Ann Hepatobiliary Pancreat Surg.  2020 May;24(2):198-202. 10.14701/ahbps.2020.24.2.198.

Living donor liver retransplantation for primary non-function of liver graft following multivisceral transplantation in a pediatric patient

• Hwang S
• Kim DY
• Namgoong J
• Kim KM
• Oh SH
• Kim KH
• Ahn CS
• Kwon H
• Cho YJ
• Kwon YJ

• KMID: 2500806
• DOI: http://doi.org/10.14701/ahbps.2020.24.2.198

Abstract

Multivisceral organ transplantation (MVOT) includes transplantation of three or more abdominal organs, generally including the small bowel, duodenum, stomach, liver, pancreas, and colon. We here presented the detailed procedures of repeat living donor liver transplantation for primary non-function of the first liver graft following MVOT in a pediatric patient. A 6-year-old girl with chronic intestinal pseudo-obstruction underwent MVOT with 5-year-old donor organs. However, the primary non-function of the liver graft developed, and an emergency living donor liver transplantation operation using a left lateral section graft was performed on the third day after MVOT. The donor was the patient’s father. Portal flow interruption induced ischemic congestion of the whole small bowel, thus we used a series of porto- caval shunt to reduce the risk of ischemic splanchnic congestion during recipient hepatectomy and graft implantation. Other surgical procedures were the same as the standardized procedures for left liver graft implantation. The graft-recipient weight ratio was 2.15. The patient was managed conservatively for 3 months and discharged in an improved condition at 4 months after MVOT. She finally passed away at 22 months after MVOT. We think that our experience will be helpful for surgeons to cope with portal vein clamping-associated splanchnic congestion during liver transplantation and other abdominal surgeries.

Keyword

Multivisceral transplantation; Primary non-function; Living donor liver transplantation; Portocaval shunt

Figure

• 

  Fig. 1 Schematic illustration of multivisceral organ transplantation.

• 

  Fig. 2 Intraoperative photographs of multivisceral organ transplantation. (A, B) Abdominal organs were completely removed. (C) An aortic conduit is anastomosed to the recipient aorta. (D) Donor multivisceral organs were prepared at the back table. (E) The graft aorta stump was reconstructed at the aortic conduit. (F) The graft inferior vena cava was reconstructed. (G) The aorta conduit clamp was released. (H) The multivisceral organs were reperfused.

• 

  Fig. 3 Intraoperative photographs of recipient hepatectomy during repeat living donor liver transplantation. (A) The first liver graft was discolored due to primary non-function. (B) The whole small bowel became discolored shortly after clamping of the main portal vein. (C, D) A cold-stored iliac vein allograft was anastomosed to the retrohepatic inferior vena cava (IVC) and the recipient portal vein (PV) stump, by which a porto-caval shunt was made.

• 

  Fig. 4 Intraoperative photographs of graft implantation during repeat living donor liver transplantation. (A) The left portal vein branch was isolated and a catheter was connected between the left portal vein stump (arrow) and the connecting part of the porto-caval shunt. (B) When the porto-caval shunt was clamped, the portal vein blood flow was bypassed through a catheter. (C) Portal vein was reconstructed under porto-caval shunt using a catheter (dotted arrow). (D) The disconnected catheter (arrow) was visible after the portal vein reconstruction.

• 

  Fig. 5 Posttransplant computed tomography scans. (A) Image taken 1 month after transplantation showed no abnormality of the graft liver. (B) Image taken 20 months after transplantation showed precirrhotic changes of the graft liver.

Reference

1. Spechtenhauser B, Königsraner A, Steurer W, Riedmann B, Pomarolli A, Hörmann C, et al. 1999; Multivisceral transplantation. Transplant Proc. 31:3175–3176. DOI: 10.1016/S0041-1345(99)00775-7.

2. Loinaz C, Mittal N, Kato T, Miller B, Rodriguez M, Tzakis A. 2004; Multivisceral transplantation for pediatric intestinal pseudo-obstruction: single center's experience of 16 cases. Transplant Proc. 36:312–313. DOI: 10.1016/j.transproceed.2004.01.084. PMID: 15050142.

3. Abu-Elmagd KM, Costa G, Bond GJ, Soltys K, Sindhi R, Wu T, et al. 2009; Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg. 250:567–581. DOI: 10.1097/SLA.0b013e3181b67725. PMID: 19730240.

4. Park YS, Oh JY, Hwang BY, Moon Y, Lee HM, Hwang GS. 2014; Prolonged post-reperfusion syndrome during multivisceral organ transplantation in a pediatric patient: a case report. Korean J Anesthesiol. 66:467–471. DOI: 10.4097/kjae.2014.66.6.467. PMID: 25006372. PMCID: PMC4085269.

5. Moon DB, Lee SG, Hwang S, Kim KH, Ahn CS, Ha TY, et al. 2013; More than 300 consecutive living donor liver transplants a year at a single center. Transplant Proc. 45:1942–1947. DOI: 10.1016/j.transproceed.2013.02.041. PMID: 23769079.

6. Moon DB, Lee SG, Hwang S, Kim KH, Ahn CS, Ha TY, et al. 2013; Toward more than 400 liver transplantations a year at a single center. Transplant Proc. 45:1937–1941. DOI: 10.1016/j.transproceed.2012.12.015. PMID: 23769078.

7. Cai J. 2009; Intestine and multivisceral transplantation in the United States: a report of 20-year national registry data (1990-2009). Clin Transpl. 83–101. PMID: 20524278.

8. Namgoong JM, Hwang S, Oh SH, Kim KM, Park GC, Ahn CS, et al. 2020; Living donor liver transplantation with total pancreatectomy and portal vein homograft replacement in a pediatric patient with advanced pancreatoblastoma. Ann Hepatobiliary Pancreat Surg. 24:78–84. DOI: 10.14701/ahbps.2020.24.1.78. PMID: 32181434. PMCID: PMC7061052.

9. Chang HK, Kim SY, Kim JI, Kim SI, Whang JK, Choi JY, et al. 2016; Ten-year experience with bowel transplantation at Seoul St. Mary's Hospital. Transplant Proc. 48:473–478. DOI: 10.1016/j.transproceed.2015.12.065. PMID: 27109981.