Left Lateral Segment Grafts Research Articles

Combining living and deceased donation for pediatric first isolated liver transplantation: A win-win even in countries with high deceased donor donation rates.

Split and living donor liver transplantations are both key surgical strategies for development of pediatric liver transplant programs. Often, however, teams tend to prioritize only one preferentially. In the context of a very active national split liver graft allocation program (Italy), retrospective study of 226 consecutive pediatric first isolated liver transplants performed by a single team using organs from both deceased and living donors. Clinical characterisitics and outcome were compared. In the context of a steadily slowly decreasing split graft offer, living donation activity steadily increased. Deceased and living donation accounted for 52.6% and 47.4% of transplantations, respectively. Both strategies were equally used for transplanting patients up to 30 kg of weight, while deceased donors were predominantly used for older recipients. Technical variants represented 86% of all transplants, with 183 conisting of left lateral segment grafts (76 split liver grafts and 107 left grafts from living donors). Outcome of both surgical strategies was similar, with excellent outcomes at early, mid-, and long-term. Splitting livers of deceased donors and using living donation were complementary and non-competitive strategies for developping pediatric liver transplant activity. Implementing both activities in parallell allowed to maintain stable the number of annual transplant in Italy and allowed to reach superior outcomes. This analysis provides evidence that living donation plays a role in Italy despite an existing very active "mandatory-split" national policy.

Microbial Contamination During Long-term Ex Vivo Normothermic Machine Perfusion of Human Livers.

Normothermic machine perfusion permits the ex vivo preservation of human livers before transplantation. Long-term perfusion for days-to-weeks provides the opportunity for enhanced pretransplant assessment and potential regeneration of organs. However, this risks microbial contamination and infection of the recipient if the organ is transplanted. An understanding of perfusate microbial contamination is required to inform infection control procedures and antimicrobial prophylaxis for this technology. We modified a liver perfusion machine for long-term use by adding long-term oxygenators and a dialysis filter. Human livers that were not suitable for transplantation were perfused using a red-cell-based perfusate under aseptic and normothermic conditions (36 °C) with a goal of 14 d. Cephazolin was added to the perfusate for antimicrobial prophylaxis. Perfusate and bile were sampled every 72 h for microbial culture. Eighteen partial human livers (9 left lateral segment grafts and 9 extended right grafts) were perfused using our perfusion system. The median survival was 7.2 d. All organs surviving longer than 7 d (9/18) had negative perfusate cultures at 24 and 48 h. Half of the grafts (9/18) became culture-positive by the end of perfusion. Microbial contaminants included Gram-negative (Pseudomonas species, Proteus mirabilis, Stenotrophomonas maltophilia) and Gram-positive bacteria (Staphylococcus epidermidis, Enterococcus faecalis, and Bacillus species) as well as yeast (Candida albicans). Microbial contamination of perfusate is common during long-term perfusion of human livers with both exogenous and endogenous sources. Enhanced infection control practices and review of targeted antimicrobial prophylaxis are likely to be necessary for translation into the clinical arena.

Effects of Adding Congested Segment IV to the Left Lateral Graft on Short-term Outcomes in Pediatric Living-donor Liver-transplant Recipients.

In some pediatric patients undergoing living-donor liver transplantation, segment IV without the middle hepatic vein can be added to a left lateral segment graft to obtain larger graft volume. Because no clear consensus on this technique exists, this study investigated the effects of congested areas on postoperative outcomes in pediatric patients with biliary atresia undergoing living-donor liver transplantation. We retrospectively reviewed data of recipients with biliary atresia aged ≤15 y who had undergone living-donor liver transplantation at Kyoto University Hospital between 2006 and 2021 and with graft-to-recipient weight ratios (GRWR) of ≤2%. Based on the percentage of congested area in the graft, patients were classified into the noncongestion (n = 40; ≤10%) and congestion (n = 13; >10%) groups. To compare the differences between groups with similar nooncongestive GRWRs and investigate the effect of adding congested areas, patients in the noncongestion group with GRWRs of ≤1.5% were categorized into the small noncongestion group (n = 24). GRWRs and backgrounds were similar between the noncongestion and congestion groups; however, patients in the congestion group demonstrated significantly longer prothrombin times, higher ascites volumes, and longer hospitalization. Further, compared with the small noncongestion group, the congestion group had significantly greater GRWR and similar noncongestive GRWR; however, the congestion group had significantly longer prothrombin time recovery (P = 0.020, postoperative d 14), higher volume of ascites (P < 0.05, consistently), and longer hospitalization (P = 0.045), requiring significantly higher albumin and gamma-globulin transfusion volumes than the small noncongestion group (P = 0.027 and P = 0.0083, respectively). Reoperation for wound dehiscence was significantly more frequent in the congestion group (P = 0.048). In pediatric liver-transplant recipients, adding a congested segment IV to the left lateral segment to obtain larger graft volume may negatively impact short-term postoperative outcomes.

