Forearm skin flap for monitoring of acute transplant rejection in children and adolescents

At the same time as receiving their bowel or liver transplant, study participants will receive a transplant of skin from the same donor as their solid organ. This intervention is performed surgically and requires standard surgical techniques performed in a standard operating theatre. Surgery requires retrieval of a skin flap from the organ donor followed by transplantation of the skin flap into the recipient. Both surgeries are performed by members of the Plastic & Maxillofacial Surgery department of the Royal Children's Hospital, Melbourne or suitably trained delegated representatives and will only be performed once. Donor and recipient surgery are conducted alongside surgery to perform solid organ transplantation. Additional anaesthetic is therefore not required. No additional investigations or interventions are required prior to surgery. Surgery to retrieve the skin flap from the donor takes approximately 45 minutes and will occur simultaneously with the solid organ donation (which takes approximately 4-5 hours). Skin will be elevated from the volar forearm along with its artery and vein. The is a standard procedure (called a radial forearm flap) regularly performed by plastic surgeons. The radial forearm flap will be divided from its blood supply at the same time as the liver or small bowel is removed. The skin will then be stored in a damp gauze, inside a water-proof bag, and placed on ice along with the bowel or liver for transport. The skin and organ are transported to the theatre suite of The Royal Children's Hospital, Melbourne where surgery to perform the transplant will be undertaken. The surgery to transplant the liver or small bowel usually takes 6 hours. The radial forearm flap will be joined to an artery and vein in the patient's forearm whilst the liver or small bowel is being transplanted. This procedure will take approximately 90 minutes but may not increase total operative time if performed concurrently. Postoperative care is delivered in accordance with standards for the solid organ transplantation. Postoperative medication, length of stay, and level of care varies and is determined by the type of solid organ transplant and the underlying cause of organ failure. The sentinel flap will not require any change to routine postoperative care other than clinical assessment by trained nursing staff every hour for 24 hours, then 4 hourly thereafter until discharge.