Ann Hepatobiliary Pancreat Surg.  2021 Aug;25(3):431-435. 10.14701/ahbps.2021.25.3.431.

Pediatric deceased donor liver transplantation with in situ size reduction for recipient-graft size matching

• Namgoong JM
• Hwang S
• Kim DY
• Ha TY
• Song GW
• Jung DH
• Kim KM
• Oh SH

• KMID: 2519304
• DOI: http://doi.org/10.14701/ahbps.2021.25.3.431

Abstract

We present a case of pediatric deceased donor liver transplantation using a reduced whole liver graft in a 25-month-old boy weighing 12.7 kg. After he had undergone Kasai portoenterostomy for biliary atresia, his general condition deteriorated progressively. He was enrolled on the waiting list for liver transplantation with Pediatric End-stage Liver Disease score of 15. The donor was a 51-monthold boy with body weight of 20 kg. The donor-to-recipient body weight ratio was 158%. The liver graft appeared to be larger than the recipient’s abdominal cavity. Thus, we planned to do in situ size reduction. Recipient surgery was performed following standard procedures. We performed graft outf low vein reconstruction using a modified piggyback technique like the double inferior vena cava method. Since the portal vein was hypoplastic, a side-to-side anastomosis technique was used. We also performed intraoperative portogram to embolize venous collaterals. After completing the graft implantation, we found that the liver graft was too large to be accommodated within the abdomen. After in situ resection of the left lateral section parenchyma, we successfully performed primary closure of the abdominal wound. This patient experienced episodes of acute rejection. He has been doing well for four years after the transplantation.

Keyword

Large-for-size graft; Pediatric transplantation; Graft-recipient weight ratio; Reduced graft; Left lateral section

Figure

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  Fig. 1 Pretransplant computed tomography (CT) taken at 1 year (A), 6 months (B), and 1 month (C) before transplantation showing progression of liver cirrhosis. Hypoplastic portal vein with development of collateral veins were visible at the CT scan taken at 1 month before transplantation (D).

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  Fig. 2 Intraoperative photographs showing in situ size reduction of the whole liver graft. The left lateral section parenchyma was transected (A) and removed (B) to perform primary closure of the abdominal wound.

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  Fig. 3 Gross photograph of the explanted native liver, showing hepatomegaly combined with advanced liver cirrhosis.

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  Fig. 4 Findings of intraoperative direct portography. The reconstructed portal vein showed good blood flow (A). Some collateral veins form the splenic hilum were identified (B, C) and completely embolized with coils (D).

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  Fig. 5 Posttransplant computed tomography (CT) scan follow-up. The CT scan taken 4 days after transplantation showed parenchymal ischemia at the right posterior section (A, B). The CT scan taken 14 days after transplantation showed resolution of the parenchymal ischemia (C, D). However, swelling of the liver graft and ascites developed because of acute cellular rejection.

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