Pediatric Living Donor Liver Transplantation Research Articles

Sonographic Evaluation of Post-transplantation Portal Vein Stenosis in Pediatric Living-donor Liver Transplant Recipients With Left-liver Grafts

IntroductionPortal vein (PV) stenosis is not uncommon in post-transplantation pediatric living-donor liver transplant (PLDLT) recipients. The purpose of this study was to identify specific ultrasound criteria that may be used to detect PV stenosis in PLDLT with left-liver grafts. Patients and MethodsFrom January 2010 to October 2014, 87 pediatric recipients underwent PLDLT with left lobes or left lateral segments at our hospital. All patients underwent routine liver Doppler ultrasound (DUS) as follow-up protocol. The morphologic narrowing and mean time averaged velocity (TAV) at the PV anastomotic site, change in anastomotic/pre-anastomotic TAV (ΔTAV), and the umbilical portal width were evaluated and analyzed. Ultrasound findings were correlated with computed tomography angiography where PV stenosis was suspected. ResultsIn the liver graft follow-up study, 80.4% (70 of 87 patients) of PV anastomosis was well visualized and measured by Doppler ultrasound. The optimal threshold values for TAV and ΔTAV were 49.6 cm/s and 30 cm/s, respectively, for significant PV anastomosis stenosis. In the other 19.5% (17/87), the PV anastomosis could not be identified properly. The PV anastomosis was not always visible with ultrasound; however, the optimal dilated umbilical portion of the PV indicating possible PV anastomosis narrowing threshold was umbilical portal width >1.5 cm. ConclusionsIncreased anastomotic TAV and ΔTAV are useful features for diagnosing PV stenosis. The identification of a dilated umbilical portion of the left PV helps in detection of PV stenosis in PLDLT recipients especially when the anastomotic narrowed region cannot be visualized.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study).

ObjectivesHepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.MethodsWe retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.ResultsThe overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.ConclusionHA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

Pediatric living donor liver transplantation: a single center experience from Pakistan

Pediatric living donor liver transplantation: a single center experience from Pakistan

Significance of changes in serum troponin and myocardial enzymes in children with living donor liver transplantation

Objective To explore the characteristics and its clinical significance of troponin I (cTnI), myocardial enzymes and intraoperative hemodynamic changes in the pediatric patients undergoing living donor liver transplantation. Methods Liver transplantation was performed in 50 congenital biliary atresia children who were ranged from grade Ⅲ or Ⅳ in Tianjin First Central Hospital from January 2013 to December 2014 according to the American Society of Anesthesiologists (ASA), meanwhile, the method of the combined intravenous-inhalation anesthesia was applied during operation.Blood samples were drawn from central vein before skin incision (T0 baseline), at 30 min of anhepatic phase (T1), 30 min of neohepatic phase (T2), and 12 h, 36 h after operation (T3, T4). Levels of cTnI, creatine kinase (CK), lactate dehydrogenase (LDH)and α-hydroxy butyric acid dehydrogenase (α-HBDH) were mearsured, respectively.Furthermore, heart rate(HR), mean arterial blood pressure(MAP), central venous pressure(CVP) and arterial blood gas analysis[pH value, pa(O2), pa(CO2), and base excess(BE)] were monitored at the moment of T0, T1, T2 as well as the end of surgery. Results The levels of cTnI, CK, LDH and α-HBDH in T1-T3 were increased, and there was a peak at the T2 compared with the baseline at T0 (all P<0.05). At T3 and T4, cTnI, CK, LDH and α-HBDH levels significantly decreased compared with those at T2 (all P<0.05), the levels of cTnI were (0.06±0.02) μg/L, (0.37±0.52) μg/L, (0.05±0.02) μg/L, CK levels were (344.6±209.5)U/L, (466.1±116.4)U/L, (219.3±111.5)U/L, LDH levels were (552.3±414.9)U/L, (966.4±454.1)U/L, (322.8±108.8)U/L, and α-HBDH levels were (301.6±124.0)U/L, (456.4±168.4)U/L, (146.2±80.2)U/L, respectively.The levels of hemodynamics significantly changed in anhepatic phase and neohepatic phase.Compared with T0: T1, HR accelerated, MAP, CVP decreased, BE value increased, and the differences were statistically significant (all P<0.05); T2, open vena cava and back to the blood volume surge, CVP, MAP increased, HR decreased but still higher than T0, BE value further increased, and the differences were statistically significant (all P<0.05). After the surgery, various hemodynamic indexes fell to preoperative levels, the levels of HR were (103.1±5.9) times/min, (128.8±8.5) times/min, (115.1±0.3) times/min, (103.5±5.9) times/min, MAP levels were (59.7±9.1) kPa, (48.7±5.4) kPa, (58.6±7.1) kPa, (59.1±8.6) kPa, CVP levels were (7.5±4.3) kPa, (3.9±4.6) kPa, (5.8±3.5) kPa, (7.2±4.1) kPa, BE levels were (-1.5±5.0) mmol/L, (-0.4±5.7) mmol/L, (1.0±3.8) mmol/L, (2.4±2.2) mmol/L, respectively. Conclusions The myocardial injury may appear during the perioperation of pediatric living donor liver transplantation and gradually aggravated during the anhepatic phase.The worst injury peaks at 12h and it gradually returns to the preoperative level 36 h postoperativelly. Key words: Liver transplantation; Troponin; Myocardial enzyme; Hemodynamic; Infant

