Graft Reduction for Size and High GRWR in Pediatric Living Donor Liver Transplantation

Abstract

Introduction: Large graft size is a commonly encountered problem in infants undergoing liver transplantation. Various graft reduction techniques have been described- anatomical vs non-anatomical, in vivo vs ex situ, and hyper-reduced grafts. We present our experience of using graft reduction techniques for pediatric liver transplantation. Methods: Two patients 6 and 7 months old weighing 7.5 kgs and 4.1 kgs underwent living donor liver transplantation for acute liver failure and cryptogenic cirrhosis respectively. For the first patient, mother was the donor for left lateral segment (LLS), with a GRWR of 3.5. Based on the pre-operative imaging, in-situ graft reduction was done in view of the bigger size of the graft relative to child’s abdominal cavity. Second patient received LLS from her mother and had a GRWR of 8. In-situ graft reduction was done till mono-segment 2. However, because of high GRWR, non-anatomical graft reduction was done on the back table making it a hyper-reduced graft. Graft reduction was done using CUSA. Results: Liver grafts in both the recipients could be accommodated well without any signs of poor portal blood flow. The resultant GRWR was 1.5 and 2.3 for the first and second patient. Post-operatively, first patient developed chylous ascites which settled with conservative management over 3 weeks and was discharged. Second patient succumbed to sepsis and expired. However, there was no sign of graft dysfunction. Conclusion: Graft reduction technique are safe, effective and easily reproducible technique and is an important part of the armamentarium of a Pediatric Liver Transplantation Center.