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Kasahara M, Fukuda A, Uchida H, Yanagi Y, Shimizu S, Komine R, Nakao T, Kodama T, Deguchi H, Ninomiya A, Sakamoto S. "Reduced Size Liver Grafts in Pediatric Liver Transplantation; Technical Considerations". J Clin Exp Hepatol 2024; 14:101349. [PMID: 38371608 PMCID: PMC10869284 DOI: 10.1016/j.jceh.2024.101349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Liver transplantation (LT) has become a vital treatment option for children with end-stage liver disease. Left lateral segment (LLS) grafts are particularly common in split and living donor LT for pediatric patients. However, challenges arise in small infants receiving LLS grafts, primarily due to graft-size mismatches, resulting in "large-for-size" grafts. To overcome this issue, the practice of further reducing grafts from the LLS to diminish graft thickness has been explored. Currently, the indication for reducing the thickness of LLS grafts includes recipients with a body weight (BW) under 5.0 kg, neonates with acute liver failure, or those with metabolic liver disease. At the National Center for Child Health and Development in Tokyo, Japan, among 131 recipients of reduced-size LLS grafts, a remarkable 15-year graft survival rate of 89.9% has been achieved in small infants. This success indicates that with experience and refinement of the technique, there's a trend towards improved graft survival in recipients with reduced-thickness LLS grafts. This advancement underscores the importance of BW-appropriate methods in graft selection to ensure exceptional outcomes in vulnerable pediatric patients in need of LT. These techniques' ongoing development and refinement are crucial in enhancing the survival rates and overall outcomes for these young patients.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ryuji Komine
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshimasa Nakao
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tasuku Kodama
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Harunori Deguchi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Aoi Ninomiya
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Kasahara M, Sakamoto S. Optimal graft size in pediatric living donor liver transplantation: How are children different from adults? Pediatr Transplant 2023; 27:e14543. [PMID: 37243395 DOI: 10.1111/petr.14543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Pediatric liver transplantation is an established treatment for end-stage liver disease in children. However, it is still posing relevant challenges, such as optimizing the graft selection according to the recipient size. Unlike adults, small children tolerate large-for-size grafts and insufficient graft volume might represent an issue in adolescents when graft size is disproportionate. METHODS Graft-size matching strategies over time were examined in pediatric liver transplantation. This review traces the measures/principles put in place to prevent large-for-size or small-for-size grafts in small children to adolescents with a literature review and an analysis of the data issued from the National Center for Child Health and Development, Tokyo, Japan. RESULTS Reduced left lateral segment (LLS; Couinaud's segment II and III) was widely applicable for small children less than 5 kg with metabolic liver disease or acute liver failure. There was significantly worse graft survival if the actual graft-to-recipient weight ratio (GRWR) was less than 1.5% in the adolescent with LLS graft due to the small-for-size graft. Children, particularly adolescents, may then require larger GRWR than adults to prevent small-for-size syndrome. The suggested ideal graft selections in pediatric LDLT are: reduced LLS, recipient body weight (BW) < 5.0 kg; LLS, 5.0 kg ≤ BW < 25 kg; left lobe (Couinaud's segment II, III, IV with middle hepatic vein), 25 kg ≤ BW < 50 kg; right lobe (Couinaud's segment V, VI, VII, VIII without middle hepatic vein), 50 kg ≤ BW. Children, particularly adolescents, may then require larger GRWR than adults to prevent small-for-size syndrome. CONCLUSION Age-appropriate and BW-appropriate strategies of graft selection are crucial to secure an excellent outcome in pediatric living donor liver transplantation.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Karaca CA, Farajov R, Iakobadze Z, Kilic K, Yilmaz C, Kilic M. Reduced-Size Left Lateral Segment Grafts in Infants Weighing <10 kg. Transplant Proc 2023; 55:1605-1610. [PMID: 37487862 DOI: 10.1016/j.transproceed.2023.03.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/12/2023] [Accepted: 03/30/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Live donor liver transplantation for infants weighing <10 kg has unique complexities, as patient/graft size discrepancies may cause vascular perfusion deficiencies. Failure of the abdominal closure further complicates this already challenging procedure. To overcome these potential problems, several techniques for graft size reduction-either anatomic or nonanatomic-have been proposed in the literature. Technically easier and less time-consuming, nonanatomic size reductions have the advantage of avoiding the risk of injury to the portal pedicle. This study aimed to evaluate and compare the effects of nonanatomic graft size reduction in infants weighing <10 kg with a large estimated preoperative graft recipient weight ratio. METHODS We enrolled 106 infants weighing <10 kg. Of these infants, 50 received reduced-size grafts. The outcomes were compared between the groups. RESULTS No difference was observed between the groups according to survival and vascular or biliary complications. None of the patients required an open abdomen or mesh closure. CONCLUSION Nonanatomic size reduction of left lateral segment grafts can be safely applied without compromising vascular supply, graft function, and patient survival with comparable vascular and biliary complication rates. This technique is safe and efficient in overcoming the complications caused by large-for-size syndrome in infants weighing <10 kg.
