Reducing graft thickness is essential to prevent large-for-size graft problems in pediatric living donor liver transplantation (LDLT). However, long-term outcomes of LDLT using reduced-thickness left lateral segment (LLS) grafts are unclear. In 89 patients who underwent LDLT using reduced LLS grafts between 2005 and 2017, short-term and long-term outcomes were compared between a nonanatomically reduced LLS (NAR-LLS) graft group and a reduced-thickness LLS graft group. Estimated blood loss was lower and abdominal skin closure was less needed in the recipient operation in the reduced-thickness LLS graft group. Postoperatively, portal vein (PV) flow was significantly decreased in the NAR-LLS graft group, and there was shorter intensive care unit (ICU) stay and fewer postoperative complications, especially bacteremia, in the reduced-thickness LLS graft group. Graft survival at 1 and 3 years after LDLT using reduced-thickness LLS grafts was 95.2% and 92.4%, respectively, which was significantly better than for NAR-LLS grafts. Multivariate analysis revealed that fulminant liver failure, hepatofugal PV flow before LDLT, and NAR-LLS graft were associated with poor graft survival. In conclusion, LDLT using reduced-thickness LLS grafts is a safe and feasible option with better short- and long-term outcomes in comparison with NAR-LLS grafts.

This large consecutive case series demonstrates that our LAHDS procedure can be performed as safely as ODH, and it can improve quality of life without impaired donor and recipient outcomes.

Liver transplantation is now an established treatment for children with end-stage liver disease. Left lateral segment (LLS) grafts are most commonly used in split and living donor liver transplantation in children. In very small children, LLS grafts can be too large, and further nonanatomical reduction has recently been introduced to mitigate the problem of large-for-size grafts. However, the implantation of LLS grafts can be a problem in infants and very small children because of the thickness of the grafts, and these techniques do not address problems related to thickness. We herein describe a technique for reducing the thickness of living donor left lateral grafts and successful transplantation in a 2.8-kg infant with acute liver failure. The lack of size-matched pediatric liver grafts has led to the development of reduced, split, and living donor liver transplantation. These techniques have expanded the potential donor pool and decreased waiting-list mortality for children. 1 Transplantation in children who weigh less than 5 kg remains a problem because the left lateral segment (LLS) from an adult may be too large when the graft-to-recipient weight ratio is greater than 4.0% and thus may result in a large-for-size graft and its associated morbidity. 2 Further reduced LLS grafts that can be transplanted safely without compromise to patient survival have been introduced for these children to mitigate the problem of large-for-size grafts. 3 In very small children (neonates) who have no portal hypertension, hepatomegaly, or ascites, the abdominal cavity may be small, and the anteroposterior thickness of the graft remains a problem. 4,5 Abdominal closure may require a temporary Silastic mesh, and this is associated with complications. We have developed a modified LLS reduction by which the thickness of the graft is addressed and transplantation is allowed in very small infants. The clinical study protocol was approved by the institutional review committee. CASE PRESENTATIONA 23-day-old Asian girl weighing 2.8 kg who presented with deteriorated liver function was admitted to our hospital. The laboratory study showed a total bilirubin level of 22.7 mg/dL, a prothrombin time/international normalized ratio of 10.0, an alanine aminotransferase level of 500 U/L, and a serum ammonia level of 217 lmol/L. The investigations for infectious and inherited metabolic pathogenesis were all negative. The patient was diagnosed with neonatal acute Abbreviations: LHV, left hepatic vein; LLS, left lateral segment; LPV, left portal vein; MHV, middle hepatic vein; P2, segment II portal vein; P3, segment III portal vein; PV, portal vein; RHV, right hepatic vein; RPV, right portal vein.

Living donor liver transplantation (LDLT) is now an established technique for treating children with end-stage liver disease. Few data exist about liver transplantation (LT) for exclusively young infants, especially infants of <3 months of age. We report our single-center experience with 12 patients in which LDLT was performed during the first 3 months of life and compare the results with those of older infants who underwent LT. All of the patients were treated at the National Center of Child Health and Development, Tokyo, Japan. Between November 2005 to November 2016, 436 children underwent LT. Twelve of these patients underwent LT in the first 3 months of life (median age, 41 days; median weight, 4.0 kg). The indications for transplantation were fulminant hepatic failure (n = 11) and metabolic liver disease (n = 1). All the patients received the left lateral segment (LLS) in situ to mitigate the problem of graft-to-recipient size discrepancy. A reduced LLS graft was used in 11 patients and a segment 2 monosegment graft was used in 1 patient. We compared the results with those of infants who were 4-6 months of age (n = 67) and 7-12 months of age (n = 110) who were treated in the same study period. There were significant differences in the Pediatric End-Stage Liver Disease score and the conversion rate of tacrolimus to cyclosporine in younger infants. Furthermore, the incidence of biliary complications, bloodstream infection, and cytomegalovirus infection tended to be higher, whereas the incidence of acute cellular rejection tended to be lower in younger infants. The overall cumulative 10-year patient and graft survival rates in recipients of <3 months of age were both 90.9%. LDLT during the first 3 months of life appears to be a feasible option with excellent patient and graft survival. Liver Transplantation 23 1051-1057 2017 AASLD.

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