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Case Report

Ann Liver Transplant 2023; 3(1): 50-56

Published online May 31, 2023 https://doi.org/10.52604/alt.23.0001

Copyright © The Korean Liver Transplantation Society.

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

Jung-Man Namgoong1 , Gil-Chun Park1 , Shin Hwang1 , Sang-Hoon Kim1 , Suhyeon Ha1 , Kyung Mo Kim2 , Seak Hee Oh2

1Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
2Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to:Shin Hwang
Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
E-mail: shwang@amc.seoul.kr
https://orcid.org/0000-0002-9045-2531

Received: March 20, 2023; Revised: April 9, 2023; Accepted: April 10, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Infant, Large-for-size graft, Monosegment graft, Graft-to-recipient weight ratio, Size reduction

In liver transplantation (LT) for small infants, graft size matching to the recipient’s abdomen is the most important factor because implantation of a large-for-size graft hinders primary closure of the abdomen and can induce various vascular complications [1,2]. To make a left lateral segment (LLS) graft as small as possible, a LLS graft can be reduced to a segment II (S2) or III (S3) monosegment or hyperreduced LLS graft [1-9]. For very small infants weighing around 3 kilograms (kg), such a monosegment or hyperreduced LLS graft can be very large for abdominal implantation. Thus, there is an urgent need to create a hyperreduced monosegment graft through thorough assessment of the donor LLS anatomy. We herein present the surgical technique and clinical outcome of pediatric living donor liver transplantation (LDLT) using a hyperreduced S2 monosegment (HRS2MS) graft in an infant weighing 3 kg.

A female infant was born through cesarean section at a gestational age of 28 weeks 5 days due to oligohydramnios and failure of growth for more than one week. Her birth weight was 1,030 g. This patient with multiple congenital anomalies was cared at the neonate intensive care unit.

At three months after birth, neonatal cholestasis developed with gradual rise in total bilirubin and liver enzymes. A magnetic resonance imaging study showed hepatosplenomegaly (Fig. 1). Percutaneous liver biopsy showed neonatal giant cell hepatitis.

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).

At four months after birth, progression of liver failure continued with deterioration of the general condition and vital signs. Thus, we decided to perform urgent LDLT at the patient body weight of 3.0 kg with marked hepatosplenomegaly and ascites (Fig. 2). Considering that her height was 49 cm at actual two months after calculation of the gestational age of 28 weeks 5 days and 10 weeks at the neonatal intensive care, her ideal body weight was estimated to be only 2.1 kg. It was not possible to wait further for patient growth because of rapid deterioration of liver function.

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.

The living donor was a 33-year-old mother of the patient. Her LLS volume was estimated to be 292 mL (Fig. 3A, B). For graft-recipient size matching, we planned to perform procurement of a HRS2MS graft by making the size of the liver graft as small as possible.

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

We measured the size of the LLS liver and marked the surface along the falciform ligament to split the usual LLS graft, and then made additional markings at the lateral part of segment II and ventral part of segment III. After identification of the running course of the left hepatic vein course using intraoperative Doppler ultrasonography, the lateral aspect of the LLS liver was resected while preserving the medial branch of the left hepatic vein. Glissonean pedicles of the S2 and S3 to the left of the umbilical fissure were identified and the distal pedicle of S3 was ligated. The plane of resection of S3 was determined by a demarcation line along the inferior aspect of the S2. Finally, the ventral part of segment III and the lateral part of segment II were removed (Fig. 4).

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.

We performed recipient hepatectomy according to the standard procedure for pediatric LDLT. The liver was enlarged with abundant ascites. The recipient’s native portal vein appeared normal (Fig. 5A, B).

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.

At the back table, the weight of this HRS2MS graft was 123 g, which was a graft-to-recipient weight ratio (GRWR) of 4.1%. The orifice of the graft left hepatic vein appeared to be large enough; thus, we did not perform any venoplasty procedure (Fig. 6A–C).

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).