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Affiliation(s)
- Can A Karaca
- Faculty of Medicine, Izmir University of Economics, Izmir, Turkey.
| | - Rasim Farajov
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Zaza Iakobadze
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Kamil Kilic
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Cahit Yilmaz
- Faculty of Medicine, Izmir University of Economics, Izmir, Turkey; Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Murat Kilic
- Faculty of Medicine, Izmir University of Economics, Izmir, Turkey; Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
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Wang Z, Gao W, Dong C, Sun C, Wang K, Zhang W, Song Z, Qin H, Han C, Yang Y, Zhang F, Xu M, Zheng W, Shen Z. Outcome of split-liver transplantation from pediatric donors weighing 25 kg or less. Liver Transpl 2023; 29:58-66. [PMID: 35715984 DOI: 10.1002/lt.26530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/28/2022] [Accepted: 06/11/2022] [Indexed: 01/14/2023]
Abstract
The lower limit of body weight for "splitable" liver grafts remains unknown. To examine the outcome of split-liver transplantation (SLT) from pediatric donors ≤25 kg relative to conventional graft-type liver transplantation from deceased donors under corresponding conditions, a total of 158 patients who received primary liver transplantation, including 22 SLTs from donors ≤25 kg, 46 SLTs from donors >25 kg, 76 whole-liver transplantations, and 14 reduced-liver transplantations in donors ≤25 kg between January 2018 and December 2019, were included in the study. There was no significant difference in the complications, patient survival, and graft survival between each of the latter three groups and the SLT ≤25 kg group. Pediatric End-Stage Liver Disease (PELD) score was the independent predictor of graft loss (death or retransplantation). Graft weight was the independent predictor of hepatic artery thrombosis. SLT using well-selected pediatric donors ≤25 kg is an effective strategy to increase organ availability, especially for low-body-weight recipients, compared with conventional graft type from deceased donors under the condition of corresponding donor weight without increasing morbidity and mortality.