Translational microsurgery. A new platform for transplantation research.

Clinical microsurgery has been introduced in many fields, while experimental microsurgery has the cross-disciplinary features of the sciences and techniques for growth of medicine, pharmacology, veterinary, engineering etc. Training protocol, proposing a new name as Translational Microsurgery, was introduced. Reconstructive skills of hepatic artery in pediatric living donor liver transplantation were summarized. Ex vivo training protocol using artificial blood vessel for surgeons was proposed. Clinical microsurgery requires anastomosis with delicate arteries and limited field of view. Our training protocol revealed that the relation between the score and speed was seen, while not all the surgeons with enough experience got high score. This training led to muster clinical skills and to apply excellent experimental works. Our microsurgical training protocol has been planned from the points of clinical setting. Training for vascular anastomosis led to rodent transplantation models. These models were used for immunology and immunosuppressant research. Microsurgical techniques led to master catheter technique and to inject various drugs or gene vectors.

The outcomes of pediatric living donor liver transplantation using small-for-size grafts: experience of a single institute.

We aimed to evaluate patients who had undergone pediatric LDLT with small-for-size graft (SFSG) and identify risk factors of graft failure to establish a preoperative graft selection strategy. The data was collected retrospectively. SFSG was used in 14LDLTs (5.7%) of 245 LDLTs performed between May 2001 and March 2014. The mean patient age and body weight at LDLT were 12.6 ± 2.0 years and 40.5 ± 9.9 kg, respectively. The graft type was left lobe in six patients, left + caudate lobe in seven patients, and posterior segment in one patient. The graft survival rates in SFSG and non-SFSG groups were 78.9 and 93.1%, respectively (p = 0.045). In the univariate analysis, bleeding volume during LDLT were an independent risk factors for graft failure (p = 0.011). Graft failure was caused by sepsis in all three patients and occurred at a median of 70 postoperative days 70 (range 14-88 days). Among them, two cases showed high preoperative PELD/MELD score (PELD; 19.4 and MELD; 22, respectively). Pediatric LDLT using SFSG had poor outcome and prognosis, especially when it accompanies the surgical infectious complications with preoperative high PELD/MELD scores.

De novo breast fibroadenoma in an adolescent female after pediatric living donor liver transplantation

De novo breast fibroadenoma in an adolescent female after pediatric living donor liver transplantation

Reconstruction of a rare variant of the left hepatic vein in a left lateral segment liver graft from a living donor: Technical notes.

Reconstruction of hepatic veins in living donor liver transplantation (LDLT) is often technically challenging and a good venous outflow is essential for survival of the graft and patient. We describe a quadrangular patch venoplasty technique used for the reconstruction of a rare variant of the left hepatic vein (LHV) in a pediatric LDLT with left lateral segment (LLS) graft. Segment II vein in the graft was draining directly into the inferior vena cava (IVC) and segment III vein was draining into the middle hepatic vein (MHV) after receiving a tributary from segment IV so that there were two widely separated ostia at the cut surface. This is one of the rarest variations of the LHV and is so called type 3 variant; it is usually reconstructed using interposition tubular conduits necessitating two separate anastomoses at the IVC.