After performing native liver removal, we opened the three hepatic vein orifices of the recipient’s inferior vena cava to make a large orifice, which was well matched in size with the graft hepatic vein (Fig. 5C, D). We used the branch patch of the recipient’s portal vein for portal vein reconstruction (Fig. 5E, F). One left hepatic artery was reconstructed under surgical microscopy (Fig. 5G). We performed Roux-en-Y hepaticojejunostomy for biliary reconstruction (Fig. 5H).

The recipient’s native liver was enlarged and weighed 336 g, and there was massive ascites. The abdomen was distended to accommodate this HRS2MS graft, permitting primary closure of the abdomen. The explant liver pathology showed marked hepatic necrosis with marked cholestasis and mild hemosiderosis, supporting neonatal giant cell hepatitis (Fig. 7).

Figure 7.Gross photograph of the explanted liver.

A computed tomography scan taken four days (Fig. 8) and 3 months (Fig. 9) after transplantation showed uneventful vascular reconstruction. Currently, she has been doing well for more than three months after transplantation. The donor also recovered uneventfully (Fig. 3C, D).

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).

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).

Accumulating experience with LT for small infants is being gathered worldwide [1-11], but it is still regarded as challenging because large-for-size graft-related problems are big hurdles for successful LT, especially in very small infants. The critical issues in implantation of large-for-size grafts are the risk of abdominal compartment syndrome caused by the recipient’s small abdominal cavity, size discrepancies in vessel size, and insufficient portal circulation and tissue oxygenation [1,12-15]. To solve such critical issues, it is essential to reduce the size of liver grafts as much as possible.

The target size in graft size reduction is to make the estimated GRWR less than 4% for LT in infants [9]. An S2 or S3 monosegment graft would be ideal for making a very small liver graft with effective reduction in graft thickness. It is essential to assess the donor liver anatomy thoroughly to create a monosegment graft. The shape of a donor’s LLS liver is important for size reduction because reduction in the graft thickness is a difficult procedure [1]. The graft shape was evaluated using the graft thickness-to-anteroposterior diameter in the recipient’s abdominal cavity ratio [16]. If this ratio of thickness exceeds 1.0, primary abdominal wall closure can induce excessive graft compression and abdominal compartment syndrome; thus, so closure with a prosthetic mesh should be considered. To help reduce the graft thickness, the modified technique of a reduced-thickness LLS graft has also been reported [9]. In the present case, because of exceptional abdominal distension from hepatosplenomegaly and ascites, the latitude for graft thickness was markedly expanded, permitting primary abdominal wall closure. In our previous cases, all small infant recipients required staged abdominal wall repair through mesh coverage [10,11].

To the best of our knowledge, the present case is one of the smallest LT recipients in the world. Considering premature delivery by more than two months and growth retardation, the height of the patient was less than 1 percentile, suggesting an ideal body weight of 2.1 kg. If abdominal distension from hepatosplenomegaly and ascites was not present, LDLT operation for such a small infant would have been much difficult.

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.

All authors have no conflicts of interest to declare.

Conceptualization: JMN, GCP, SH, KMK, SHO. Data curation: GCP, SH. Investigation: JMN, SH. Methodology: All. Supervision: SH. Visualization: SH, SHK, S Ha. Writing - original draft: All. Writing - review &editing: JMN, GCP, SH.