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Affiliation(s)
- Zhen Wang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Wei Gao
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China.,Tianjin Key Laboratory of Organ Transplantation , Tianjin , China
| | - Chong Dong
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Chao Sun
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Kai Wang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Wei Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Zhuolun Song
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Hong Qin
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Chao Han
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Yang Yang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Fubo Zhang
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Min Xu
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Weiping Zheng
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China
| | - Zhongyang Shen
- Department of Pediatric Transplantation, Organ Transplantation Center , Tianjin First Central Hospital , Tianjin , China.,Tianjin Key Laboratory of Organ Transplantation , Tianjin , China
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Zakaria HM, Alobthani S, Elsarawy A, Saleh Y, Zidan A, Alabbad S, Elsheikh Y, Algoufi T, Shagrani M, Troisi RI, Broering D. Large for size in pediatrics liver transplant using left lateral segment grafts: A single center experience. Pediatr Transplant 2021; 25:e14044. [PMID: 34076330 DOI: 10.1111/petr.14044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/01/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are still controversies in using the large left lateral segment in pediatrics LT, with the possibility of the problem of LFS grafts, and the use of monosegmental or reduced liver grafts in small infants. This study aimed to evaluate our experience with LFSG in pediatrics LT. METHODS A cohort retrospective analysis was conducted including pediatric recipients who underwent LT between January 2011 and October 2019. We compared recipients with GRWR ≥ 4% (LFS) vs GRWR < 4% as an average for size grafts. RESULTS There were 331 pediatric LT, 74 patients with GRWR ≥ 4%, and 257 patients with GRWR < 4%. In the group of LFS grafts, temporary abdominal closure by silicon patch was done in 39 patients (52.7%), 2 patients (2.7%) had postoperative HAT, 3 patients (4.1%) early PVT, 1 patient (1.3%) bile leak, and 3 patients (4.1%) had wound infection, with no significant difference in these complications between the 2 groups. In patients with LFS- grafts, the 1-, 3-, 5-, and 7-year patients survival rates were 94.6%, 91.7%, 91.7%, and 91.7%, respectively, while the survival rates in patients of the other group were 96.1%, 92.6%, 91.9%, and 91.9%, respectively, with no significant difference (p = .85). CONCLUSION Using LFS graft by left lateral segment in pediatric LT with potential delayed abdominal closure is a safe and feasible option with good outcomes and unnecessary need for graft reduction if performed by an experienced multidisciplinary team.
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Affiliation(s)
- Hazem Mohamed Zakaria
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, National Liver Institute, Menoufia University, Shebin El-koom, Egypt.,Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Salah Alobthani
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed Elsarawy
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Oncosurgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Yahia Saleh
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed Zidan
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of General Surgery, Assiut University, Assiut, Egypt
| | - Saleh Alabbad
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Yasser Elsheikh
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of General Surgery, Fayoum University, Fayoum, Egypt
| | - Talal Algoufi
- Department of Pediatric Hepatology, Liver and Small Bowel Transplantation, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammad Shagrani
- Department of Pediatric Hepatology, Liver and Small Bowel Transplantation, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Roberto Ivan Troisi
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Dieter Broering
- Department of Liver and Small Bowel Transplantation & HPB Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Namgoong JM, Hwang S, Song GW, Kim DY, Ha TY, Jung DH, Park GC, Ahn CS, Kim KM, Oh SH, Kwon H, Kwon YJ. Pediatric liver transplantation with hyperreduced left lateral segment graft. Ann Hepatobiliary Pancreat Surg 2020; 24:503-512. [PMID: 33234754 PMCID: PMC7691208 DOI: 10.14701/ahbps.2020.24.4.503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
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.
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Affiliation(s)
- Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Yeon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunhee Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Jae Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Namgoong JM, Hwang S, Kim DY, Song GW, Ahn CS, Kim KM, Oh SH. Pediatric split liver transplantation using a hyperreduced left lateral segment graft in an infant weighing 4 kg. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:204-209. [PMID: 35769065 PMCID: PMC9187033 DOI: 10.4285/kjt.2020.34.3.204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/04/2022] Open
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.