Living Donor Liver Transplantation in Children: Surgical and Immunological Results in 250 Recipients at Université Catholique de Louvain.

To evaluate the outcome of pediatric living donor liver transplantation (LDLT) regarding portal vein (PV) reconstruction, ABO compatibility, and impact of maternal donation on graft acceptance. LDLT and ABO-mismatched transplantation constitute feasible options to alleviate organ shortage in children. Vascular complications of portal hypoplasia in biliary atresia (BA) and acute rejection (AR) are still major concerns in this field. Data from 250 pediatric LDLT recipients, performed at Cliniques Universitaires Saint-Luc between July 1993 and June 2012, were collected retrospectively. Results were analyzed according to ABO matching and PV complications. Uni- and multivariate analyses were performed to study the impact of immunosuppression, sex matching, and maternal donation on AR rate. Overall, the 10-year patient survival rate was 93.2%. Neither patient or graft loss nor vascular rejection, nor hemolysis, was encountered in the ABO nonidentical patients (n = 58), provided pretransplant levels of relevant isoagglutinins were below 1/16. In BA recipients, the rate of PV complications was lower after portoplasty (4.6%) than after truncal PV anastomosis (9.8%) and to jump graft interposition (26.9%; P = 0.027). In parental donation, maternal grafts were associated with higher 1-year AR-free survival (55.2%) than paternal grafts (39.8%; P = 0.041), but only in BA patients. LDLT, including ABO-mismatched transplantation, constitutes a safe and efficient therapy for liver failure in children. In BA patients with PV hypoplasia, portoplasty seems to constitute the best technique for PV reconstruction. Maternal donation might be a protective factor for AR.

Laparoscopic living donor hepatectomy: a review of current status.

Over the last two decades, laparoscopic surgery has been adopted in various surgical fields. Its advantages of reduced blood loss, reduced postoperative morbidity, shorter hospital stay, and excellent cosmetic outcome compared with conventional open surgery are well validated. In comparison with other abdominal organs, laparoscopic hepatectomy has developed relatively slowly due to the potential for massive bleeding, technical difficulties and a protracted learning curve. Furthermore, applications to liver graft procurement in living donor liver transplantation (LDLT) have been delayed significantly due to concerns about donor safety, graft outcome and the need for expertise in both laparoscopic liver surgery and LDLT. Now, laparoscopic left lateral sectionectomy in adult-to-pediatric LDLT is considered the standard of care in some experienced centers. Currently, the shift in application has been towards left lobe and right lobe graft procurement in adult LDLT from left lateral section in pediatric LDLT. However, the number of cases is too small to validate the safety and reproducibility. The most important concern in LDLT is donor safety. Even though a few studies reported the technical feasibility and comparable outcomes to conventional open surgery, careful validating through larger sample sized studies is needed to achieve standardization and wide application.

Bile duct kinking after adult living donor liver transplantation: Case reports and literature review

Regeneration of the partial allograft and the growth of children may cause kinking of the biliary tract after pediatric living donor liver transplantation (LDLT), but bile duct kinking after adult LDLT is rarely reported. We herein presented two patients who suffered from anastomotic strictures caused by severe bile duct kinking after LDLT. The first patient was a 57-year-old woman with hepatitis B virus (HBV)-related liver cirrhosis, who developed biliary stricture 5 months after receiving right-lobe LDLT. Subsequently, endoscopic and percutaneous treatments were attempted, but both failed to solve the problem. The second was a 44-year-old woman also having HBV-related liver cirrhosis. Biliary stricture occurred 14 months after LDLT. Likewise, the guide wire failed to pass through the stricture when endoscopic interventions were conducted. Afterwards, both of the two cases underwent reexploration, showing that compensatory hypertrophy of the allografts resulted in kinking and sharp angulation of the bile ducts, and the anastomotic sites were found to be severely stenotic. Finally, re-anastomosis by Roux-en-Y procedure was successfully performed, and long-term stenosis-free survival was achieved in both of them. Our experience suggests that bile duct kinking after LDLT may play a role in the high incidence of anastomotic strictures in adult LDLT recipients, which may also result in the treatment failure of the non-surgical techniques for anastomotic strictures. Re-anastomosis in the form of Roux-en-Y hepaticojejunostomy is an effective surgical option for the treatment of such a condition.

