Ann Liver Transplant.  2023 May;3(1):50-56. 10.52604/alt.23.0001.

Living donor liver transplantation with hyperreduced segment II monosegment graft for an infant weighing 3 kilograms

• Namgoong JM
• Park GC
• Hwang S
• Kim SH
• Ha S
• Kim KM
• Oh SH

• KMID: 2560922
• DOI: http://doi.org/10.52604/alt.23.0001

Abstract

In liver transplantation for small infants, graft-size matching to the recipient’s abdomen is the most important factor for successful transplantation. We herein present the surgical technique and clinical outcome of pediatric living donor liver transplantation (LDLT) using a hyperreduced segment II monosegment (HRS2MS) graft in an infant weighing 3 kilograms (kg). A female patient was prematurely born at 28 weeks 5 days with a body weight of 1,030 g. At 4 months after birth, LDLT was performed due to progression of liver failure with deterioration of the general condition and vital signs at the patient body weight of 3.0 kg. Considering that her height was 49 cm at transplantation, her ideal body weight was estimated to be only 2.1 kg. The living donor was a 33-year-old mother of the patient. A HRS2MS graft of 123 g was recovered, which was equivalent to a graft-to-recipient weight ratio of 4.1%. The standard surgical procedures for pediatric LDLT were performed. Because the recipient’s native liver was enlarged and weighed 336 g and there was massive ascites, primary closure of the abdomen was successfully performed. Follow-up computed tomography studies showed uneventful graft implantation. Currently, she has been doing well for more than three months after transplantation. In conclusion, pediatric LDLT using a HRS2MS graft can be a useful option for treating a very small infant although large-for-size graft-related issues still remain to be solved.

Keyword

Infant; Large-for-size graft; Monosegment graft; Graft-to-recipient weight ratio; Size reduction

Figure

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  Figure 1 Pretransplant magnetic resonance imaging findings at three months after birth showing hepatomegaly (A), normal intrahepatic vasculature (B), and hepatosplenomegaly with mild ascites (C).

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  Figure 2 Perioperative computed tomography (CT) findings of the donor liver. The preoperative left lateral segment volume was estimated to be 292 mL (A) and the maximal anterior-posterior diameter was 5 cm (B). CT scans taken at 7 days (C) and one month (D) after donation showed uneventful recovery of the remnant donor liver.

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  Figure 3 Pretransplant computed tomography findings at transplantation showing marked hepatomegaly (A), massive ascites (B), and marked hepatosplenomegaly (C).

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  Figure 4 Recovery of the hyperreduced S2 monosegment (HRS2MS) segment graft (A, B). The size of the left lateral segment was measured (C, D). The lines for hepatic transection were marked at the surface of the donor liver (E). Intrahepatic vascular anatomy was depicted (F–H). Liver splitting and size reduction were performed (I). Hilar vascular structures were isolated (J–L). The size of the HRS2MS segment graft was measured at the back table.

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  Figure 5 Recipient hepatectomy and graft implantation (A, B). Recipient hepatectomy was performed (C, D). The three hepatic vein orifices of the recipient’s inferior vena cava were opened to make a large orifice, which was well matched in size with the graft hepatic vein (E, F). The branch patch of the recipient’s portal vein was used for portal vein reconstruction (G). One left hepatic artery was reconstructed under surgical microscopy (H). Roux-en-Y hepaticojejunostomy was performed for biliary reconstruction.

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  Figure 6 Graft preparation at the back table. Graft size (A), graft outflow vein diameter (B) and graft portal vein diameter (C) were assessed. The size of the implanted liver graft was compared with the size of the surgeon’s hand (D).

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  Figure 7 Gross photograph of the explanted liver.

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  Figure 8 Computed tomography scan taken four days after transplantation. The abdominal wall was primarily repaired with uneventful vascular reconstruction (A, B). Ileus and splenomegaly were identified (C).

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  Figure 9 Computed tomography scan taken three months after transplantation. The graft liver was remodeled according to the abdominal cavity with uneventful vascular reconstruction (A, B). Mild ascites and persistent splenomegaly were identified (C).

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