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Affiliation(s)
- Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Yeon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Short- and Long-Term Outcomes After Live-Donor Transplantation with Hyper-Reduced Liver Grafts in Low-Weight Pediatric Recipients. J Gastrointest Surg 2019; 23:2411-2420. [PMID: 30887299 DOI: 10.1007/s11605-019-04188-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate short- and long-term outcomes after live-donor liver transplantation (LT) with hyper-reduced grafts in low-weight pediatric recipients. LT is an established curative therapy for children with end-stage chronic liver disease or acute liver failure. A major problem in pediatric LT has been the lack of size-matched donor organs. The disadvantage of the use of large-for-size grafts is the insufficient tissue oxygenation and graft compression, which result in poor outcomes. The shortage of suitable donors is most notable in children under 10 kg. To overcome such obstacle, in situ hyper-reduced live-donor liver grafts have been introduced. Available articles in the literature are based on small samples and are deficient in long-term follow-up. METHODS A single-cohort, retrospective analysis was conducted including 59 pediatric patients under 10 kg who underwent hyper-reduced (in situ "a la carte" left lateral segment reduction) live-donor LT (LDLT) between February 1994 and February 2018. RESULTS The most frequent cause of liver failure was biliary atresia (70%). Median recipient weight was 8 kg. Vascular complications were confirmed in 15% of the sample, while 45% presented biliary complications. Median follow-up time was 40.3 months. Ten-year overall survival rate was 74%. Pediatric end-stage liver disease score > 23 was associated with a higher risk of post-operative complications. CONCLUSION LDLT can be undertaken in children with body weight < 10 kg achieving good results in high-volume centers by experienced surgeons.
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Yamamoto H, Khorsandi SE, Cortes‐Cerisuelo M, Kawano Y, Dhawan A, McCall J, Vilca‐Melendez H, Rela M, Heaton N. Outcomes of Liver Transplantation in Small Infants. Liver Transpl 2019; 25:1561-1570. [PMID: 31379050 PMCID: PMC6856963 DOI: 10.1002/lt.25619] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/14/2019] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) for small infants remains challenging because of the demands related to graft selection, surgical technique, and perioperative management. The aim of this study was to evaluate the short-term and longterm outcomes of LT regarding vascular/biliary complications, renal function, growth, and patient/graft survival in infants ≤3 months compared with those of an age between >3 and 6 months at a single transplant center. A total of 64 infants ≤6 months underwent LT and were divided into 2 groups according to age at LT: those of age ≤3 months (range, 6-118 days; XS group, n = 37) and those of age >3 to ≤6 months (range, 124-179 days; S group, n = 27) between 1989 and 2014. Acute liver failure was the main indication for LT in the XS group (n = 31, 84%) versus S (n = 7, 26%). The overall incidence of hepatic artery thrombosis and portal vein thrombosis/stricture were 5.4% and 10.8% in the XS group and 7.4% and 11.1% in the S group, respectively (not significant). The overall incidence of biliary stricture and leakage were 5.4% and 2.7% in the XS group and 3.7% and 3.7% in the S group, respectively (not significant). There was no significant difference between the 2 groups in terms of renal function. No significant difference was found between the 2 groups for each year after LT in terms of height and weight z score. The 1-, 5-, and 10-year patient survival rates were 70.3%, 70.3%, and 70.3% in the XS group compared with 92.6%, 88.9%, and 88.9% in the S group, respectively (not significant). In conclusion, LT for smaller infants has acceptable outcomes despite the challenges of surgical technique, including vascular reconstruction and graft preparation, and perioperative management.
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Affiliation(s)
- Hidekazu Yamamoto
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Shirin E. Khorsandi
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Miriam Cortes‐Cerisuelo
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Yoichi Kawano
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Anil Dhawan
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - John McCall
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Hector Vilca‐Melendez
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Mohamed Rela
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
| | - Nigel Heaton
- Liver Transplantation, Institute of Liver StudiesKing’s College HospitalLondonUnited Kingdom
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Glinka J, de Santibañes M, Biagiola D, D Agostino D, Ardiles V, Ciardullo M, Mattera J, Pekolj J, de Santibañes E. Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living-donor liver transplantation using hyper-reduced left lateral segment grafts: A novel technical strategy. Pediatr Transplant 2019; 23:e13516. [PMID: 31215179 DOI: 10.1111/petr.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 01/10/2023]
Abstract
LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.