Living donor liver transplantation in Taiwan-challenges beyond surgery.

Taiwan has a high prevalence of hepatitis B and C viral infections, and consequently a high burden of chronic liver diseases. Liver transplantation (LT) began in Taiwan in 1984, and living donor liver transplantation (LDLT) in 1994. Education and collaboration between physicians on a national and international scale were important factors in the development of transplantation in East Asia. Technical innovations in donor hepatectomy, vascular and biliary reconstruction, and interventional radiology, perioperative management of transplant patients and development of associated specialties have enabled achievement of excellent results after both adult and pediatric LDLT. The establishment of rigorous protocols to withstand strict medico-legal scrutiny, combined with technical excellence has contributed to excellent surgical outcomes. The socioeconomic development of Taiwan and the first nationwide hepatitis B vaccination program in the world have also contributed to the decrease in disease burden and improvement of quality of healthcare. This article examines the factors enabling the development of LT in Taiwan, the innovations that have contributed to excellent outcomes, and indicates the future prospects of LDLT in Taiwan.

Long-Term Outcome of Percutaneous Biliary Interventions for Biliary Anastomotic Stricture in Pediatric Patients after Living Donor Liver Transplantation with Roux-en-Y Hepaticojejunostomy

PurposeTo retrospectively evaluate long-term outcomes of percutaneous transhepatic biliary drainage (PTBD) followed by balloon dilation and placement of an internal drainage tube for anastomotic stricture in pediatric patients who underwent living donor liver transplantation (LDLT) with Roux-en-Y hepaticojejunostomy (RYHJ). Materials and MethodsFifty-two patients (23 male, 29 female; median age, 5 y) with anastomotic biliary stricture were treated with PTBD followed by balloon catheter dilation and long-term placement of an internal drainage tube, which was removed upon cholangiographic confirmation of free flow of bile into the small bowel. Clinical success, tube independence rate, risk factors of recurrent biliary stricture, and patency rates were evaluated. ResultsThirty-nine patients (75%) had no stricture recurrence. Of 13 patients (25%) with recurrence, six were treated again with the same percutaneous biliary interventions and showed no further recurrence. Clinical success was noted in 43 of 52 patients (83%). Drainage tubes were removed from 49 patients (94%). Multivariate logistic regression analysis indicated that serum alanine aminotransferase level > 53 IU/L at discharge after the initial series of percutaneous biliary interventions was a significant risk factor for recurrent biliary stricture (P = .002). Kaplan–Meier analysis showed 1-, 3-, 5-, and 10-year primary and primary assisted patency rates of 75%, 70%, 70%, and 68%, and 94%, 92%, 88%, and 88%, respectively. ConclusionsPTBD followed by balloon dilation and internal drainage may be an effective treatment for anastomotic biliary stricture after pediatric LDLT with RYHJ.

Changes in Surgical Site Infections after Living Donor Liver Transplantation.

