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?

Abstract

Summary 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.

Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

“…However, the resulting configuration is not hemodynamically compliant, especially under the conditions of IVC compression in infant recipients receiving a large-for-size graft. 9,10 Therefore, this method is usually not suggested for major hepatic veins in grafts. In contrast to older pediatric or adult patients, unification venoplasty should not make the graft hepatic vein orifice too large in an infant patient because the diameter of the recipient's IVC is usually as small as 1 cm or less.…”

Matching donor to recipient in liver transplantation: Relevance in clinical practice

“…Reduced left lateral segment grafts and monosegmental grafts have been used [27,28] . Hyper-reduction of grafts to provide liver grafts for very small babies has been reported with satisfactory results [29] .…”

“…Wound closure may be difficult in these babies due to the relative size of the graft. Use of temporary closure with synthetic material followed by delayed closure is usually feasible [27] . Transplanting a small liver into a large adult may be technically easier as there is adequate space for the liver to be rotated during implantation.…”

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“…For the recipient, there are increased risks of biliary leakage, impaired venous drainage, and longer cold ischemia time (in case of graft reduction at back table). 15 Temporary abdominal closure using prosthetic materials has been reported in pediatric liver transplant. 16,17 Such prosthetic materials are associated with increased risk of infection.…”