  1. Kanazawa H, Sakamoto S, Fukuda A, Uchida H, Hamano I, Shigeta T, et al. Living-donor liver transplantation with hyperreduced left lateral segment grafts: a single-center experience. Transplantation 2013;95:750-754.
    Pubmed CrossRef
  2. Shehata MR, Yagi S, Okamura Y, Iida T, Hori T, Yoshizawa A, et al. Pediatric liver transplantation using reduced and hyper-reduced left lateral segment grafts: a 10-year single-center experience. Am J Transplant 2012;12:3406-3413.
    Pubmed CrossRef
  3. Ardiles V, Ciardullo MA, D'Agostino D, Pekolj J, Mattera FJ, Boldrini GH, et al. Transplantation with hyper-reduced liver grafts in children under 10 kg of weight. Langenbecks Arch Surg 2013;398:79-85.
    Pubmed CrossRef
  4. Thomas N, Thomas G, Verran D, Stormon M, O'Loughlin E, Shun A. Liver transplantation in children with hyper-reduced grafts - a single-center experience. Pediatr Transplant 2010; 14:426-430.
    Pubmed CrossRef
  5. Yamada N, Sanada Y, Hirata Y, Okada N, Wakiya T, Ihara Y, et al. Selection of living donor liver grafts for patients weighing 6 kg or less. Liver Transpl 2015;21:233-238.
    Pubmed CrossRef
  6. Sakuma Y, Sasanuma H, Miki A, Shimizu A, Sata N, Yasuda Y, et al. Living-donor liver transplantation using segment 2 monosegment graft: a single-center experience. Transplant Proc 2016;48:1110-1114.
    Pubmed CrossRef
  7. Hong SK, Suh KS, Kim HS, Yoon KC, Ahn SW, Kim H, et al. Pediatric living donor liver transplantation using a monosegment procured by pure 3D laparoscopic left lateral sectionectomy and in situ reduction. J Gastrointest Surg 2018;22:1135-1136.
    Pubmed CrossRef
  8. Srinivasan P, Vilca-Melendez H, Muiesan P, Prachalias A, Heaton ND, Rela M. Liver transplantation with monosegments. Surgery 1999;126:10-12.
    Pubmed CrossRef
  9. Kitajima T, Sakamoto S, Sasaki K, Narumoto S, Kazemi K, Hirata Y, et al. Impact of graft thickness reduction of left lateral segment on outcomes following pediatric living donor liver transplantation. Am J Transplant 2018;18:2208-2219.
    Pubmed CrossRef
  10. Namgoong JM, Hwang S, Kim DY, Song GW, Ahn CS, Kim KM, et al. Pediatric split liver transplantation using a hyperreduced left lateral segment graft in an infant weighing 4 kg. Korean J Transplant 2020;34:204-209.
    Pubmed KoreaMed CrossRef
  11. Namgoong JM, Hwang S, Song GW, Kim DY, Ha TY, Jung DH, et al. Pediatric liver transplantation with hyperreduced left lateral segment graft. Ann Hepatobiliary Pancreat Surg 2020;24: 503-512.
    Pubmed KoreaMed CrossRef
  12. Kiuchi T, Kasahara M, Uryuhara K, Inomata Y, Uemoto S, Asonuma K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors. Transplantation 1999;67:321-327.
    Pubmed CrossRef
  13. Kasahara M, Fukuda A, Yokoyama S, Sato S, Tanaka H, Kuroda T, et al. Living donor liver transplantation with hyperreduced left lateral segments. J Pediatr Surg 2008;43:1575-1578.
    Pubmed CrossRef
  14. Vanatta JM, Esquivel CO. Status of liver transplantation in infants < 5 kg. Pediatr Transplant 2007;11:5-9.
    Pubmed CrossRef
  15. Raices M, Czerwonko ME, Ardiles V, Boldrini G, D'Agostino D, Marcó Del Pont J, et al. 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.
    Pubmed CrossRef
  16. Sakamoto S, Kanazawa H, Shigeta T, Uchida H, Sasaki K, Hamano I, et al. Technical considerations of living donor hepatectomy of segment 2 grafts for infants. Surgery 2014;156: 1232-1237.
    Pubmed CrossRef

Article

Case Report

Ann Liver Transplant 2023; 3(1): 50-56

Published online May 31, 2023 https://doi.org/10.52604/alt.23.0001

Copyright © The Korean Liver Transplantation Society.