Surgical site infections (SSIs) are a major threat for liver transplant recipients. We prospectively studied SSIs after living donor liver transplantation (LDLT) at Kyoto University Hospital from April 2001 to March 2002 (1st period) and from January 2011 to June 2012 (2nd period). We investigated the epidemiology of SSIs after LDLT and determined the differences between the two periods. A total of 129 adult recipients (66 during the 1st period and 63 during the 2nd period) and 72 pediatric recipients (39 and 33) were included in this study. The SSI rates for each period were 30.3% (1st period) and 41.3% (2nd period) among the adult recipients and 25.6% and 30.3% among the pediatric recipients. The overall rates of 30-day mortality among adult transplant recipients with SSIs were 10.0% (1st period) and 3.9% (2nd period). No pediatric recipient died from SSIs after LDLT in either period. The incidence of Enterococcus faecium increased from 5.0% to 26.9% in the adults and from 10.0% to 40.0% in the pediatric patients. Extended-spectrum β-lactamase-producing Enterobacteriaceae were emerging important isolates during the 2nd period. For this period, a univariate analysis showed that ABO incompatibility (P = 0.02), total operation duration (P = 0.01), graft-to-recipient body weight ratio (GRWR [P = 0.04]), and Roux-en-Y biliary reconstruction (P<0.01) in the adults and age (P = 0.01) and NHSN risk index (P = 0.02) in the children were associated with SSI development. In a multivariate analysis, lower GRWR (P = 0.02) and Roux-en-Y biliary reconstruction (P<0.01) in the adults and older age (P = 0.01) in the children were independent risk factors for SSIs during the 2nd period. In conclusion, SSIs caused by antibiotic resistant bacteria may become a major concern. Lower GRWR and Roux-en-Y biliary reconstruction among adult LDLT recipients and older age among pediatric LDLT recipients increased the risk of developing SSIs after LDLT.

A central approach to splenorenal shunt in pediatric living donor liver transplantation

The management of LSRS is a crucial problem to ensure a sufficient PV flow during pediatric LT. Although several techniques have been indicated to solve this problem, a more appropriate approach to LSRS is still needed in pediatric LT. We herein present a modified surgical approach to the ligation of LSRS via the left side of the IVC for a nine-month-old boy with severe portal hypertension and a history of Kasai portoenterostomy. LSRS was identified and exposed through the left side of the IVC and the dorsal surface of the pancreas from the superior side of the body of the pancreas. The post-operative course was uneventful with an excellent PV flow. The central approach for the ligation of LSRS is worth considering as an alternative procedure for a patient with collateral vessels and a history of multiple laparotomies.

EVALUATION, SELECTION AND PREPARATION OF LIVING DONOR FOR PARTIAL LIVER TRANSPLANTATION IN CHILDREN

Living donor liver transplantation is a highly effective method to help children with end stage liver diseases. Projected success of operation is largely determined at the stage of selection of potential donor. In our review of the literature is presented historical information, are considered «eastern» and «western» way of development of pediatric living donor liver transplantation, are analyzed the ethical and psychosocial aspects of living donor liver transplantation, and also are set out principles and protocols for evaluation potential donors. In addition, the modern views on volumetry of the potential donor liver and on choice of graft type for transplantation, including for children with low weight are presented.

Pure Laparoscopic Left Lateral Sectionectomy in Living Donors

In this study, we report the results obtained from 70 living donors in France. Left lateral sectionectomy for pediatric live donor liver transplantation is a well-standardized surgical procedure. Our team introduced the laparoscopic approach to live donation in 2002, and the reproducibility and safety of this method was discussed in 2006. Between March 2001 and October 2012, a total of 70 donors underwent a liver procurement. Sixty-seven donors (95.7%) underwent a left lateral sectionectomy, and 3 underwent a left hepatectomy without middle hepatic vein procurement. All data were prospectively recorded in a database. Of the 70 donors, 66 (94%) liver grafts were procured by laparoscopy, whereas 4 (6%) patients required conversion into an open technique. Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (16%) had grade 1 complications, according to the Clavien system. Five donors (7.1%) presented grade 2 complications, and 1 donor (1.4%) had a grade 3 complication. No death occurred. Overall, patient and graft survival rates for pediatric recipients were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively. The laparoscopic retrieval of the left lateral section for live donor liver transplantation is safe and reproducible and has transitioned from an innovative surgery to a development phase in France.

The impact of rituximab in ABO-incompatible pediatric living donor liver transplantation: the experience of a single center.

