTx, the prevalence of fibrosis increased from 31% to 65% (n ‫؍‬ 66) but remained stable thereafter (at 10 years, 69%, n ‫؍‬ 55). At 10 years after LTx, however, the percentage of patients with severe fibrosis had increased from 10% (at 5 years) to 29%. Of the 69% of children without fibrosis at 1 year post-transplantation, 64% (n ‫؍‬ 39) had developed some degree of fibrosis at 10 years. Fibrosis was strongly related to transplant-related factors such as prolonged cold ischemia time, young age at the time of transplantation, high donor/recipient age ratio, and the use of partial grafts (P < 0.05). Fibrosis was not significantly related to rejection, chronic hepatitis, or the nature of the immunosuppressive therapy. Conclusion: Biopsies after pediatric LTx show that most grafts developed fibrosis within 5 years. At 10 years after LTx, the graft fibrosis had progressed to severe fibrosis in at least 25% of the patients. Development of fibrosis, starting either before or after the first year post-LTx, was strongly related to transplantrelated factors, indicating the importance of these factors to long-term graft prognosis.

l~lb~ el bu~rgrmic Chemi,~lr~' aml Catra!vsix, EindhoPen tJni,~6(1~) MB Eimlhocen. Netherlands Received 16 December 1Ot)0; revised 31 January 1997 AhsiraelThe: c~,clroca|alyliqr |vdBcIion of uilrale has been investigated on Pt, Pd and Pl k Pd elecu~od¢,~ covered wi|h a ,~ubmonolayeJ of gern~aniunk PI + Pd eleo,~des were prepared by electrol¢~s deposition of stubmnnolayer~ of Pd on Pl by exchange of PdCI~ for preadsod~ed eopl~,r, Underpote~ ~i,dly deposited germanium enhances the reduction rale of nitrate strongly. The reduction of nitrite i~ euhanced to a lesser extent, whezeas germanium is inactive for NO and hydroxylamine reduction. Furlher. cyclic voltammetry shows that the well known inhibition of the nitrate reduction at low potentials is absent fi~r germaniumomodified electrodes. Amperometry shows lhat the cun~nt densities for nitrate reduction at 0.1 V depend strongly on the composition of the electrode surface. The activities increase in the order Pd, PI and Pt + Pd and all electrodes display a plopurtional relation between the activity and the germanium coverage. This shows that gemmnium is involved in the rate determining step, which is the reduction of nitrate to nitrite and its role is to bind the oxygen atom of nitrate, The higher activities for Pt + Pd electrodes can be understood in terms of changes in the electronic structure of the metals as a result of alloying. Selectivity measurements with a rotating ring-disk electrode have shown for all electrodes that the hydroxylamine selectivity increases for increasing germanium coverage. Pd displays higher hydroxylamine ,;electivides than Pt and Pt + Pd electrode~. No gaseous products were observed for Pi. whereas for Pt + Pd and Pd N~O selectivitie~ up to 8% were found. © 1997 Elsevier Science S.A.

Fax: +31-50-3613763 - re-intervention after orthotopic liver transplantationAbstract Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and 'bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) reintervention. Vascular re-intervention, re-transplantation, and reintervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, ChildPugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 1 (range 0-18.8 1) in the re-intervention group compared with 1.5 1 (range 0-13.4 1) in the non-re-intervention group (P < 0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Introduction A choledochal malformation (CM) is a rare entity, especially in the Western world. We aimed to determine the incidence of CM in the Netherlands and the outcome of surgery for CM in childhood. Methods All pediatric patients who underwent a surgical procedure for type I-IV CM between 1989 and 2014 were entered into the Netherlands Study group on choledochal cyst/malformation. Patients with type V CM were excluded from the present analysis. Symptoms, surgical details, short-term (\30 days) and long-term ([30 days) complications were studied retrospectively. Results Between January 1989 and December 2014, 91 pediatric patients underwent surgery for CM at a median age of 2.1 years (0.0-17.7 years). All patients underwent resection of the extrahepatic biliary tree with restoration of the continuity via Roux-en-Y hepaticojejunostomy. Twelve patients (12%) were operated laparoscopically. Short-term complications, mainly biliary leakage and cholangitis, occurred in 20 patients (22%), without significant correlations with weight or age at surgery or surgical approach. Long-term postoperative complications were mainly cholangitis (13%) and anastomotic stricture (4%). Eight patients (9%) required radiological intervention or additional surgery. Surgery before 1 year of age (OR 9.3) and laparoscopic surgery (OR 4.4) were associated with more postoperative long-term complications. We did not observe biliary malignancies during treatment or follow-up. Conclusion Surgery for CM carries a significant short-and long-term morbidity. Given the low incidence, we would suggest that (laparoscopic) hepatobiliary surgery for CM should be performed in specialized pediatric surgical centers with a wide experience in laparoscopy and hepatobiliary surgery.