Reduced-Size Left Lateral Segment Grafts in Infants Weighing

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. We enrolled 106 infants weighing <10 kg. Of these infants, 50 received reduced-size grafts. The outcomes were compared between the groups. 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. 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.

Comparative analysis of whole vs. split liver transplantation in infants.

Liver transplantation (LT) in infants can be challenging due to their small size and small vasculature. Although both whole LT (WLT) and split LT (SLT) have been described in infants, the head-to-head comparison of these techniques in this population is sparse. We retrospectively analyzed the records of all patients with age ≤1 year at Indiana University between 2016 and 2022. All SLT were left lateral segment grafts split in situ. A total of 24 infants were transplanted, with 11 SLT and 13 WLT. The median follow-up time was 52.1 months. Donor and recipient characteristics were comparable except for donor age (19 years vs. 2 years; p < .01) and weight (64 kg vs. 14.2 kg; p < .01). Early allograft dysfunction, primary nonfunction, and hepatic artery thrombosis developed more frequently in the WLT group. There were no biliary complications. There were two early deaths (2 and 4 days) in the WLT group. One-year graft survival (100% vs. 77%; p = .10) and patient survival (100% vs. 85%; p = .18) were numerically higher in the SLT group. SLT with LLS offers a safe and viable option for liver transplantation in infants and is associated with a trend toward superior outcomes. SLT should be considered as a strategy to reduce waitlist times for infants in the absence of small, deceased donors for WLT.

Long-term outcomes of left lateral segment grafts in low-weight pediatric recipients liver transplantation: Comparing reduced versus full grafts

Jiyoung KIM, Eui Soo HAN, Nam-Joon YI*, Sola LEE, Suyoung HONG, Suk-Kyun HONG, YoungRok CHOI, Kwang-Woong LEE, Kyung-Suk SUH. Ann Hepatobiliary Pancreat Surg 2023;27:S199. https://doi.org/10.14701/ahbps.2023S1.LV-PP-5-6

Epidemiology and Risk Factors for Viral Infections in Pediatric Liver Transplant Recipients and Impact on Outcome.

Infections after liver transplantation (LT) are risk factors for morbidity and mortality. Infections, especially of viral etiologies, still have an impact on the graft function and overall outcome. The aim was to review the epidemiology and risk factors of EBV, CMV and non-EBV non-CMV viral infections and their impacts on outcomes after LT. Demographic, clinical, and laboratory data were retrieved from patients' electronic databases. Over 2 years, 96 patients were transplanted at the Pediatric Liver Centre at Kings College Hospital. The majority of the infections were of viral origin; 73 (76%) patients. The incidence of EBV viremia was 60.4%, CMV infection 35.4%, and other viruses 30%. Older donor age, auxiliary graft, and bacterial infections were risk factors for EBV infection. Younger recipient age, D+R- CMV IgG, and left lateral segment graft were risk factors for CMV infection. More than 70% of patients with non-EBV and CMV viral infections stayed positive post-LT but did not contribute to increased complications. Despite the high prevalence of viral infections, EBV, CMV, and non-EBV non-CMV viral infections were not associated with rejection, morbidity, or mortality. Although some of the risk factors for viral infections are unavoidable, identifying the characteristics and risk pattern will help improve the care for pediatric LT recipients.

