Pediatric living donor liver transplantation with large-for-size left lateral segment grafts

Abstract

Usage of “large‐for‐size” left lateral segment (LLS) liver grafts in children with high graft to recipient weight ratio (GRWR) is controversial due to concerns about increased recipient complications. During the study period, 77 pediatric living donor liver transplantations (LDLTs) with LLS grafts were performed. We compared recipients with GRWR ≥2.5% (GR‐High = 50) vs GRWR <2.5% (GR‐Low = 27). Median age was higher in the GR‐Low group (40 vs 8 months, P> .0001). Graft (GR‐High: 98%, 98%, 98% vs GR‐Low: 96%, 93%, 93%) and patient (GR‐High: 98%, 98%, 98% vs GR‐Low: 100%, 96%, 96%) survival at 1, 3, and 5 years was similar between groups (P = NS). Overall complications were also similar (34% vs 30%; P = .8). Hepatic artery and portal vein thrombosis following transplantation was not different (P = NS). Delayed abdominal fascia closure was more common in GR‐High patients (17 vs 1; P = .002). Subgroup analysis comparing recipients with GRWR ≥4% (GR‐XL = 20) to GRWR <2.5% (GRWR‐Low = 27) revealed that delayed abdominal fascia closure was more common in the GR‐XL group, but postoperative complications and graft and patient survival were similar. We conclude that pediatric LDLT with large‐for‐size LLS grafts is associated with excellent clinical outcomes. There is an increased need for delayed abdominal closure with no compromise of long‐term outcomes. The use of high GRWR expands the donor pool and improves timely access to the benefits of transplantation without extra risks.

Impact of Graft Size Matching on the Early Post-Transplant Complications and Patients Survival in Children after Living Donor Liver Transplantations

“…In a study by Li et al, 252 patients underwent LDLT and were categorized into three Groups by GRWR; the authors concluded that the GRWR in pediatric LDLT is a major risk factor that affects survival and recommended a GRWR between 2% and 4% as the optimal range [ 8 ]. Goldaracena et al reported that pediatric LDLT with grafts having a GRWR ≥ 2.5%, and even >4%, can be performed safely with similar results as graft having a GRWR < 2.5% [ 10 ]. They also observed a higher rate of delayed abdominal wall closure that did not impact on the overall outcome.…”

Alternatives to left lateral sector in paediatric liver transplantation—a systematic review on monosegmental and reduced grafts

“…Alternatives to left lateral sector in paediatric liver transplantation-a systematic review on monosegmental and reduced grafts and delaying abdominal wall closure (4,5) or surgically altering the LLS and aiming for a primary closure. In 1992, to confront this problem, Strong et al (6) published the first monosegmental pLT, implanting the segment 3 from a DD into a 4-month-old baby (a redo transplant for HAT).…”

“…Accordingly, a 5 Kg child receiving a LLS graft, will likely face a GRWR close to 5% (1:1 equivalence between cc and grams). It is well documented that GRWR is a strong predictor of graft survival and the vast majority of reports concur that those grafts exceeding 4% will likely generate a conflict with the abdominal cavity's capacity (4,5,13,(16)(17)(18)(19)(20)(21)25,(36)(37)(38). Hence, some groups advocate for altering the LLS, reducing or converting it into a monosegment.…”

“…Nevertheless, the Gordian Knot of the paediatric LT continues to be the large-for-size scenario, seen when the volume of the graft exceeds the capacity of the abdominal cavity (2)(3)(4)(5)(6). The alternatives are using a standard LLS…”

Outcome after pediatric liver transplantation for staged abdominal wall closure with use of biological mesh—Study with long‐term follow‐up

“…Nevertheless, the shortage of size‐matched donors in pLT regularly requires the implantation of LFS grafts from adult donors. This donor‐recipient size discrepancy is one of the most complex and challenging problems for transplant surgeon …”