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Affiliation(s)
- Juan Glinka
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martin de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - David Biagiola
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel D Agostino
- Pediatric Gastroenterology-Hepatology Division, Liver-Intestinal Transplantation Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Miguel Ciardullo
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Mattera
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hepato-bilio-pancreatic & Liver Transplantation Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Khorsandi SE, Day AWR, Cortes M, Deep A, Dhawan A, Vilca-Melendez H, Heaton N. Is size the only determinant of delayed abdominal closure in pediatric liver transplant? Liver Transpl 2017; 23:352-360. [PMID: 28027602 DOI: 10.1002/lt.24712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022]
Abstract
The aim was to determine the factors associated with the use of delayed abdominal closure in pediatric liver transplantation (LT) and whether this affected outcome. From a prospectively maintained database, transplants performed in children (≤18 years) were identified (October 2010 to March 2015). Primary abdominal closure was defined as mass closure performed at time of transplant. Delayed abdominal closure was defined as mass closure not initially performed at the same time as transplant; 230 children underwent LT. Of these, 176 (76.5%) had primary closure. Age was similar between the primary and delayed groups (5.0 ± 4.9 versus 3.9 ± 5.0 years; P = 0.13). There was no difference in the graft-to-recipient weight ratio (GRWR) in the primary and delayed groups (3.4 ± 2.8 versus 4.1 ± 2.1; P = 0.12). Children with acute liver failure (ALF) were more likely to experience delayed closure then those with chronic liver disease (CLD; P < 0.001). GRWR was similar between the ALF and CLD (3.4 ± 2.4 versus 3.6 ± 2.7; P = 0.68). Primary closure children had a shorter hospital stay (P < 0.001), spent fewer days in pediatric intensive care unit (PICU; P = 0.001), and required a shorter duration of ventilation (P < 0.001). Vascular complications (arterial and venous) were similar (primary 8.2% versus delayed 5.6%; P = 0.52). Graft (P = 0.42) and child survival (P = 0.65) in the primary and delayed groups were similar. Considering timing of mass closure after transplant, patients in the early delayed closure group (<6 weeks) were found to experience a shorter time of ventilation (P = 0.03) and in PICU (P = 0.003). In conclusion, ALF was the main determinant of delayed abdominal closure rather than GRWR. The optimal time for delayed closure is within 6 weeks. The use of delayed abdominal closure does not adversely affect graft/child survival. Liver Transplantation 23 352-360 2017 AASLD.
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Affiliation(s)
| | | | - Miriam Cortes
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Akash Deep
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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12
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Soejima Y, Taguchi T, Sugimoto M, Hayashida M, Yoshizumi T, Ikegami T, Uchiyama H, Shirabe K, Maehara Y. Three-dimensional printing and biotexture modeling for preoperative simulation in living donor liver transplantation for small infants. Liver Transpl 2016; 22:1610-1614. [PMID: 27434755 DOI: 10.1002/lt.24516] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/09/2016] [Accepted: 06/23/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Yuji Soejima
- Departments of Surgery and Science, Kyushu University, Fukuoka, Japan.
| | - Tomoaki Taguchi
- Pediatric Surgery Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Maki Sugimoto
- Department of Gastroenterology Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Makoto Hayashida
- Pediatric Surgery Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Toru Ikegami
- Departments of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Hideaki Uchiyama
- Departments of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Departments of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Departments of Surgery and Science, Kyushu University, Fukuoka, Japan
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13
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Sanada Y, Hishikawa S, Okada N, Yamada N, Katano T, Hirata Y, Ihara Y, Urahashi T, Mizuta K. Dorsal approach plus branch patch technique is the preferred method for liver transplanting small babies with monosegmental grafts. Langenbecks Arch Surg 2016; 402:123-133. [PMID: 27456678 DOI: 10.1007/s00423-016-1479-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 07/12/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE When living donor liver transplantation (LDLT) is performed on small infant patients, the incidence of hepatic artery complications (HACs) is high. Here, we present a retrospective analysis that focuses on our surgical procedure for hepatic arterial reconstruction and the outcomes of monosegmental LDLT. METHODS Of the 275 patients who underwent LDLT between May 2001 and December 2015, 13 patients (4.7 %) underwent monosegmental LDLT. Hepatic artery reconstruction was performed under a microscope. The size discrepancy between the graft and the recipient's abdominal cavity was defined as the graft to recipient distance ratio (GRDR) between the left hepatic vein and the portal vein (PV) bifurcation on a preoperative computed tomography scan. HACs were defined as hepatic arterial hypoperfusion. RESULTS Recipient hepatic arteries were selected for the branch patch technique in five cases (38.5 %), and the diameter was 2.2 ± 0.6 mm. The anastomotic approaches selected were the dorsal position of the PV in seven cases (53.8 %) and the ventral position in six, and the GRDRs were 2.8 ± 0.4 and 1.9 ± 0.5, respectively (p = 0.012). The incidence rate of HACs caused by external factors, such as compression or inflammation around the anastomotic site, was significantly higher in monosegmental than in non-monosegmental graft recipients (15.4 vs. 1.1 %, p < 0.001). CONCLUSION Although monosegmental graft recipients experienced HACs caused by external factors around the anastomotic field, hepatic arterial reconstruction could be safely performed. Important components of successful hepatic arterial reconstructions include the employment of the branch patch technique and the selection of the dorsal approach.