Anatomical variations of left hepatic vein and outflow reconstruction techniques in pediatric living donor liver transplantation

Anatomical variations of left hepatic vein are observed in nearly a third of left lateral segment (LLS) donors in living donor liver transplantation. However, there is a paucity of studies and no structured algorithm for customized outflow reconstruction in LLS grafts with variant anatomy. Analysis of a prospectively collected database of 296 LLS pediatric living donor liver transplantation was done to identify different venous drainage patterns of segments 2 (V2) and 3 (V3). Left hepatic vein anatomy was classified into 3 types: type 1 (n = 270, 91.2%): V2 and V3 joined to form a common trunk which drains into the middle hepatic vein/inferior vena cava (IVC), subtype 1a length of trunk ≥9 mm and subtype 1b length of trunk <9 mm; type 2(n = 6, 2%): V2 and V3 drain independently into IVC; type 3 (n = 20, 6.8%): V2 and V3 drain into IVC and middle hepatic vein respectively. Analysis of postoperative outcomes between LLS grafts with single and reconstructed multiple outflows showed no difference in the occurrence of hepatic vein thrombosis/stenosis, major morbidity (P = .91), and 5-year survival (log-rank P = .562). This classification is a simple yet effective tool for preoperative donor assessment, and we propose a schema for the customized reconstruction of LLS grafts with excellent and consistently reproducible outcomes.

Hepatic venous reconstruction of the left lateral segment with emphasis on anomalous hepatic vein in pediatric liver transplantation.

Left lateral segment grafts have become a suitable option in pediatric liver transplantation (PLT). The correlation between hepatic vein (HV) reconstruction and outcome is relevant when assessing the safe use of these grafts. We retrospectively reviewed the medical records prospectively collected from a pediatric living donor liver transplantation database and conducted a comparative analysis of the different left lateral segment graft types according to HV reconstruction. Donor, recipient, and intraoperative variables were analyzed. Post-transplant outcomes included vascular complications such as hepatic vein outflow obstruction, early (≤30d) and late (>30d) PVT, hepatic artery thrombosis, and graft survival. From February 2017 to August 2021, 303 PLTs were performed. According to venous anatomy, the distribution of the left lateral segment was as follows: single HV (type I) in 174 (57.4%), close HVs, simple venoplasty for reconstruction (type II) in 97 (32.01%), anomalous hepatic vein (AHV) with a distance between the HVs orifices that allowed simple venoplasty (type IIIA) in 25 (8.26%) and AHV with a distance between the HVs orifices requiring homologous venous graft interposition (type IIIB) in 07 (2.31%) grafts. Type IIIB grafts came from male donors ( p =0.04) and had a higher mean donor height ( p =0.008), a higher mean graft weight, and a higher graft-to-recipient weight ratio, both p =0.002. The median follow-up time was 41.4 months. The overall cumulative graft survival was 96.3%, and comparative graft survival showed no difference (log-rank p =0.61). No hepatic vein outflow obstructions were observed in this cohort study. There was no statistically significant difference in the post-transplant outcomes between the graft types. The venous reconstruction of the AHV with homologous venous graft interposition had similar outcomes in the short and long term.

Liver splitting during normothermic machine perfusion: a novel method to combine the advantages of both in-situ and ex-vivo techniques

BackgroundSplit liver transplantation permits the transplant of two recipients using a single donor liver. Liver splitting can be performed using the ex-vivo technique (more convenient), or the in-situ technique (shorter cold ischaemic time). We aimed to develop a technique for liver splitting during normothermic machine perfusion which combines the advantages of both techniques and permits graft assessment prior to transplant. MethodsHuman livers declined for transplantation were perfused at 36 °C using a modified-commercial perfusion machine. We developed a six-step method to split whole livers into left lateral segment grafts and extended right grafts. Both partial livers were then perfused on separate machines for individual assessment. ResultsUsing our technique, 10 whole livers were successfully split during normothermic perfusion resulting in 20 partial grafts. Apart from a single graft which failed due to a technical error, all grafts survived for 24-h after splitting. Survival was demonstrated by lactate clearance, bile production and synthesis of coagulation factors. ConclusionsLiver splitting during normothermic machine perfusion has the potential to revolutionise split liver transplantation. We describe a novel technique that reliably achieves two grafts from a single donor liver. This raises the possibility of semi-elective transplantation, and sophisticated graft assessment prior to implant.