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

Jung-Man Namgoong1 , Gil-Chun Park1 , Shin Hwang1 , Sang-Hoon Kim1 , Suhyeon Ha1 , Kyung Mo Kim2 , Seak Hee Oh2

1Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
2Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to:Shin Hwang
Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
E-mail: shwang@amc.seoul.kr
https://orcid.org/0000-0002-9045-2531

Received: March 20, 2023; Revised: April 9, 2023; Accepted: April 10, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Infant, Large-for-size graft, Monosegment graft, Graft-to-recipient weight ratio, Size reduction

INTRODUCTION

In liver transplantation (LT) for small infants, graft size matching to the recipient’s abdomen is the most important factor because implantation of a large-for-size graft hinders primary closure of the abdomen and can induce various vascular complications [1,2]. To make a left lateral segment (LLS) graft as small as possible, a LLS graft can be reduced to a segment II (S2) or III (S3) monosegment or hyperreduced LLS graft [1-9]. For very small infants weighing around 3 kilograms (kg), such a monosegment or hyperreduced LLS graft can be very large for abdominal implantation. Thus, there is an urgent need to create a hyperreduced monosegment graft through thorough assessment of the donor LLS anatomy. We herein present the surgical technique and clinical outcome of pediatric living donor liver transplantation (LDLT) using a hyperreduced S2 monosegment (HRS2MS) graft in an infant weighing 3 kg.

CASE PRESENTATION

A female infant was born through cesarean section at a gestational age of 28 weeks 5 days due to oligohydramnios and failure of growth for more than one week. Her birth weight was 1,030 g. This patient with multiple congenital anomalies was cared at the neonate intensive care unit.

At three months after birth, neonatal cholestasis developed with gradual rise in total bilirubin and liver enzymes. A magnetic resonance imaging study showed hepatosplenomegaly (Fig. 1). Percutaneous liver biopsy showed neonatal giant cell hepatitis.

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).

At four months after birth, progression of liver failure continued with deterioration of the general condition and vital signs. Thus, we decided to perform urgent LDLT at the patient body weight of 3.0 kg with marked hepatosplenomegaly and ascites (Fig. 2). Considering that her height was 49 cm at actual two months after calculation of the gestational age of 28 weeks 5 days and 10 weeks at the neonatal intensive care, her ideal body weight was estimated to be only 2.1 kg. It was not possible to wait further for patient growth because of rapid deterioration of liver function.

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.

The living donor was a 33-year-old mother of the patient. Her LLS volume was estimated to be 292 mL (Fig. 3A, B). For graft-recipient size matching, we planned to perform procurement of a HRS2MS graft by making the size of the liver graft as small as possible.

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

We measured the size of the LLS liver and marked the surface along the falciform ligament to split the usual LLS graft, and then made additional markings at the lateral part of segment II and ventral part of segment III. After identification of the running course of the left hepatic vein course using intraoperative Doppler ultrasonography, the lateral aspect of the LLS liver was resected while preserving the medial branch of the left hepatic vein. Glissonean pedicles of the S2 and S3 to the left of the umbilical fissure were identified and the distal pedicle of S3 was ligated. The plane of resection of S3 was determined by a demarcation line along the inferior aspect of the S2. Finally, the ventral part of segment III and the lateral part of segment II were removed (Fig. 4).

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.

We performed recipient hepatectomy according to the standard procedure for pediatric LDLT. The liver was enlarged with abundant ascites. The recipient’s native portal vein appeared normal (Fig. 5A, B).

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.

At the back table, the weight of this HRS2MS graft was 123 g, which was a graft-to-recipient weight ratio (GRWR) of 4.1%. The orifice of the graft left hepatic vein appeared to be large enough; thus, we did not perform any venoplasty procedure (Fig. 6A–C).

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).

After performing native liver removal, we opened the three hepatic vein orifices of the recipient’s inferior vena cava to make a large orifice, which was well matched in size with the graft hepatic vein (Fig. 5C, D). We used the branch patch of the recipient’s portal vein for portal vein reconstruction (Fig. 5E, F). One left hepatic artery was reconstructed under surgical microscopy (Fig. 5G). We performed Roux-en-Y hepaticojejunostomy for biliary reconstruction (Fig. 5H).

The recipient’s native liver was enlarged and weighed 336 g, and there was massive ascites. The abdomen was distended to accommodate this HRS2MS graft, permitting primary closure of the abdomen. The explant liver pathology showed marked hepatic necrosis with marked cholestasis and mild hemosiderosis, supporting neonatal giant cell hepatitis (Fig. 7).

Figure 7. Gross photograph of the explanted liver.