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Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan.
| | - Shuji Hishikawa
- Center for Development of Advanced Medical Technology, Jichi Medical University, Shimotsuke City, Japan
| | - Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Naoya Yamada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Takumi Katano
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Yuta Hirata
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
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15
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Living-donor liver transplantation with hyperreduced left lateral segment grafts: a single-center experience. Transplantation 2013; 95:750-4. [PMID: 23503505 DOI: 10.1097/tp.0b013e31827a93b4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the setting of liver transplantation in small infants who receive left lateral segment (LLS) grafts, problems are encountered related to graft-size mismatching in the form of so-called "large-for-size" grafts. To address these problems, the feasibility of further reducing the size of LLS grafts to form hyperreduced LLS (HRLLS) grafts was investigated. METHODS Of the 175 pediatric living-donor liver transplantations performed between November 2005 and December 2011 at our institute, 31 cases were performed using HRLLS grafts. The medical records were reviewed and data were collected retrospectively. RESULTS The graft-to-recipient body weight ratio was successfully reduced from 5.2% ± 2.0% to 2.9% ± 0.5%. Portal vein thrombosis was observed in one case, and biliary stenosis was seen in two cases. No hepatic artery thrombosis was encountered. The graft and patient 2-year survival rate was 87%. When the results categorized according to the original disease were verified, patients with fulminant hepatic failure (FHF) weighed less and had smaller abdominal cavities compared with patients with cholestatic or metabolic disease. Patients with FHF frequently required skin or partial skin closure to avoid graft compression. For this reason, the anteroposterior diameters in the recipients' abdominal cavities were not adequately large to accommodate the graft thickness, especially in patients with FHF. CONCLUSIONS In conclusion, living-donor liver transplantation using HRLLS grafts offers a safe and useful option for treating smaller infants.
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Shehata MR, Yagi S, Okamura Y, Iida T, Hori T, Yoshizawa A, Hata K, Fujimoto Y, Ogawa K, Okamoto S, Ogura Y, Mori A, Teramukai S, Kaido T, Uemoto S. Pediatric liver transplantation using reduced and hyper-reduced left lateral segment grafts: a 10-year single-center experience. Am J Transplant 2012; 12:3406-13. [PMID: 22994696 DOI: 10.1111/j.1600-6143.2012.04268.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Few studies have examined the long-term outcomes and prognostic factors associated with pediatric living living-donor liver transplantation (LDLT) using reduced and hyper-reduced left lateral segment grafts. We conducted a retrospective, single-center assessment of the outcomes of this procedure, as well as clinical factors that influenced graft and patient survival. Between September 2000 and December 2009, 49 patients (median age: 7 months, weight: 5.45 kg) underwent LDLT using reduced (partial left lateral segment; n = 5, monosegment; n = 26), or hyper-reduced (reduced monosegment grafts; n = 18) left lateral segment grafts. In all cases, the estimated graft-to-recipient body weight ratio of the left lateral segment was more than 4%, as assessed by preoperative computed tomography volumetry, and therefore further reduction was required. A hepatic artery thrombosis occurred in two patients (4.1%). Portal venous complications occurred in eight patients (16.3%). The overall patient survival rate at 1, 3 and 10 years after LDLT were 83.7%, 81.4% and 78.9%, respectively. Multivariate analysis revealed that recipient age of less than 2 months and warm ischemic time of more than 40 min affected patient survival. Pediatric LDLT using reduced and hyper-reduced left lateral segment grafts appears to be a feasible option with acceptable graft survival and vascular complication rates.