Left lateral segment pediatric liver transplantation: a 25 year experience at Mount Sinai.

Outcomes of left lateral segment (LLS) grafts in pediatric recipients were compared between living (LD-LLS) and deceased donor (DD-LLS) grafts. 195 LLS grafts (99DD-LLS-96LD-LLS) were analyzed with a median follow-up of 9.1years. The primary endpoints were overall patient/graft survival. LD-LLS grafts were younger (0.9vs.1.4years, p=0.039), more likely to have a fulminant liver failure (17.9%vs.5.3%,p=0.002), less likely to have a metabolic disorder (6.3%vs.25.5%,p=0.002), and less likely to be undergoing retransplantation (5.3% vs.16.2%,p=0.015). There was a trend toward decreased hepatic artery thrombosis in LD-LLS grafts (6.6% vs. 15.5%,p=0.054). No differences in the overall biliary complications occurred. The LD-LLS group had prolonged survival compared to the DD-LLS group with 10-year survival rates of 81%, and 74% (p=0.005), respectively. LD-LLS grafts had longer graft survival compared to DD-LLS grafts (10-year graft survival 85%vs.67%,p=0.005). Recipient age >1year (HR 2.39,p=0.026), aortic reconstruction (HR 2.12,p=0.046) and vascular complication (HR 3.12,p<0.001) were independent predictors of poor patient survival. Non-biliary liver disease (HR 2.17,p=0.015), DD-LLS (HR 2.06,p=0.034) and vascular complication (HR 4.61,p<0.001) were independent predictors of poor graft survival. The use of SLT remains a viable option with excellent long-term outcomes. We show improved graft and patient survival with living donor grafts.

Technical Aspects and Considerations of Meso-Rex Bypass Following Liver Transplantation With Left Lateral Segment Grafts: Case Report and Review of the Literature.

In pediatric patients with extrahepatic portal vein obstruction and complications of portal hypertension, but with normal liver function, a meso-Rex bypass (MRB) connecting the superior mesenteric vein to the intrahepatic left portal is the favored surgical management. Pediatric patients with a history of a partial liver transplant (LT), especially living donors, are at greater risk for portal vein complications. Hence, an adequate knowledge of this technique and its additional challenges in the post-LT patient setting is crucial. We provide an overview of the available literature on technical aspects for an MRB post-LT. Preoperative considerations are highlighted, along with intraoperative considerations and postoperative management. Special attention is given to the even-more-demanding aspect of performing an MRB post-liver transplantation with a left lateral segment. Surgical alternatives are also discussed. In addition, we report here a unique case in which this surgical technique was performed on a complex pediatric patient with a history of a living-donor LT with a left lateral segment graft over a decade ago.

Outflow reconstruction of left lateral graft with two widely spaced hepatic veins in pediatric living donor liver transplantation

BackgroundLiving donor liver transplantation using the left lateral segment of the liver is the most common type of pediatric liver transplantation. An appropriate surgical approach is crucial for decreasing the risk of vascular complications using these grafts with anatomical variations. MethodsBetween January 2017 and December 2020, 631 living donor liver transplantations using left lateral segment grafts were performed at Tianjin First Central Hospital. The grafts from 162 (25.7%) donors have 2 hepatic vein openings. A total number of 21 transplantations using left lateral segment grafts with 2 widely spaced hepatic vein openings were performed. In group 1, the unification venoplasty technique with interposition vein graft was used at the back table for the reconstruction of hepatic vein from grafts. In group 2, dual hepatic vein reconstructions were performed, in which venoplasty of recipients’ left hepatic vein, middle hepatic vein, and inferior vena cava was performed to create a large orifice for anastomosis with segment Ⅱ hepatic vein from the graft. Segment III hepatic vein from the graft was anastomosed with the recipient’s right hepatic vein. The incidence, treatment, and outcomes of hepatic venous outflow obstruction were compared between the 2 groups. ResultsThe median follow-up time was 12.8 months. There was no significant difference in the incidence of hepatic venous outflow obstruction between the 2 groups. ConclusionDual hepatic vein reconstruction is an alternate surgical option for grafts with 2 widely spaced hepatic veins, and it is associated with ideal graft recovery and vascular condition. However, long-term follow-up is still needed to verify the efficacy and safety of this approach.