A computed tomography scan taken four days (Fig. 8) and 3 months (Fig. 9) after transplantation showed uneventful vascular reconstruction. Currently, she has been doing well for more than three months after transplantation. The donor also recovered uneventfully (Fig. 3C, D).

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).

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).

DISCUSSION

Accumulating experience with LT for small infants is being gathered worldwide [1-11], but it is still regarded as challenging because large-for-size graft-related problems are big hurdles for successful LT, especially in very small infants. The critical issues in implantation of large-for-size grafts are the risk of abdominal compartment syndrome caused by the recipient’s small abdominal cavity, size discrepancies in vessel size, and insufficient portal circulation and tissue oxygenation [1,12-15]. To solve such critical issues, it is essential to reduce the size of liver grafts as much as possible.

The target size in graft size reduction is to make the estimated GRWR less than 4% for LT in infants [9]. An S2 or S3 monosegment graft would be ideal for making a very small liver graft with effective reduction in graft thickness. It is essential to assess the donor liver anatomy thoroughly to create a monosegment graft. The shape of a donor’s LLS liver is important for size reduction because reduction in the graft thickness is a difficult procedure [1]. The graft shape was evaluated using the graft thickness-to-anteroposterior diameter in the recipient’s abdominal cavity ratio [16]. If this ratio of thickness exceeds 1.0, primary abdominal wall closure can induce excessive graft compression and abdominal compartment syndrome; thus, so closure with a prosthetic mesh should be considered. To help reduce the graft thickness, the modified technique of a reduced-thickness LLS graft has also been reported [9]. In the present case, because of exceptional abdominal distension from hepatosplenomegaly and ascites, the latitude for graft thickness was markedly expanded, permitting primary abdominal wall closure. In our previous cases, all small infant recipients required staged abdominal wall repair through mesh coverage [10,11].

To the best of our knowledge, the present case is one of the smallest LT recipients in the world. Considering premature delivery by more than two months and growth retardation, the height of the patient was less than 1 percentile, suggesting an ideal body weight of 2.1 kg. If abdominal distension from hepatosplenomegaly and ascites was not present, LDLT operation for such a small infant would have been much difficult.

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.

FUNDING

There was no funding related to this study.

CONFLICT OF INTEREST

All authors have no conflicts of interest to declare.

AUTHORS' CONTRIBUTIONS

Conceptualization: JMN, GCP, SH, KMK, SHO. Data curation: GCP, SH. Investigation: JMN, SH. Methodology: All. Supervision: SH. Visualization: SH, SHK, S Ha. Writing - original draft: All. Writing - review &editing: JMN, GCP, SH.

Fig 1.

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).
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 2.

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.
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 3.

Figure 3.Pretransplant computed tomography findings at transplantation showing marked hepatomegaly (A), massive ascites (B), and marked hepatosplenomegaly (C).
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 4.

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.
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 5.

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.
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 6.

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).
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 7.

Figure 7.Gross photograph of the explanted liver.
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 8.

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).
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

Fig 9.

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).
Annals of Liver Transplantation 2023; 3: 50-56https://doi.org/10.52604/alt.23.0001

References

  1. Kanazawa H, Sakamoto S, Fukuda A, Uchida H, Hamano I, Shigeta T, et al. Living-donor liver transplantation with hyperreduced left lateral segment grafts: a single-center experience. Transplantation 2013;95:750-754.
    Pubmed CrossRef
  2. Shehata MR, Yagi S, Okamura Y, Iida T, Hori T, Yoshizawa A, et al. Pediatric liver transplantation using reduced and hyper-reduced left lateral segment grafts: a 10-year single-center experience. Am J Transplant 2012;12:3406-3413.
    Pubmed CrossRef
  3. Ardiles V, Ciardullo MA, D'Agostino D, Pekolj J, Mattera FJ, Boldrini GH, et al. Transplantation with hyper-reduced liver grafts in children under 10 kg of weight. Langenbecks Arch Surg 2013;398:79-85.
    Pubmed CrossRef
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The Korean Liver Transplantation Society

Vol.4 No.1
May 2024

pISSN 2765-5121
eISSN 2765-6098

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