Korean J Transplant.  2020 Sep;34(3):204-209. 10.4285/kjt.2020.34.3.204.

Pediatric split liver transplantation using a hyperreduced left lateral segment graft in an infant weighing 4 kg

• Namgoong JM
• Hwang S
• Kim DY
• Song GW
• Ahn CS
• Kim KM
• Oh SH

• KMID: 2507166
• DOI: http://doi.org/10.4285/kjt.2020.34.3.204

Abstract

We present a case of successful split liver transplantation (LT) using a hyperreduced left lateral segment (LLS) graft in a 106-day-old female infant patient weighing 4 kg. The patient was diagnosed with progressive familial intrahepatic cholestasis. Her general condition and liver function deteriorated progressively and she was finally allocated for a split LT under status 1. The deceased donor was a 20-year-old female weighing 63.7 kg. We performed in situ liver splitting and in situ size reduction sequentially. The weight of the hyperreduced LLS graft was 225 g, with a graft-recipient weight ratio of 5.5%. We performed recipient hepatectomy and graft implantation according to the standard procedures for pediatric living-donor LT. Since the graft was too large for primary abdomen closure, the abdominal wall was closed in three stages to make a prosthetic silo, temporary closure with a xenograft sheet, and final primary repair over 2 weeks. The patient has been doing well for more than 6 years after transplantation. In conclusion, split LT using a hyperreduced LLS graft can be a useful option for treating small infants. However, large-for-size graft-related problems, particularly in terms of graft thickness, still remain to be solved.

Keyword

Infant; Large-for-size graft; Pediatric transplantation; Graft-recipient weight ratio; Left lateral segment

Figure

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  Fig. 1 Pretransplant computed tomography (CT) and explant liver findings. (A) CT scan taken 2 months after birth showed marked hepatomegaly and liver cirrhosis. (B) The explant liver showed a mixed type of macronodular and micronodular cirrhosis.

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  Fig. 2 Recovery of the hyperreduced left lateral segment graft through in situ splitting and in situ reduction. (A) The lines for in situ splitting and size reduction were marked at the surface of the donor liver. (B) In situ size reduction was carried out without a Pringle maneuver. (C) Liver splitting and size reduction were completed. (D) The split liver grafts were divided at the back table in the operating room.

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  Fig. 3 Graft preparation and vascular reconstruction. (A) The graft hepatic vein branches were unified through unification venoplasty after septotomy and excision of the intervening hepatic parenchyma. (B) The size of the graft portal vein was measured. (C) The hepatic vein orifice of the graft was anastomosed to the unified hepatic vein openings at the inferior vena cava. (D) Portal vein reconstruction was carried out using a branch patch of the recipient’s portal vein and one left hepatic artery was reconstructed under surgical microscopy.

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  Fig. 4 Temporary abdominal wall closure. A silo using a transparent prosthetic sheet was attached to cover the liver graft as the liver graft bulged out through the abdominal incision.

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  Fig. 5 Computed tomography scan taken four days after transplantation. There was an abdominal wall defect (A, B) but the configurations of the hepatic vein (C) and portal vein (D) reconstruction were both smoothly streamlined.

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  Fig. 6 Computed tomography scan taken 14 days after transplantation. The abdominal wall was closed completely (A, B) and the graft hepatic vein (C) and portal vein (D) reconstructions were uneventful.

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