Impact of Monosegment Graft Use for Infants in Pediatric Living Donor Liver Transplantation

Left lateral segment grafts are generally used for very young pediatric patients undergoing living donor liver transplantation (LDLT). Recently, graft reduction techniques were developed for LDLT. Monosegment grafting has been used in newborns. The aim of this study was to determine the usefulness of monosegment grafting for infants. Recipients <2 years of age who underwent LDLT with a monosegment graft between 2010 and 2020 were gathered. Parents comprised all LDLT donors. A segment 2 monosegment graft was resected as a graft from the donor. Standard liver volume (SLV) was estimated using Urata's equation. Graft type, graft weight (GW), and native liver weight were assessed. Eight patients were included in the study. Original diseases consisted of biliary atresia (n=6) and fulminant hepatitis (n=2). Final graft type included monosegment (n=5) and reduced monosegment (n=3). Median final GW/body weight after reduction was 3% (range, 2%-3.4%). Median native liver weight/SLV was 134% except in patients with fulminant hepatitis. Median pre-reduction graft volume (GV)/estimated GV was 113% (range, 60%-208%). Median pre-reduction GV/SLV of monosegment grafts that required reduction (n=3) was 109% (range, 106%-121%). Median final reduced graft GV/SLV was 80% (range, 74%-91%). Complications due to large-for-size grafts were not observed. One case of bile leakage due to graft reduction occurred as a complication. Grafts were functioning well with the exception of one graft loss due to antibody-mediated rejection. Estimated GV in infants varies widely. Monosegment grafting can be useful for infants as well as newborns.

Impact of Donor and Recipient Age on Outcomes After Living Donor Liver Transplant

Living donor liver transplant between elderly donors and recipients has gained popularity, but the effects of their age remain unknown. Our aim is to evaluate the effects of matching by donor and recipient age with special insights into their recovery periods. Ninety-five living donor liver transplant pairs, excluding the left lateral segment graft cases, who underwent surgery were enrolled. Median follow-up was 97 months (range, 1-212 months). Elderly recipients were classified as being 51 years or older. Donor-recipient pairs were divided into (1) nonelderly donor/nonelderly recipient (YY) (n=26), (2) elderly donor/nonelderly recipient (n=8), (3) nonelderly donor/elderly recipient (n=38), and (4) elderly donor/elderly recipient (EE) (n=23). The 1-, 3-, and 5-year survival rates were 92.7%, 92.7%, and 88.9% (YY); 75.0%, 62.5%, and 62.5% (EY); 80.5%, 76.3%, and 67.9% (EY); and 86.9%, 82.6%, and 78.1% (EE) (P=.30), respectively. Perioperative parameters were comparable between the 4 groups. Liver grafts from the elderly population exhibited higher peaks of transaminases post-transplant regardless of recipient age (P ≤ .05). Postoperative recovery of total bilirubin in the EE group was relatively slower (P=.27). Required rates of plasma exchange postoperatively were relatively higher in the EE group (34.8% vs 15.4% in the YY group). These findings suggest a modest and not statistically significant effect that elderly liver grafts exhibit slower recovery trajectories in the acute phase but finally achieve acceptable outcomes.

