Ann Hepatobiliary Pancreat Surg.  2020 Nov;24(4):503-512. 10.14701/ahbps.2020.24.4.503.

Pediatric liver transplantation with hyperreduced left lateral segment graft

• Namgoong JM
• Hwang S
• Song GW
• Kim DY
• Ha TY
• Jung DH
• Park GC
• Ahn CS
• Kim KM
• Oh SH
• Kwon H
• Kwon YJ

• KMID: 2508860
• DOI: http://doi.org/10.14701/ahbps.2020.24.4.503

Abstract

Backgrounds/Aims
To prevent large-for-size graft-related complications in small infant patients, the size of a left lateral segment (LLS) graft can be reduced to be a hyperreduced LLS (HRLLS) graft.
Methods
This study was intended to describe the detailed techniques for harvesting and implanting HRLLS grafts developed in a high-volume liver transplantation (LT) center.
Results
The mean recipient age was 4.0±1.7 months (range: 3-6) and body weight was 5.3±1.4 kg (range: 4.1-6.9). Primary diagnoses of the recipients were progressive familial intrahepatic cholestasis in 2 and biliary atresia in 1. The types of LT were living donor LT in 1 and split deceased donor LT in 2. Non-anatomical size reduction was performed to the transected LLS grafts. The mean weight of the HRLLS grafts was 191.7±62.1 g (range: 120-230) and graft-recipient weight ratio was 3.75±1.57% (range: 2.45-5.49). Widening venoplasty was applied to the graft left hepatic vein outflow orifice. Vein homograft interposition was used in a case with portal vein hypoplasia. Types of the abdomen wound closure were one case of primary repair, one of two-staged closure with a mesh, and one of three-staged repair with a silo and a mesh. All three patients recovered uneventfully from the LT operation and are doing well to date for more than 6 years after transplantation.
Conclusions
Making a HRLLS graft through non-anatomical resection during living donor LT and split deceased donor LT can be a useful option for treating small infant patients.

Keyword

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

Figure

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  Fig. 1 Computed tomography scans showing the left lateral segment appearing to be a flat fish (A) and puffy fish (B).

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  Fig. 2 Computed tomography scans showing the graft thickness-to-anteroposterior diameter in the recipient’s abdominal cavity ratio.

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  Fig. 3 Illustration of the extent of non-anatomic hepatic resection to make a hyperreduced left lateral segment graft.

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  Fig. 4 Computed tomography scans showing the graft thickness (A)-to-anteroposterior diameter in the recipient’s abdominal cavity (B) ratio in Case No. 1. The graft thickness ratio was 0.89.

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  Fig. 5 Intraoperative photographs showing the size of abdomen (A) and native liver (B) in Case No. 1.

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  Fig. 6 Intraoperative photographs showing the surgical procedures for making a hyperreduced left lateral segment graft in Case No. 1. (A) The left hepatic artery and portal vein were isolated and hepatic parenchyma was transected. (B and C) The size of the left lateral segment graft was measured with a paper ruler. (D) Test parenchymal clamping was attempted. (E) The lines for size reduction were drawn on the liver surface. (F and G) The peripheral parts of the segment II and III were resected. (H) Some liver parenchyma was resected from the graft.

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  Fig. 7 Computed tomography scan taken four days after transplantation in the Case No. 1. The configurations of the graft left hepatic vein (A and B) and portal vein (C and D) reconstruction were smoothly streamlined.

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  Fig. 8 Computed tomography of the recipient at the age of 2 months (A) and gross photograph of the resected recipient’s liver (B) in Case No. 2.

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  Fig. 9 Intraoperative photographs showing the surgical procedures for making a split hyperreduced left lateral segment graft in Case No. 2. (A) The lines for liver splitting and size reduction were drawn on the liver surface. (B) The liver was split and size was also reduced. (C) The whole split liver was harvested. (D) An unification venoplasty was performed after septotomy and excision of the intervening hepatic parenchyma. (E) The hyperreduced liver graft was implanted. (F) The protruded liver graft was covered by a silo.

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  Fig. 10 Computed tomography scan taken 14 days after transplantation in Case No. 2. The abdominal wall was closed completely (A and B), and the graft hepatic vein (C) and portal vein (D) reconstructions were uneventful.

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  Fig. 11 Computed tomography of the recipient at the age of 5 months (A) and gross photograph of the resected recipient’s liver (B) in Case No. 3.

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  Fig. 12 Intraoperative photographs showing the surgical procedures for implantation of a split hyperreduced left lateral segment graft in Case No. 3. (A and B) The reduced graft was harvested. (C) The recipient’s portal vein was hypoplastic. (D) Recipient hepatectomy was performed. (E and F) The recipient’s portal vein was replaced with an external iliac vein homograft and portal vein reconstruction was performed. (G and H) The reduced graft was implanted, but it was too large to be accommodated within the abdomen, so the abdominal wound was temporarily closed with a xenograft patch.

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  Fig. 13 Computed tomography scan taken at 5 days after transplantation in Case No. 3. The abdominal wall was temporarily closed with a thin patch (A and B), and the graft hepatic vein (A and B) and portal vein (C and D) reconstructions were uneventful.

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