Previous studies have demonstrated the safety of ABO-incompatible pediatric LDLT using preoperative plasmapheresis and rituximab; however, no reports have described the timing and dosage of rituximab administration for pediatric LDLT. This study aimed to describe a safe and effective dosage and timing of rituximab for patients undergoing pediatric ABO-incompatible LDLT based on the experience of our single center. A total of 192 LDLTs in 187 patients were examined. These cases included 29 ABO-incompatible LDLTs in 28 patients. Rituximab was used beginning in January 2004 in recipients older than twoyr of age (first period: 375mg/m(2) in two cases; second period: 50mg/m(2) in two cases; and 200mg/m(2) in eight cases). Two patients who received 375mg/m(2) rituximab died of Pneumocystis carinii pneumonia and hemophagocytic syndrome. One patient who received 50mg/m(2) rituximab required retransplantation as a consequence of antibody-mediated complications. All eight patients administered 200mg/m(2) survived, and the mean CD20(+) lymphocyte count was 0.1% at the time of LDLT. In the preoperative management of patients undergoing pediatric ABO-incompatible LDLT, the administration of 200mg/m(2) rituximab threewk prior to LDLT was safe and effective.

Technique advance to avoid hepatic venous outflow obstruction in pediatric living-donor liver transplantation.

HVOO represents a serious critical complication of pediatric living-donor liver transplantation because open surgical repair is virtually impossible. Currently, despite several technical innovations and the introduction of triangulated anastomosis for hepatic vein reconstruction, the reported incidence of HVOO is still considerable. The aim of this study was to propose a new technique for hepatic venous reconstruction that avoids the original orifice of the recipient hepatic veins. Instead, anastomosis is performed in a newly created wide longitudinal orifice in the anterior wall of the recipient inferior vena cava. A total of 210 living related-donor liver transplantations were performed using two methods for reconstruction of the hepatic vein. Group 1 included 69 patients subjected to direct anastomosis of the orifice of the graft hepatic vein and a wide orifice created in the recipient inferior vena cava by the confluence of the orifices of the right, left, and middle hepatic veins. Group 2 included 141 patients in whom the original orifices of the recipient hepatic veins were closed, the inferior vena cava was widely opened, and a long longitudinal anastomosis was performed using two lines of continuous sutures. Diagnosis of HVOO was suspected based on clinical findings and ultrasound studies and then confirmed by liver biopsy and interventional radiology examinations. Among the 69 recipients in group 1, 16 patients died due to graft problems during the postoperative period and eight of the survivors (15.1%) presented with HVOO. In group 2 (141 patients), 21 patients died, and there were no cases of HVOO. A comparison of the incidence of HVOO between groups revealed a significant difference (p=0.01). Hepatic venous reconstruction during pediatric living-donor liver transplantation should be performed using a wide longitudinal incision in the anterior wall of the recipient inferior vena cava because this technique eliminated anastomosis complications.

Selection of living donor liver grafts for patients weighing 6kg or less.

In the field of pediatric living donor liver transplantation (LDLT), physicians sometimes must reduce the volume of left lateral segment (LLS) grafts to prevent large-for-size syndrome. There are 2 established methods for decreasing the size of an LLS graft: the use of a segment 2 (S2) monosegment graft and the use of a reduced LLS graft. However, no procedure for selecting the proper graft type has been established. In this study, we conducted a retrospective investigation of LDLT and examined the strategy of graft selection for patients weighing ≤6 kg. LDLT was conducted 225 times between May 2001 and December 2012, and 15 of the procedures were performed in patients weighing ≤6 kg. We selected S2 monosegment grafts and reduced LLS grafts if the preoperative computed tomography (CT)-volumetry value of the LLS graft was >5% and 4% to 5% of the graft/recipient weight ratio, respectively. We used LLS grafts in 7 recipients, S2 monosegment grafts in 4 recipients, reduced S2 monosegment grafts in 3 recipients, and a reduced LLS graft in 1 recipient. The reduction rate of S2 monosegment grafts for use as LLS grafts was 48.3%. The overall recipient and graft survival rates were both 93.3%, and 1 patient died of a brain hemorrhage. Major surgical complications included hepatic artery thrombosis in 2 recipients, bilioenteric anastomotic strictures in 2 recipients, and portal vein thrombosis in 1 recipient. In conclusion, our graft selection strategy based on preoperative CT-volumetry is highly useful in patients weighing ≤6 kg. S2 monosegment grafts are effective and safe in very small infants particularly neonates.