Living Donor Liver Transplantation vs Split Liver Transplantation Using Left Lateral Segment Grafts in Pediatric Recipients: An Analysis of the UNOS/OPTN Database

Introduction: Split and LDLT in pediatric patients has the potential to decrease wait-times and waitlist mortality. We aim to compare outcomes of pediatric patients undergoing LDLT and split liver transplantation (SLT) using left lateral segment (LLS) grafts. Methods: Using UNOS-STAR data, we compared outcomes of pediatric patients undergoing LDLT and SLT using LLS grafts. Baseline characteristics and post-operative outcomes were compared between groups. Actuarial graft and patient survival were analyzed with Kaplan-Meier curves. Results: Between 2010-2019, 911 pediatric LT were included in the analysis (LD graft group, n=508, split graft group, n=403). LD graft recipients spent more time on the waitlist vs. the split graft group (60 (22-138) days vs. 46 (16-108) days; p=0.007). LD recipients had a lower rate of graft failure, found in 9.8% of patients compared with 14.6% in the split graft group (p=0.02). HAT was the most common graft failure cause, with similar rates. Graft and patient survival at 1-,3-and 5-years was comparable between LDLT and SLT. In subgroup analyses, patients with biliary atresia, those ≤10kg or ≤10years old receiving a LD graft showed improved graft survival. Conclusion: LDLT is associated with a lower rate of graft failure in pediatric patients. The use of LLS regardless of the type of donor is a safe way to facilitate access to transplantation to pediatric patients with acceptable short and long-term outcomes.

Classification of Left Hepatic Vein Anatomy and Customised Outflow Reconstruction Techniques for Left Lateral Segment Grafts in Paediatric Liver Transplantation

Introduction: Anatomical variations of left hepatic vein (LHV) are commonly encountered in paediatric liver transplantation. Meticulous reconstruction is required to prevent hepatic venous outflow obstruction (HVOO). We share our experience of classifying LHV anatomy and customising outflow reconstruction in left lateral segment (LLS) grafts with complex anatomy. Methods: We retrospectively studied 296 paediatric LLS transplants done over a 10 year period. Donor Computed Tomographic images of segment 2 (V2) and 3 (V3) venous drainage, reconstruction techniques used in grafts obtained and surgical outcomes were thoroughly analysed. Results: Three unique variations of LHV were described as in table below and ROC curve analysis (AUC 0.98, p 0.0001) was done to subdivide type 1 LHV. The venous outflow in the LLS graft was classified as graft A with single orifice and graft B with 2 orifices. LHV types 1b, 2 and 3 gave rise to graft B necessitating customised reconstruction techniques as described in table below. We formulated a bespoke algorithm for selecting appropriate reconstruction techniques depending upon donor LHV anatomy (picture). On follow up for a minimum of 1 year, none of the patients developed early or late HVOO. The incidence of early graft dysfunction (p 0.64), acute cellular rejection (p 0.93), intractable ascites (p 0.97), major complications with Clavien-Dindo score ≥3b (p 0.35) and overall survival (p 0.62) were similar between graft A and graft B. Conclusion: Identifying anatomical variations of LHV and tailoring outflow reconstruction, helps to increase the donor pool without compromising surgical outcomes.Tabled 1Type Of LHVn (%)Reconstruction doneType 1a: V2 and V3 join to form a common trunk of length >9mm which joins middle hepatic vein (MHV)Type 1b: V2 and V3 join to form a common trunk of length <9mm which joins middle hepatic vein (MHV)254 (85.8%)16 (5.4%)NoneSimple / extension venoplasty (10), Conjoint Unification venoplasty (6)Type 2: V2 and V3 open separately into IVC6 (2%)Simple / extension venoplasty (2), Conjoint Unification venoplasty (4)Type 3: V2 joins IVC, V3 joins MHV20 (6.8%)Simple / extension venoplasty (2), Conjoint Unification venoplasty (12), Extension unification venoplasty (3), Extension with separate caval anastomosis (3) Open table in a new tab

Modified Dual Hepatic Vein Anastomosis in Pediatric Living-Donor Liver Transplantation Using Left Lateral Segment Grafts With Two Wide Orifices.