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Affiliation(s)
- M R Shehata
- Department of Hepatobiliary, Pancreas and Transplant Surgery, Kyoto University, Kyoto, Japan
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Saeki I, Tokunaga S, Matsuura T, Hayashida M, Yanagi Y, Taguchi T. A formula for determining the standard liver volume in children: a special reference for neonates and infants. Pediatr Transplant 2012; 16:244-9. [PMID: 22151603 DOI: 10.1111/j.1399-3046.2011.01624.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Accurately evaluating the ratio of GV to the SLV (GV/SLV) is important in successful pediatric liver transplantation. However, the formula used to calculate the SLV of children, including neonates and infants, has not yet been established. The aim of the current study was to estimate the SLV of children, including neonates, and to establish an accurate formula. The LV of 100 children (including 7 neonates and 15 infants) were measured using thin slice (3-5 mm) helical CT images. Their BSA was calculated from height and weight. A new formula to estimate the SLV was established as follows: SLV (mL) =689.9 × BSA (m(2)) -24.7. The SLV of children was significantly lower than that in previous reports (p < 0.001). A formula for calculating the SLV of children including neonates was established. This new formula will be useful in pediatric liver transplantation.
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Affiliation(s)
- Isamu Saeki
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University Hospital, Fukuoka, Japan.
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Yi NJ, Lee KW, Suh KS, Lee KU, Kim ST. Transplantation Techniques Unique in Pediatric Liver Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2011. [DOI: 10.4285/jkstn.2011.25.3.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nam-Joon Yi
- Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kuhn Uk Lee
- Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Tae Kim
- Division of HBP Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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20
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Schulze M, Dresske B, Deinzer J, Braun F, Kohl M, Schulz-Jürgensen S, Borggrefe J, Burdelski M, Bröring DC. Implications for the usage of the left lateral liver graft for infants ≤10 kg, irrespective of a large-for-size situation--are monosegmental grafts redundant? Transpl Int 2011; 24:797-804. [PMID: 21649741 DOI: 10.1111/j.1432-2277.2011.01277.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Organ donor shortage for infant liver transplant recipients has lead to an increase in splitting and living donation. For cases in which even transplantation of the left lateral graft (Couinaud's segments II + III) results in a "large for size situation" with an estimated graft body weight ratio (GBWR) of >4%, monosegmental liver transplantation was developed. This, however, bears complications because of greater parenchymal surface and suboptimal vascular flow. We exclusively use the left lateral graft from living donors or split grafts. Temporary abdominal closure is attempted in cases of increased pressure. We report of 41 pediatric transplants in 38 children ≤10 kg. Within this group, there were 23 cases with a GBWR of ≥4, and 15 cases with a GBWR <4. There was no statistical difference in vascular or biliary complications. Despite a more frequent rate of temporary abdominal closure, we did not find a higher rate of intra-abdominal infections. Overall, patient and graft survival was excellent in both groups (one death, three re-transplants). We noticed, however, that the ventro-dorsal diameter of the graft appears to be more relevant to potential graft necrosis than the actual graft size. In conclusion, the usage of monosegmental grafts seems unnecessary if transplantation of left lateral grafts is performed by an experienced multidisciplinary team, and temporary abdominal closure is favored in cases of increased abdominal pressure.
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Affiliation(s)
- Maren Schulze
- Department of General and Thoracic Surgery, University of Schleswig-Holstein, Campus Kiel, Germany.
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