Background: The anatomic variation of hepatic vein in the left lateral segment (LLS) increases the risk of outflow complication in pediatric living liver transplantation (LDLT). Here, we share a modified method for dual hepatic vein reconstruction in pediatric LDLT using LLS with two wide orifices.Methods: From Sep 2018 to Dec 2019, 434 pediatric LDLTs using LLS were performed in our center. Hepatic veins of grafts were classified into three types with emphasis on the number, size, and location of orifices at the cut surface: a single opening (type I, n = 341, 78.57%); two adjacent orifices (type II, n = 66, 15.21%); two wide orifices with orifices distances <20 mm (type IIIa, n = 15, 3.46%); and two wide orifices with orifices distances >20 mm (type IIIb, n = 12, 2.76%). Rv was defined as the ratio of diameter of V2 and V3 (refer to hepatic vein drained segments II and III). We developed a modified dual hepatic vein anastomosis to reconstruct outflow for type IIIb grafts with Rv ≤1. Briefly, the hepatic vein of segment II was anastomosed to the common stump of middle hepatic vein (MHV) and left hepatic vein (LHV), followed by unification of V3 and the longitudinal incision orifice in inferior venous cave (IVC).Results: During median follow-up of 15.6 months (7.5–22.9 months), no hepatic vein complications occurred.Conclusion: This novel modified dual hepatic vein anastomosis could serve as a feasible surgical option for type IIIb LLS grafts with Rv ≤1 in pediatric LDLT.

3D-reconstruction and heterotopic implantation of reduced size monosegment or left lateral segment grafts in small infants: A new technique in pediatric living donor liver transplantation to overcome large-for-size syndrome

BackgroundMonosegmental grafts and reduced left lateral segment grafts have been introduced to overcome the problems of large-for-size grafts in pediatric living donor liver transplantation. Here, we introduce a new method of reduced size monosegment or left lateral segment grafts transplanted in the right diaphragmatic fossa heterotopically in small infants. MethodsThere were 4 infants who underwent living donor liver transplantation with heterotopically implanted reduced monosegmental or left lateral segment grafts at our center. The demographic, operative, postoperative, and follow-up data of these infants were collected from our prospectively designed database and reviewed. Technical details of the donor and recipient operation are shared and a supplemental provided. ResultsThe mean recipient age was 7.5 ± 0.9 months (range: 5–10 months), and body weight was 5.9 ± 0.7 kg (range: 4.6–7.8). Primary diagnoses of the recipients were biliary atresia (n:3) and progressive familial intrahepatic cholestasis (n:1). Mean graft-recipient weight ratio was 3.3 ± 0.2. Reduced monosegment III grafts were used in 2 cases, and reduced left lateral segment grafts were used in the other 2 patients. Bile duct reconstruction was done by Roux-en-Y hepaticojejunostomy in 3 patients and duct-to-duct anastomosis in the remaining patient. All patients recovered from the liver transplantation operation and are doing well at a mean follow-up of 8 months. ConclusionLiving donor liver transplantation with heterotopically implanted reduced monosegmental or left lateral segment seems feasible for the treatment of neonates and extremely small infants. Further accumulation of cases and long-term follow-up are necessary to collect data for the establishment of this treatment modality.

Ex Situ Dual Hypothermic Oxygenated Machine Perfusion for Human Split Liver Transplantation.

After transport using static cold storage, a 51-year-old brain death donor liver underwent end-ischemic DHOPE. During DHOPE, the donor liver was maintained <10 °C and oxygenated with a Po2 of >106 kPa. An ex situ ERL/LLS split was performed with continuing DHOPE throughout the procedure to avoid additional ischemia time. Total cold ischemia times for the LLS and ERL were 205 minutes and 468 minutes, respectively. Both partial grafts were successfully transplanted at 2 different transplant centers. Peak aspartate aminotransferase and alanine aminotransferase were 172 IU/L and 107 IU/L for the LLS graft, and 839 IU/L and 502 IU/L for the ERL graft, respectively. The recipient of the LLS experienced an episode of acute cellular rejection. The ERL transplantation was complicated by severe acute pancreatitis with jejunum perforation requiring percutaneous drainage and acute cellular rejection. No device-related adverse events were observed. Liver splitting during continuous DHOPE preservation is feasible, has the potential to substantially shorten cold ischemia time and may optimize transplant logistics. Therefore liver splitting with DHOPE can potentially improve utilization of split liver transplantation.